Fundamentalism and The Improving Access To Psychological Therapies (IAPT) Service

The IAPT Service is a fundamentalist translation of evidence-based psychological therapy. ‘The power of evidence-based psychological treatment’ is the sub-title of the book ‘Thrive’ by Layard and Clark (2014,) the prime movers in the development of IAPT. Whilst acknowledging the potency of evidence-based psychological treatment, it is disingenuous of IAPT fellow-travellers to muddy the distinction between the latter and the IAPT service. IAPT is like a guest at a ball, masquerading as evidence-based psychological treatment. But the hosts: politicians, NHS England and Clinical Commissioning Groups consider it impolite to make detailed enquiry of the guest, they enjoy the company. Further the National Audit Office cares not that, the ‘ball’ costs £1 bilion this year. 

The important differences between the IAPT service and the psychological therapies delivered in randomised controlled trials are apparent in the extract from Table 1 Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803 summarised below:

A comparison of low intensity CBT and brief traditional CBT

 

 

‘Low Intensity’CBT

Brief Traditional ‘High Intensity’ CBT

Who – is it suitable for?

 

Widely used to address anxiety and depression across the age range and behavioural problems in children (e.g., Bennett et al., 2019; Cuijpers et al., 2010). Evidence supports its use for cases of all severity (Bower et al., 2013; Karyotaki et al., 2018). Typically not advocated where there are significant risk issues.

 

Typically used widely for disorders where longer traditional CBT would be appropriate

What – is delivered?

 

Interventions are based on the principles of generic CBT to enable individuals to learn specific techniques (for example graded exposure, cognitive restructuring, problem solving) with the goal of alleviating emotional distress and improving functioning. Between-session reading and excercises are central.

 

Intervention is an abbreviated version of full CBT, supplemented with provision of between session materials and excercises.

 

How long is the therapy?

Any input is typically 6 hours or less of contact, often delivered in 20-30 minute sessions

Therapy contact time is typically 50% or less than the full CBT intervention, usually delivered in 50-60 minute sessions

 

It is implicitly assumed by the advocates of IAPT that the identified differences in Table 1 do not matter. But they provide no evidence for this. The IAPT powerholders declare how therapy is to be delivered, in the absence of independent evidence of effectiveness. It represents the operation and implementation of a fundamentalist translation of the randomised controlled trials of primarily CBT for depression and the anxiety disorders. In keeping with a fundamentalist zeitgeist there is no open debate within IAPT or BABCP of the evidence for the effectiveness of the ‘alleged CBT’ in routine practice.

IAPT claims that it obtains results comparable to those achieved in rct’s but is this credible when in high intensity therapy ‘Therapy contact time is typically 50% or less than the full CBT intervention’ according to Table1? Is it credible that the organisers of the rct’s made the treatments they examined more than twice the length that was necessary? If this was indeed the case, the luminaries responsible for the trials would have been sanctioned by their funding bodies and their ability to attract further research funds, severely curtailed. The more plausible hypothesis is that IAPT does not in fact deliver evidence-based psychological treatment This despite its’ claim to do so to appease NICE, whose seal of approval is the gateway to funding..IAPT muddies the distinction between the power of evidence-based psychological treatment and the power of its’ service. 

Table 1 specifies that ‘low intensity CBT’ consists of ‘generic CBT’ but there has never been an rct of ‘generic CBT’, the rcts are of diagnosis specific protociols. Low intensity CBT cannot be regarded as an evidence-based treatment. Nevertheless, Shafran et al (2021) claim that low intensity CBT is evidence-based but inspection of the cited references reveal a different picture.

