IAPT’s Below Intensity CBT Revolution

IAPT’s low intensity CBT should be re-branded ‘below intensity CBT’, as all the methodologically rigorous CBT outcome studies were conducted  on full dose CBT.  Guided self-help (GSH) interventions were first recommended by a NICE committee in 2007 and 2009 for depression and the anxiety disorders. In its’ wake IAPT enthusiastically adopted GSH such that by 2018, 70% of clients were being given it. But recently therapists have been told not to use the term ‘GSH’ but talk to clients instead of ‘low intensity CBT’. This re-labelling appears to have occurred because of the difficulties of engaging the public in this more obviously cheap option (see previous post).

But NICE did not conduct a systematic review of the outcome literature, rather its’ recommendations were simply the advice of its’ committee. It failed to acknowledge that there were no studies of ‘guided self-help (GSH)’ with a hard outcome measure i.e studies involving an independent blind assessor using a standardised diagnostic interview. Thus there was no evidence that the man/woman in the street would recognise that the GSH had returned them to normal functioning. However the recommendation of NICE was that the low intensity interventions had to be matched to the particular depression or anxiety disorder. But IAPT took what it wanted from the NICE guidance, jettisoned making a diagnosis and proclaimed that appropriate treatment could follow a problem descriptor, without any empirical evidence for the latter.  The upshot is that for a decade IAPT clients have largely been subjected to ‘below intensity cbt’.

There has been a decade of ‘the below intensity CBT’ revolution and it has failed. This is not to say that there may not be cheaper effective options for service delivery such as group CBT, but the scope for such interventions is limited to depression and some anxiety disorders and much more methodologically rigorous outcome studies are necessary to confirm its place.

Dr Mike Scott 

CBT’s House of Cards?

applying the acid tests of the Cochrane Collaboration Tool and the GRADE Handbook for the quality of randomised controlled trials, studies of low intensity CBT fail to clear the methodological bar. Whilst only high intensity studies for depression and the anxiety disorders make a successful jump. This calls into question IAPT’s penchant for disseminating CBT for everything, with an imprimatur from BABCP, paying travel expenses of upto £100 for special interest group members to attend a pre-conference workshop Revolution in Mental Health Service Delivery: The Evolution of Low Intensity CBT on Tuesday 3rd September.

One of the seven domains highlighted by the Cochrane Collaboration tool for assessing bias is the blinding of outcome assessment. I have been unable to locate one outcome study of low intensity CBT that fulfills this criteria whilst there are a significant minority of studies of high intensity interventions for depression and the anxiety disorders that do.

The GRADE handbook for assessing the quality of trials comments in section 3.4 ‘not infrequently, outcomes most important to patients remain unexplored’, with regards to psychological interventions clients are rarely asked by someone independent of the study whether and if for how long they are back to their usual selves since treatment. Instead most commonly reliance is placed on a surrogate measure a client completed questionnaire, as opposed to an independent clinicians assessment using a standardised diagnostic interview to determine whether there has been a loss diagnostic status.

These concerns are crystallised in a study of CBT for Health Anxiety conducted by Cooper et al (2017), Behavioural and Cognitive Psychotherapy, 2017, 45, 110–123 doi:10.1017/S1352465816000527

whilst 10 of the 13 studies in a meta analysis used the DSM or ICD-10 to determine whether people should be admitted to the meta analysis, in no study was meeting these criteria used as an outcome measure. To be no longer suffering from the identified health anxiety at end of treatment/follow up would have been a client important outcome. Instead the self-report Health Anxiety Questionnaire was used as surrogate. Cooper et al (2017) attempted to rate studies using the Cochrane Collaboration tool using a summary score for the seven domains, but this bore no relation to outcome and as the authors admitted was a questionable procedure. Despite this CBT was claimed to be an effective treatment for health anxiety.

I am afraid I can’t join in the jamboree for IAPT services that takes place at the BABCP annual conference. I doubt that the ‘House of Cards’ will be discussed and it would likely be seen as banned literature on IAPT training courses.

Cochrane https://www.dropbox.com/s/bmr98o8z8fcfuzv/paths%20to%20mh%20Cochrane%20Risk%20of%20bias%20assessment%20tool.pdf?dl=0

GRADE handbook

https://www.dropbox.com/s/wudv2eu2oxw7qsr/GRADE%20handbook.html?dl=0

Dr Mike Scott

Clinical Commissioning Groups Need To Know What Actually Happens Behind IAPT’s Closed Doors

this can be achieved by asking local GPs to ask patients about their experience and crucially to determine what proportion of patients returned to normal functioning after referral to IAPT.

