Duplicity In IAPT On MUS

my colleague Joan Crawford wrote the following letter to the Journal of Psychosomatic Research, it highlights that IAPT advises its’ clinicians not to use the term Medically Unexplained Symptoms (MUS). Her letter was rejected. But Prof Chalder, Improving Access to Psychological Treatments (IAPT) adviser on MUS and LTC’s (long term conditions) , regularly holds workshops using the MUS descriptor (see webcast for BABCP sponsored Workshop on June 8th 2020). Joan’s letter reads;

 
 

‘The systematic review into the use of language and relational issues during the patient-doctor interaction where there is medical uncertainty is welcome [1]. However, there are flaws in the methodology and underlying assumptions within this paper that require closer examination.

Medically unexplained symptoms (MUS) were not clearly defined. A broad, assumptive approach was used which included: chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome, without justification or criticism. These are all separately listed World Health Organisation medical conditions [2]. Using MUS gives an illusion of medical respectability, which is ambiguous if not misleading. At no point was there recognition of controversy of the MUS approach or any engagement with extensive alternative literatures. While many routine tests may fail to find a specific underlying disease, it is misleading to assume; therefore, that no objective abnormalities can be identified.

In the UK, chronic pain (explained or unexplained by routine assessment), including fibromyalgia, is managed within the NHS via pain management programmes. This is under the rubric of The British Pain Society guidelines [3]. Such an approach teaches patients the central sensitisation and dysregulation model of chronic pain. This science-based model encourages patients to pace, plan and prioritise tasks to maximise activity; set appropriate goals; minimise flare ups and to live well despite being in pain. At no point does the evidence suggest that their pain is medically unexplained, quite the opposite. Patients adapt well to this model. They improve their self-efficacy, reduce distress along with decreasing presentation at their GPs unnecessarily as they have the confidence to decide how to best manage themselves.

Taking the MUS approach has the potential to de-validate patients’ symptoms as described in this paper [1]. Patients can erroneously be given the impression during the medical encounter, consciously or otherwise, that their symptoms and suffering are not of worth; that they are derived

from within themselves via a self-generated, autopoietic mechanism [4], which they have the power to overcome. For example, “MUS arise when benign bodily sensations, such as those resulting from normal variation, emotional disturbance or minor pathology, are selectively attended to and misinterpreted as evidence of illness [4]; the resulting changes in behaviour (e.g. reduced activity) and physiology (e.g. increased autonomic arousal) then create a vicious cycle that maintains symptom reporting.” [5]. The apparent rarity of misdiagnosis is often cited as good reason to proceed with a MUS approach. Of note, Newton [6] reviewed 375 patients attending a CFS clinic in England and found that 40% of patients did not to have CFS. Caution is required.

What evidence does the practitioner have that their option is sound other than their own belief? Should the patient not return, does the doctor then conclude that the patient has been cured of a false belief? Or has the patient abandoned hope that their practitioner can help them? Deary’s cognitive behavioural model [5] is potentially self-blaming and shaming which can silence patients discouraging them from further medical interaction and emotional and social support. Patients’ can experience disbelief about their symptoms as an assault on their sense of self. This causes harm and unnecessary suffering. This can have tragic consequences for patients and their families.

Openly sharing the speculative MUS model in the clinical context would allow the patient to decide if it has face validity. Worryingly in the UK, IAPT clinicians are encouraged to not use the term MUS [7]. This is duplicitous. Obfuscation here is dishonest and unethical [8]. It is encouraging to note that, “healthcare providers are cautious when raising psychosomatic attributions” [1] as the evidence base for such is flimsy. The absence of good quality evidence-based objective, real world changes for psychological or behavioural interventions for MUS was omitted and therefore not subject to critical analysis [9]. The paper does approach the importance of the psychosocial context; however, it fails to critically analyse the social and emotional consequences for the patient.

It is unfortunate that some doctors continue to have negative experiences. This may well be true for those who are not up to date in their knowledge. When current information is shared with patients, they are enlightened and appreciative of clinician’s honesty and skills.