  1. The study by Karyotaki et al (2018) https://doi.org/10.1016/j.cpr.2018.06.007 is an analysis guided internet-based interventions for depression compared to control groups, with respective remission rates of 38.51% and 21.5%. But patients in the predominantly waiting list control groups do not expect to get better, so that any differences may reflect a placebo effect. There were no active control groups with a credible rationale. The studies did not involve blind assessors and there was no determination of diagnostic status at the start or end of treatment. Patients chose to enter the study online and there could be no certainty that they were representative of depressed patients in general. The mean Beck Depression inventory score at entry to the internet studies 19.4, was almost a standard deviation down on mean scores of about 27 in established rcts [Scott and Stradling (1991)]. It is doubtful that the studies reviewed by Karyotaki et al (2018) provide any evidence that this low intensity CBT makes a real-world difference to clients lives.
  2. The study by Bower et al (2013) https://doi.org/10.1136/bmj.f540 focused on whether the initial severity of depression influenced the effectiveness of low intensity interventions. As such it is not germane to the question of whether low intensity CBT is an evidence based treatment, however it cites the Cuijpers et al 2010 study doi:10.1017/S0033291710000772 as demonstrating the effectiveness of the latter. This study is also cited by Shafran et al (2021) in Table 1. In the Cuijpers et al (2010) study guided self help was compared with face to face therapy, but both treatments were determined largely by the results of a diagnostic interview (15 out of 21 studies), so that the intervention matched the diagnosis. No such diagnostic interview is conducted in either low or hight intensity IAPT.  The IAPT service has once again performed its’ own translation of the results of randomised controlled trials. Further in the Cuijpers et al (2010) review  the majority of the studies, 17 out of 21 involved media recruited clients, making the study of doubtful relevance to routine practice. In none of the studies was outcome assessed by a diagnostic interview involving a blind assessor. 

The clinical case for low intensity CBT has not been made, it is simply a short term economic convenience.Evidence that being stepped up to high intensity therapy makes a real-world difference is lacking.

 

Dr  Mike Scott

It’s A Myth That The Improving Access to Psychological Therapies (IAPT) Service Pays for Itself

IAPT has flourished over the last decade by proclaiming that it pays for itself [see Layard and Clark’s book Thrive  (2014)]. It has been music to the ears of politicians, NHS England and Clinical Commissioning Groups  but none, including the National Audit Office, has bothered to question it. Despite the £1bn price tag this year, see footnote 1. Anyone with the temerity to raise doubts, risks being accused of lacking a commitment to mental health, a pre-requisite of being considered progressive, whatever one’s political hue. 

 

When will the funding and professional bodies such as the British Psychological Society (BPS) and British Association for Behavioural and Cognitive Psychotherapy (BABCP) see that the ‘Emperor Has No Clothes’? IAPT claims the service pays for itself by getting people off unemployment benefit (16.8% of IAPT clients) Davis et al (2020) http://dx.doi.org/10.1136  and/or long term sick or disabled benefit (6.9% of IAPT clients).   It is therefore a change in the employment status of minority of IAPT clients that may justify the belief that the service pays for itself. But further elaboration of this population shows that the proportion of clients who could make an economic difference is smaller still. Further when the psychological mechanism by which a change of occupational status may operate is considered, it is improbable that the service pays for itself.  

 IAPT could in principle get 20-25% of clients off benefits. Assuming the target clientele this year is 20%, i.e 0.3 million people, how would the service pay for itself?  Well 40% of IAPT clients do not attend their 1st treatment appointment, so only 0.18 million will be exposed to an IAPT treatment therapist. Of these 42% attend just one treatment appointment, thus 0.1044 million have exposure  to IAPTs treatments and are in the categories of unemployed or long term sick, and potentially might have their employment status changed by the Service i.e 104,440. Those undergoing IAPT treatment ( defined by the Service as attending 2 or more treatment sessions) have an average of 8 treatment sessions in 2018-2019 Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 but the unemployed and those on long term sickness benefit are less likely to attend a treatment session, Davis et al (2020)http://dx.doi.org/10.1136, as are those who have been referred previously. Thus one might expect this 104,440 to attend a mean of 6 sessions and treatment typically spans 12 weeks according to Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 . But the population who may return to employment is smaller still because of the following considerations:

  1. There will be a sub-population of the ‘unemployed’ whose unemployment is  related to a work related negative life event, e.g now being physically unable to do the manual work they were employed to do or maltreatment at work. It is difficult to see how 6 sessions of psychological therapy  delivered over 12 weeks would change the diagnostic status of this sub population. There is absence of evidence that such a dosage of psychological therapy can change the employment status of this sub-population. If the sub-population of clients for whom work has been an iatrogenic factor in their debility, are excluded from the analysis, then the population that IAPT’s ministrations could conceivably address is much less than 100,000.
  2.  There will be a further ‘sub-population’ of the unemployed for whom work within their training is simply not available e.g a redundant fisherman. IAPT does not have the resources to conjure up new opportunities, albeit it might direct a client towards re-training.  

