Tag: Medically unexplained symptoms

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Spurious Claims For The Impact of Transdiagnostic CBT on Persistent Physical Symptoms 

 

In a just published study James et al (2022) extol the virtues of their transdiagnostic CBT therapy (plus standard medical care) for Persistent Physical Symptoms.
s. In an earlier study  these authors found no difference in outcome at 52 weeks follow up on the Work and Social Adjustment Scale (WSAS: the declared primary outcome measure) between those undergoing the transdiagnostic CBT plus standard medical care and those having the latter alone. Not to be outdone they have gone on a fishing expedition in their latest paper  James et al (2022) and focus on two secondary outcome measures, WSAS score at the end of active treatment  and the PHQ-15 score at 52 weeks, claiming that there was a significant difference between the transdiagnostic CBT  and standard medical care using both these secondary measures.

 This looks a little fishy as they are the originators of the treatment. No mention of the need for independent replication of their findings. Further the comparison group was standard medical care, but this design does not control for attention or the presentation of a credible treatment rationale. Scepticism seems in order. This intensifies when the outcome measures used are considered.

The WSAS (Mundt et al 2002) was designed to assess the impact of mental health on functioning in 5 domains work, home management, social leisure activities, private leisure activities and close relationships. As such there is clear separation between the causal agent (mental health) and effect (functioning). In the initial validation study the WSAS was administered to a sample of depressed patients and a sample of OCD patients, the WSAS scores correlated with the severity of each disorder.  

Mental Health can affect one’s ability to do certain day-to-day tasks in their lives. Please read each item below and respond based on how much your mental health impairs your ability to carry out the activity. 

Table Description automatically generated

 

If however the term ‘mental health’ in the above table is replaced with “Persistent Physical Symptoms’ the distinction between causal agent and effect is lost. Consider, a person who is terminally ill with cancer or a progressive neurological disorder, they would likely score high in each domain. But it would not be anticipated that any psychological intervention is going to attenuate their physical symptoms, because there is a fusion of physical symptoms and impairment. [In the original validation study the term ‘disorder’ was used because they were known to have either depression or OCD].

The burden of proof is on those who would reword the WSAS so that it related to PPS to demonstrate a meaningful distinction between say fibromyalgia and impairment in functioning or irritable bowel syndrome and functioning or between chronic fatigue syndrome and functioning. The WSAS was not validated for PPS  but that has not stopped James et al (2022) using it as their primary outcome measure in their study of transdiagnotic CBT for PPS compared to standard medical care.

 

The PHQ-15 is a measure of symptom severity and is rated on a 3- point Likert scale. This brief validated measure looks at a range of symptoms and asks patients to report to what extent their symptoms bothered them in the past four weeks. The PHQ-15 contains 15 items and the total score can range from 0 to 30 where a higher score indicates greater symptom severity (Kroenke et al., 2010). The items include several related to pain, (stomach pain, back pain, pain in arms and legs or other joints, headaches, chest pain), fatigue, as well as other symp- toms related to the different systems of the body i.e. shortness of breath, dizziness, bowel symptoms.

But there is no clear mechanism by which a psychological intervention impacts such an array of symptoms. The authors considered 9 possible mediating variables (7 of which were cognitive), but only 2, catastrophising and symptom focusing appeared operative (Type 2 error). Suggesting that the supposed mediating variables may be chance findings. One of the suggested variables related to depression (PHQ-9) and the other anxiety (GAD-7) but for the supposed cognitive mediation model evinced by James et al (2022), they cannot be mediators, depression is known to covary with WSAS as such it cannot be an explanatory variable.

Assessment in the study is entirely by self-report measures but the authors totally ignore that they are subject to demand characteristics e.g wanting to please the therapist by reporting improvement or to convince oneself that time has not been wasted. It would have been more meaningful for an independent assessor to ask since ‘x’ have you felt the same, a little better, a little worse, much better, much worse.  

James et al (2022) justify their transdiagnostic therapy on the basis that ‘people with different PPS share some cognitive and behavioural responses to symptoms, including catastrophising, symptom focusing, fear avoidance beliefs, avoidance behaviour and lack of acceptance (Deary, Chalder, & Sharpe, 2007)’. This is a sweeping statement certainly catastrophising and avoidance behaviour have been implicated in the development of chronic pain, but this is not to say that they are germane to the category of PPS (MUS). The use of the term ‘some’ makes the Deary, Chalder, & Sharpe, 2007 model incapable of falsification.

 

The  term PPS as used byJames et al (2022), is a smokescreen for the construct Medically Unexplained Symptoms whose validity Keith Geraghty and I have challenged.