There is a sense from this paper that clinicians should continue fear encounters with patients. Perhaps there is nothing to dread from such consultations if one approaches this with a sense of humility [8] and a science-based model and positive mindset. There needs to be honesty in the clinical and therapeutic environment. This needs to hold the tension with uncertainty, without the ethically dubiously, “subtle persuasive conduct” [1] imposing a blaming and shaming model on the patient due to lack of clinician resilience or knowledge [8]. Share the model openly [4,5] and allow the patients to vote with their feet. Those who find it meaningful will stay. The key here may be to build healthcare providers’ resilience to cope with and tolerate uncertainty and ambiguity.

[1] I. Stortenbeker, W. Stommel, S. van Dulmen, P. Lucassen, E. Das, T. I. Olde Hartman, J. Psychosom. Res. 132 (2020).
[2] World Health Organisation, International Statistical Classification of Diseases. https://www.who.int/classifications/icd/en/

[3] The British Pain Society, Guidelines for Pain Management Programmes for Adults (2013).
[4] V. Deary, T. Chalder, M. Sharpe, The cognitive behavioural model of medically unexplained symptoms, Clin. Psych. Rev. 27 (2007) 781–797.
[5] R. Brown, Explaining the unexplained, The Psychologist, 26 (12) (2013) 868-872.
[6] J.L. Newton, H. Mabillard, A. Scott, A. Hoad, G. Spickett. The Newcastle NHS Chronic Fatigue Syndrome Service: not all fatigue is the same, J R Coll Physicians Edinb. 40 (2010) 304–307.
[7] NHS IAPT Medically Unexplained Symptoms/Functional Symptoms – Positive Practice Guide, (2014).

[8] D. O’Leary, Ethical management of diagnostic uncertainty: Response to open peer commentaries on, “Why bioethics should be concerned with medically unexplained symptoms,” Am J. Bioethics. 18 (8) (2018) W6-W11.
[9] K. Geraghty, M. Scott, Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified, BMC Psychol, 8 (13) (2020).’

Well argued Joan

Dr Mike Scott

IAPT’s Mistreatment Of Those With Medically Unexplained Symptoms (MUS)

in our paper published today in BMC Psychology, Keith Geraghty and I write of Improving Access to Psychological Therapies (IAPT) malpractice with MUS clients , see link  https://doi.org/10.1186/s40359-020-0380-2

A series of seven core problems and failings are identified, including:

  1. an unproven treatment rationale
  2. a weak and contested evidence-base
  3. biases in treatment promotion
  4. exaggeration of recovery claims
  5. under-reporting of drop-out rates
  6. a significant risk of misdiagnosis
  7. inappropriate treatment.

We concluded that:

There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients’ physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

Dr Mike Scott

and the added value of low intensity IAPT is?

compared to how people would have got on anyway if not referred to IAPT (in economist terms the appropriate counterfactual), the ‘added value’ has not been demonstrated. Yet most people receive a low intensity intervention such as computerised CBT, guided self help or groupwork.

I could find no independent outcome assessors involved in the randomised controlled trials of low intensity interventions that the NICE guidance largely relies on. Instead reliance has been placed on IAPT’s marking and marketing of its’ own homework.

In a review of randomised controlled trials published in 4 medical journals Kahan, Rehal and Cro (2015) only a quarter (26%) involved blinded outcome assessment. These authors write ‘Previous reviews have found that unblinded outcome assessment can lead to estimates of treatment
effect that are exaggerated between 27% and 68%’ see link below:

https://www.dropbox.com/s/aarqu8j95udwmpl/Blinding%20independent%20assessment%20rare%20%202015.pdf?dl=0

But the position appears worse when it comes to psychological therapies with no reliable rcts for low intensity interventions, and with regards to high intensity interventions the few blind outcome assesments are clustered around depression, the anxiety disorders and PTSD. Since the millenium there has been a drift away from the use of outcome assessors, this makes research cheaper, it is much easier to massage statistics to give a positive hue, the originators of an intervention and those with a vested interest are given a free hand.