Thus the range of action of IAPT with regards to employment status is very limited and even more so when one considers by what mechanism could the typical 6 sessions change employment status over the 12 week span? To return a person to occupational functioning means addressing three key areas a) persistence – the ability to persist with a task b) pace – the ability to complete a task in a timely manner and c) adaptation – the ability to handle the inevitable hassles of the workplace. There is no evidence that IAPT specifically targets these difficulties or has provided training in tackling them. Neither has it been demonstrated that 6 sessions of psychological therapy can resolve such difficulties in 12 weeks and even less evidence as to whether such treatment is enduring.

IAPT lacks the potency to make a real world difference to the unemployed and those on long term sick. Layard and Clark (2014) muddy the distinction between the power of evidence-based psychological therapies and the power of their offspring, IAPT. It can be objected that IAPT pays for itself by increasing the productivity of those already employed, rather than by changing occupational status. But there is no evidence that it does so anymore than the pre-IAPT counselling services.

IAPT’s claim that it changes the employment status of its’ clients is akin to a Dickensian Government’s claim that Workhouses resolve employment issues.

Footnote and reference

 

  1. According to The IAPT Manual 2021 the target for 2021 is 1.5 million clients at a cost of £680 per client [data from Clark (2018) https://doi.org/10.1146/annurev-clinpsy-050817-084833] making the anticipated cost of the service this year, £1.02 billion.
  2. Layard, R and Clark, D.M ( 2014) Thrive: The Power of Evidenced-Based Psychological Therapies Penguin Limited

Dr Mike Scott

 

Improving Access to Psychological Therapists (IAPT) or Care Assistants?

The staffing costs of the Improving Access to Psychological Therapies (IAPT) Programme is set to rise to £0.5 billion per year, but the National Audit Office (NAO) has failed to determine whether it is value for money. The average Clinical Commissioning Group (CCG) will need to increase IAPT staffing by 60-75% to meet the 2024 NHS Access Target ,according to the updated IAPT Manual (August 2021). Currently the service employs 8000 staff, another 3,800-6,000 are ‘needed’, taking the total to between 11,800 and 14,000 in the next 3 years.  Assuming a staffing cost of £35K per employee per year and the employment of 13,000 IAPT therapists, annual staff costs will be £455 million a year i.e approximately £0.5 billion per year.  But the true cost will be even greater when overheads  such as rent, phone lines are included. Extrapolating backwards, over £5billion will have been spent on IAPT staff since its inception without independent audit and no intention of NAO audit.

But the pandemic has highlighted the shortage and poor pay of Care Assistants. Drew et al (2021) sampled IAPT therapist-client interactions https://doi.org/10.1016/j.socscimed.2021.113818 and noted a steadfast refusal to let clients tell the story behind their distress. A member of the public listening to these exchanges might contrast them with those of a Care Assistant making visits to a terminally ill patient so they can die at home with their family. The public would I think see the Care Assistant’s work as being more valuable and puzzled that the IAPT worker is paid twice as much.

There is a move to have health and social care under one umbrella, perhaps the NAO might explain why there should not be better pay for the Care Assistants and an increase in numbers at the expense of expansion of IAPT services. I came across this advert for Care Assistants in my area:

a much better investment than Talk Liverpool with a 10% recovery rate, Scott (2018) ‘IAPT- The Need for Radical Reform’ https://connection.sagepub.com/blog/psychology/2018/02/07/.

Dr Mike Scott

No Reduction In the Prevalence of Mental Disorders Since IAPT

this is the conclusion of Australian researchers https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30040-9/fulltext. Why then have successive Uk Governments spent £billions on the Improving Access to Psychological Therapies (IAPT) since its’ inception 13 years ago? Given that there is no evidence that IAPT represents an added value over pre-existing IAPT services, its’ continued funding suggests vested interests hold sway. The National Audit Office (NAO) had concerns and began an investigation but stopped citing Brexit, Carillion etc. Further following a Freedom of Information request from myself I was informed that they have no intention to restart the investigation.

Curiously the Australian researchers accept at face value IAPT’s claim of a 50% recovery rate, but there has never been any publicly funded independent confirmation of this. IAPT has been left to mark its’ own homework. My own study as an independent Expert Witness to the Court, and using a standardised diagnostic interview suggested that the recovery rate is 10% [Journal of Health Psychology   https://doi.org/10.1177%2F1359105318755264].