Most IAPT clients receive low intensity CBT, with only 20% recovering, half of whom relapse in a year [ Ali et al (2017)]. Only 10% of LICBT patients are stepped up to high intensity. Independent assessment suggests the overall recovery rate in IAPT is just 15%.[ Scott (2018)] https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Results Show IAPT To Be No Better Than Pre-existing Services

A study from 2006 profiled the improvement rates of 32 primary care counselling services using the CORE Outcome Measure. (CORE-OM). The mean level of reliable improvement (including clients that also recovered)  was 72%. Across IAPT, the reliable improvement figure was 66%. But services can be re-organised to transform IAPT Scott (2018)

https://www.dropbox.com/s/zhr1fkg71aqvno0/Transforming%20IAPT.pdf?dl=0

The Failure To Inspect

CCG’s and the National Audit Office show a conspicuous lack of interest in what is happening behind the closed doors of IAPT, preferring to take the Organisations marketing at face value. IAPT appears not to be accountable to the Care Quality Commission. But the CQC’s failure to effectively monitor institutions catering for those with learning difficulties and autism has unearthed a scandal, and instils little confidence in a critical appraisal of IAPT anytime soon.

An Illustration Of The Travails of a Low Intensity IAPT Recipient

Ted’s case illustrates the dire quality of service, he met IAPT in 2014, the records stated that he had been a worrier all his life, but no diagnosis was made. He was no better after 18 months of low intensity cbt. A lost soul:

Initially Ted was directed to a Psychological Wellbeing Practitioner and computerised CBT, Beating the Blues. Ted is recorded as finding the sessions helpful. At the end of LICBT it is recorded that

‘he would prefer not to access cbt again as good understanding of how his negative thoughts impact his behaviour regularly reads his previous cbt notes but implementation does not improve mood’ his psychometric test results are shown below, ‘his billboard’:

    PHQ9GAD7  
Feb 14   10   14  
 March 14 8   7
  May 14 5   9
  July 16 21 15
  August 16 20   18
     
     

At the end of his low intensity journey, there was again no assessment of his diagnostic status and he was understandably not enthusiastic about further CBT. It seems likely that few people are stepped up from low intensity to high intensity because cbt is at best seen as having limited utility.

Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8

Dr Mike Scott

My black cloud, revolving door and IAPT

‘I found Silvercloud ineffective, generic and not tailored to my personal situation. It wasn’t engaging or helpful and as such I didn’t engage with the website very much. Consequently, the following weekly call with the IAPT therapist  were sometimes made difficult by the fact I hadn’t completed the same questionnaire as the week before or read through articles. I wanted to talk about my situation, my feelings and find out why I was feeling the way I was, but I felt I was just being led back to using the online Silvercloud resource.

‘It was in 2017 that my doctor suggested I try Silvercloud online CBT with telephone support and in September 2017, I started speaking to another IAPT counsellor. He seemed to be a very nice man. After a few weekly calls, he stated that he didn’t believe I was depressed and so he changed the original Silvercloud course I had started and reset it back to a new series of 6 sessions. The weekly calls lasted between 20 minutes to an hour depending on what we discussed, but always concluded with him asking me to log onto Silvercloud and work my way through the programme before our next call. After the requisite 6 sessions finished in February 2018, that was it! No answers, no tools to help me cope, just signed off, discharged, but told I had 12 month access to SilverCloud. I haven’t used the resource since.

I had a very poor experience of counselling through IAPT around 2013. I had been scheduled 6 sessions, these hour long sessions were so ineffective and pointless I can hardly recall anything that was discussed. I may have missed a couple of sessions due to work, but once the 6 sessions expired, I was discharged even though I may have only seen the counsellor 4 times. All I can recall is going over the initial questionnaire about my mood over the previous week which I had been told to monitor through photocopied pictures and graphs which I was told to keep in a file and bring to each appointment’.

 

 

The above is the anonymous report of a depressed client of mine, who is responding very well to my cbt treatment. Not only is she scathing about her IAPT treatment but also about her treatment from her GP:

‘At its height, I was being prescribed 200mg sertraline, 80mg of propranolol. I went to see my doctor for something routine, when she commented on my ‘low mood’ and suggested increasing my antidepressants. I told her I was already taking the maximum dosage and said I didn’t want to take more prescription medicine. I was already taking 200mg of setraline and 80mg of propranolol at that time. My prescriptions had been increased over a period of time without much investigation. In a short 5-10 minute appointment, my ‘low mood’ was usually commented upon and an increase in antidepressant and/or beta blocker was almost automatically prescribed.
In early 2018, I went to see my doctor and insisted that we work together to reduce my medication as I felt so unwell and was sure that the amount of medication I was taking was actually making me feel worse rather than better’.

There is no substitute for really listening.

Dr Mike Scott