Researchers on IAPT [seee Bower et al (2013)] play fast and loose with Cochrane risk of bias tool, see link below:

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

and jettison the need for independent blind assessment implicit in the tool on the spurious grounds that ‘most outcomes are self-reported’ see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

Looked at from the perspective of independent outcome assessment the claims for low intensity interventions look spurious and the evidence base for high intensity interventions is more circumscribed than BABCP conferences or IAPT would suggest.

The IAPT Manual published last year recommends extension of the service to irritable bowel syndrome, chronic fatigue syndrome, chronic pain and medically unexplained symptoms not otherwise specified but makes no mention at all of the need for independent blind assessment of outcome, instead it suggests simply what self-report measures should be administered. See link below:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

Yet another marketing opportunity, when we need real world answers, how many people said to an impartial observer that they were back to their usual selves after the intervention? how long did this last?

Dr Mike Scott

IAPT and Rudolph

Rudolph had a very shiny nose, in a routine consultation with  his GP, Dr Touchy-Feely, the latter said that it was medically unexplained and he could be referred/or refer himself to IAPT.

He replied that it was a long term physical condition and he didn’t think a psychological service was appropriate. The GP opined that he might have persistent somatic symptom disorder and entered this in his notes. . Later that day Rudolph had a telephone conversation with Father Christmas who wondered whether he could help him out that evening. Rudolph mentioned in passing his conversation with the  GP. Father Christmas observed that everyone knew he had a very shiny nose and could on occasion feel left out or ridiculed but was this really a psychological problem, didn’t IAPT have enough to do with all the anxious and depressed people! Rudolph replied sheepishly, perhaps I should ring IAPT in the New Year, after all the GP is saying I have got persistent somatic disorder. Father Christmas replied Dr Touchy-Feely, does not know what evidence based criteria are for anything and added whimsically ‘he doesn’t even believe in me’.

Have a great Christmas Folks

 

Dr Mike Scott

IAPT Haemorrhaging Clients

The latest IAPT figures for August 2018 show 60.3% of clients attending attending less than 2 treatment sessions. Under the auspices of NHS England IAPT claims to offer NICE approved therapies for treating people with depression or anxiety but the typical recommended dosage of such therapies is 10 or more sessions! Casualties are strewn in ‘no-mans land’. The National Audit Office (NAO) rather than publish the results of its’ investigation has chosen to look the other way. Yesterday the NAO was very vocal on another Government Quango, Motability but mental disability appears not to be as deserving of critique as services for those with a physical disability. If 60% of physically disabled people were not enabled to get the vehicle they require, there would rightly be an outcry, yet the majority of IAPT referrals are expected to suffer in silence. The IAPT figures can accessed using the link below:

https://www.dropbox.com/s/crucmhktn3r88ud/IAPT%20Figures%20for%20August%202018.pdf?dl=0

Notwithstanding this IAPT in its’ pilot projects is expanding ‘IAPT care’ into the medically unexplained symptoms (MUS) field (see link below). Despite the concept of MUS being jettisoned from DSM-5 [American Psychiatric Association (2013)] –  in a radical departure from its’ predecessor DSM IV it cautions that it cannot be assumed that just because no physical explanation is proferred the problem must be psychological. Nevertheless IAPT in its report on integrated services comes up with an ‘MUS recovery rate’!

https://www.dropbox.com/s/f1taewasjrg4pyw/IAPT%20MUS%20Aug%202018.pdf?dl=0

Dr Mike scott

‘What We Need Is Good Quality Talking Therapies’

Says Will Self talking on Radio 4 this morning, a must listen on BBC i-player. He was  distressed at his friend who had been sectioned, his visit to her on a locked ward resembled still, ‘One Who  Flew Over the Cuckoo’s Nest’. When she questioned the appropriateness and mechanism of action of the drugs prescribed for her bipolar disorder the psychiatrist became defensive. After  discharge no therapy was on offer.