Dr Mike Scott

 

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Jettisoning the CBT Model of Medically Unexplained Symptoms

 

In a just published Editorial in the Journal of Health Psychology MUS and CBT Editorial we have called time on this model. The abstract reads:

The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model

 
Michael J Scott, Joan S Crawford, Keith J Geraghty, David, F Marks
First Published September 23, 2021 Editorial
https://doi.org/10.1177/13591053211038042

The American Psychiatric Association’s, 2013 DSM-5 abandoned the use of the term ‘medically unexplained symptoms’ for non-neurological disorders. In the UK, treatments for various medical illnesses with unexplained aetiology, such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia, continue to fall under an MUS umbrella with cognitive behavioural therapy promoted as a primary therapeutic approach. In this editorial, we comment on whether the MUS concept is a viable diagnostic term, the credibility of the cognitive-behavioural MUS treatment model, the necessity of practitioner training and the validity of evidence of effectiveness in routine practice.

Dr Mike Scott

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Psychological Therapy With Long Term Conditions

Improving Access to Psychological Therapies (IAPT) therapists working with long term conditions (LTC’s) have confidence and organisational, issues Carroll et al (2021) DOI: 10.1111/bjhp.12475. Whilst therapists working in secondary care, with LTC’s, face fewer obstacles to multidisciplinary working, with a focus primarily on the LTC and not on the associated depression/anxiety as in IAPT. Further the metrics for outcome in secondary care are likely to be much broader than in IAPT. LTCs by their very nature, wax and wane with a consequent impact on availability and concentration, creating a need for any therapy to be long term. But IAPT has a major focus on access and waiting times, such that any treatment is usually brief, comprising on average of 6 sessions, thus the service cannot readily accommodate working with LTCs.

The focus in the Carroll et al (2021) is on how the psychological treatment for those with LTC”s can be best integrated into primary and secondary care. They note however that the model they use to identify barriers and facilitating factors to implementation, first requires, evidence that the chosen intervention/s are effective. But they do not address this point. This is crucial, where is the evidence that the psychological therapies for disorders that are comorbid with LTCS make a real world difference?

A case has long been made that it is a matter of basic humanity to offer to accompany a person with an LTC if they so wish. A host of Charities have formalised this. The support may be social, e.g befriending, groups and/or instrumental e.g help with DWP application. The case for profferring ‘support’ is I think uncontestable. But many with LTC’s are wary of being defined by their condition. A dedicated support group may serve as a further reminder of their condition. They may decline involvement in such a group, but this is not necessarily a matter of avoidance, simply that they do not wish to define themselves or their world through the lens of their LTC. If psychological difficulties are grafted on to their LTC they may be even more likely to decline involvement with psychological therapists because it is an LTC type lens (a variant) through which they are being encouraged to view themselves and their personal world with perceived deleterious consequences. Arguably the LTC lens used in secondary care is likely to be less problematic than that used in IAPT. But the issue of centrality has not been systematically addressed with regards to LTCs. In the authors forthcoming work ‘Personalising Trauma Treatment: Reframing and Reimagining’ to be published by Routledge the issue of centrality [ Bernsten and Rubin (2006) (2007)] is addressed in detail with regards to trauma.

There is a distinction between long term physical health conditions and medically unexplained symptoms (MUS), the former are open to objective identification e.g diabetes, the latter are not. In considering the former the therapist feels that they are on solid ground, albeit that it is largely the domain of the medic, with whom there may be fruitful dialogue. But when it comes to MUS the therapist is in a fog, where are the signposts? There is no reference book for translating best practice with LTCs to clients with MUS. Because of this there is likely to be recourse to a powerful body insisting that the way forward is ‘x’ but without any evidence, a recipe for disaster. IAPT”s juxtaposition of LTCs and MUS, smacks more of pragmatism to secure maximum funding, rather than seriously addressing a clinical problem. Where is the therapeutic alliance in addressing MUS symptoms? What is the goal, What are the agreed tasks? Whither the bond, when the therapist covertly believes that the client is somatising and the client believes there physical symptoms are as real as toothache?