 

 

He is absolutely right we do need good quality talking therapies but we have not got them, rather we have a 10% recovery rate for those undergoing treatment with IAPT http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264.  I very much doubt that IAPT or anyone has an evidence based psychological treatment for a person with bipolar disorder and it would be disingenuous to pretend we have. Nevertheless IAPT has trespassed into providing treatment for medically unexplained symptoms, which is an unfortunate precedent for claiming more than we can deliver.

Will Self makes the excellent point that we need small communities to support people like his friend. But it is very difficult to create them for people who are isolated, charities, churches etc do what they can but it is a tough road to make a real world difference

 

Dr Mike Scott

‘What, If Anything, Is Beyond The Glitz Of IAPT?’ Asks Journal Editor

‘IAPT Talking Therapies All Glitz and No Substance?’  is the title of a Press Release from the Editor of the Journal of Health Psychology, Dr David Marks, The Press release reads:

 

 

‘The Journal of Health Psychology is calling for an urgent independent review of patient recovery rates
with the NHS ‘Improving Access to Psychological Therapies’ (IAPT) talking therapies programme.

A recent study by Dr. Michael Scott revealed that only one in ten mental health patients actually
recovered (http://journals.sagepub.com/doi/full/10.1177/1359105318755264).

Now JHP editor, Dr David F Marks, is calling for IAPT recovery rates to be closely scrutinized. He
wants solid evidence that patients who have recovered stay well over the long term.

Michael Scott’s study found that overall just 9.2% of patients recovered with IAPT therapies. There is
an enormous gap of 40% between these findings and IAPT’s claimed recovery figure.
The study’s recovery rates were: Post-Traumatic Stress Disorder – 16.2%, depression – 14.9%, other
mental disorders including anxiety – 2.2%.

Dr Scott, Consultant Psychologist and Expert Witness to the Courts, suggested “a pressing need to reexamine…the service”. IAPT’s economic model hinges on good recovery rates and high recruitment.
The contributors to this Special Issue of the journal, “IAPT Under the Microscope”, have all expressed
doubts about the veracity of IAPT’s recovery claims. They agree that there’s a need for an independent
assessment of the type that a drug treatment would require before being approved for use.
The theory is that better mental health will lead to fewer physical health problems so that patients will
need less care. High recovery rates should then yield the promised hefty ‘efficiency’ savings to the
physical healthcare budget that will pay for the IAPT service.

The IAPT spotlight is on patients with ‘medically unexplained symptoms’ (MUS) and ‘long-term
conditions’ (LTCs) such as diabetes and COPD. This expansion into areas beyond its already
questionable expertise is likely to be clinically risky. Experts and patients are worried about the motives behind this and concerned that a mental health diagnosis will allow providers to restrict access to healthcare and other benefits. Can these therapies really reduce patients’ physical problems and their need for care, or is this an NHS version of a ‘hostile environment’?

The programme continues to grow as more local therapy services are rolled out across England. IAPT
aims to enrol over a million patients per year but the system is already creaking under the strain.
In his Editorial, Dr Marks proposes an open debate about England’s flagship IAPT project that has so
far cost the taxpayer around £1 billion. He calls for an independent, expert review to determine if IAPT
is likely to reap the promised rewards or asks if is it all glitz and no substance?

Notes to editors

Marks, D.F. (Ed.) (2018). “IAPT Under the Microscope” published online and in print on 26 July 2018.
http://journals.sagepub.com/home/hpq [see copy attached to email]

Scott, M.J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical
Reform. Journal of Health Psychology, http://journals.sagepub.com/doi/full/10.1177/1359105318755264

Contact

Dr Michael J Scott, author of the IAPT study, is available at: 07580 644 038
michaeljscott1@virginmedia.com

Dr David F Marks, Editor of the Journal of Health Psychology, is available at: 07930 753 206 ;
editorjhp@gmail.com

 

Dr Mike Scott