Carroll, S., Moss-Morris, R., Hulme, K., & Hudson, J. (2021). Therapists’ perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. British journal of health psychology, 26(2), 307–324. https://doi.org/10.1111/bjhp.12475

Berntsen, D., & Rubin, D. C. (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and Therapy, 44, 219–231. https://doi.org/10.1016/j. brat.2005.01.009

Berntsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417–431. https://doi.org/10.1002/acp.1290

Dr Mike Scott

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Number Theatre and Routine Mental Health

the National Institute for Health Research has just published a review of studies of the psychological treatment of Medically Unexplained Symptoms (MUS) https://doi.org/10.3310/hta24460 [Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, et al. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020;24(46)] but in all studies the primary outcome measure was an improvement of symptoms on some psychometric test. No categorical measure was used such as no longer suffering from a ‘disorder’ such as fibromyalgia, irritable bowel syndrome or chronic fatigue syndrome post treatment. Likewise the Improving Access to Psychological Treatment (IAPT) markets its success on a change in score on psychometric tests the PHQ-9 and GAD-7. Further whether or not an IAPT clinician is to be subjected to a formal review of competence is based on a change of score on these measures. No categorical measure is used such as the proportion of cases of depression, panic disorder, generalised anxiety disorder etc that have lost their diagnostic status. Sir David Spiegelhalter the Statistician has coined the term ‘number theatre’ to describe the way in which the UK Government has promulgated statistics in relation to the Pandemic, but this drama been playing for years in the mental health arena.  I am reminded of a line from a song somewhere, ‘I am more than a number in a little red book’, although intended for a very different context, it seems particularly apt for IAPT.

Lies
Damned Lies
and
IAPT
 

Number theatre in the mental health field has it seems been driven by the desire of psychologists to colonise. It is a reaction against the categorical labels employed by psychiatry. But the truth of the matter is both are needed simultaneously. To take a medical example, if I have a heart problem I need to know what the problem is but also my blood pressure today.

IAPT will topple because it pivots on psychometric tests. Inspection of of its’ main pillar, the PHQ-9 exposes a crumbling structure:

  1. Client’s judgement of their functioning does not match changes on the PHQ-9 https://doi.org/10.3310/hta24460. Thus an IAPT therapist might report to his supervisor the ‘improvement’ on his/her clients score on the PHQ-9 and at the same time report that the latter said they are ‘the same old’. The overall judgement of the client is likely to be dismissed in favour of the alleged ‘moving towards recovery’ or ‘recovery’ on the PHQ-9.
  2. In the initial validation study of the PHQ-9  by Kroenke and Spitzer it was not validated against a ‘gold standard’ that it was sufficiently different to to make it an acceptable diagnostic aid according to the AMSTAR
  3. The findings of the progenitors of the PHQ-9 Kroenke and Spitzer were not replicated by independent researchers using a ‘gold standard’ diagnostic interview  such as the SCID.
  4. The diagnostic accuracy of an instrument depends very much on the prevalence of the disorder in which it was first evaluated. In the case of the PHQ-9 psychiatric outpatients in the United States. There is no reliable evidence (as assessed by a standardised diagnostic interview)  on the prevalence of disorders amongst those attending IAPT (which include both self referrers and GP referrals).  Thus the clinical utility of the PHQ-9 in this context is unknown.
  5. The PHQ-9 is purportedly a measure of the severity of depression, but there is poor concordance between it and alternative measures of the severity such as the HAD i.e a person would be in a different category of severity depending on which measure is used.

5. The use of a psychometric test with a summary score assumes that each of the items (9 in the case of the PHQ-9) contribute equally to the total score. But this is implausible an item about suicidal ideation (item  9 on the PHQ-9) is likely to  be more significant than an item about fatigue. 

6. Two patients on the PHQ-9 could have the same score, but arising from one patient endorsing all intermediate scores whilst the second endorses several items at the highest score. The same score but arguably a quite different meaning.

7. The PHQ-9 assumes that is the frequency of a symptom  that is the determinant of severity rather than the intensity. 

8. Unless the mechanism by which a PHQ9 score is changed is known it cannot determined that an evidence based treatment was in fact used. Thus those getting a supposed ‘result’ may be more at fault than those acknowledging none response, the latter may simply be more honest. 

These considerations on the PHQ-9 may not be prohibitive of its use, if employed in the context of a standardised diagnostic interview that has established the person has depression. But such an interview would likely also yield the presence of one or more coexisting disorders. The trajectory of these additional disorders would have to be tracked by other psychometric tests that are pertinent to the disorder. The idea that the  PHQ-9 can stand alone as judge and jury on a client’s mental health is absurd.

However politicians, public health bodies and clinical commissioning groups like to be told that there is a simple solution to a problem and that they can make a difference by implementing the chosen solution. Enter stage right IAPT proclaiming ‘give the PHQ9 reduce it below 10, job done and woe betide any clinician who does not manage this routinely’. As an encore IAPT uses numbers e.g throughput of clients, waiting lists to placate politicians and funders.  Exhaustion, numbing and detachment [burnout] are an inevitable consequence of these working conditions. No amount of self-reflection as advocated by Psychological Wellbeing Practitioner in the current issue of CBT Today, is going to make a real world difference. It is a shame that CBT Today has become IAPT’s comic.

Dr Mike Scott

 

 

 

 

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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

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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

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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

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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

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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

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‘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