Dr Mike Scott

IAPT’s Hidden Agenda

we can only deal with one problem, because that fits into the 6 sessions of therapy that we start with’, but the Improving Access to Psychological Treatments (IAPT) service makes no  public declaration of this.  Clients want a holistic approach in which all their problems are catered for. It is magical thinking to believe that a) a mental health problem can be resolved in 6 sessions b) the benefits gained from addressing the chosen mental health problem will, by a process of osmosis, resolve the other mental health problems. This represents delusional Organisational thinking, unfortunately I think it would take a lot more than 6 sessions to treat!

Recently I saw Ms X and she related to me her two sojourns through IAPT. I also had access to the IAPT correspondence, for confidentiality reasons, some of the details have been changed:

Five years a ago, Ms X found out that she had been adopted, she felt that she had never fitted in with her adoptive family, though they were kind. She felt that she had always been a ‘worrier’, her adoptive mum had chronic health problems and shortly after learning of her adoption she became concerned over any blemish on her skin. Ms X saw her GP and she advised self-referral to IAPT. She had a telephone assessment with a Psychological Wellbeing Practitioner and was advised that her PHQ-9 score was normal and her GAD-7 score at ‘caseness’. But no diagnosis was given. A letter from IAPT indicated that she ‘agreed to attend a worry management course’ but she said only a group programme was on offer. Ms X dropped out after attending one group session. Her GP had recorded that the treatment had not helped. I assessed her using a standardised diagnostic interview and it was clear that she had been suffering from illness anxiety disorder and general anxiety disorder (GAD) at the time of seeking help form IAPT and her diagnostic status was unchanged by IAPT’s ministrations.

Two years later she was at work, when her hair got caught in machinery at work causing a scalp injury. However the injury was under the hairline and not visible, but she could feel an indentation on her scalp. She developed a phobia about being around machinery leading to poor attendance at work and possible disciplinary action. The accident re-ignited her illness anxiety disorder that had been in remission for about 6 months. I noted that she continued to meet diagnostic criteria for GAD. Her GP advised self-referral to IAPT and she had a telephone assessment with a Trainee Psychological Wellbeing Practitioner, both PHQ-9 and GAD-7 scores were at ‘caseness’.  No diagnosis was given. Ms X was told that they could only treat one of her problems and she chose her health anxiety concerns. She was placed on a 6 week waiting list for the Silver Cloud computerised CBT. During, the course of her cCBT she had 4 interactions with IAPT staff responsible for the smooth functioning of the Silver Cloud programme. They said that she was ‘depressed and anxious’ but gave no diagnosis. During treatment her specific phobia was not addressed at all. The diagnostic interview that I conducted revealed comorbid illness anxiety disorder and GAD but she was not depressed. She understood that there was to be a review of her progress at the end of cCBT to see what if any further help might be appropriate. This never happened. The Silver Cloud programme had no impact on her diagnostic status. IAPT’s treatment was ‘in the Clouds’.

This case raises important questions:

  1. Why was a minimalist intervention repeated when the first such intervention had not worked?
  2. Why are the least well-trained clinicians given the power to direct treatment?
  3. Why are the least well-trained clinicians given the power to re-direct treatment?
  4. Why is IAPT allowed to behave in a way that would not be tolerated in physical care vis a vis a focus on just one problem and continued management by the most junior clinician when treatment fails?
  5. Where is the publicly funded independent audit of IAPT?

Unfortunately, this is not an isolated case, my own review of 90 cases suggests just a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264) . There has been a dereliction of duty by NHS England, Clinical Commissioning Groups and the National Audit Office. The British Psychological Society has rubber stamped whatever IAPT has proposed. The British Association for Behavioural and Cognitive Psychotherapy have become an IAPT mouthpiece, its’ journal CBT Today intolerant of dissent.

 

Dr Mike Scott

 

 

Who Is Monitoring The Quality of Primary Care Mental Health Services?

Nobody, Clinical Commissioning Groups (CCGs) confine themselves to operational matters, number of patients seen, waiting lists.  The Improving Access to Psychological Therapies (IAPT) service has been allowed to self-monitor since its’ inception in 2008.  The National Audit Office abandoned its’ investigation of IAPT because of competing priorities citing the Carillion debacle amongst others in June 2018. Who is listening to the voice of the recipients of the mental health services?  

The mantra appears to be to get everyone to talk about mental health, especially celebrities, get everyone involved in mental health, teachers etc, secure more funding for anything with a mental health flavour on the basis that ‘it must be good’. But frenetic activity does not equal making a real world difference, achieving this has to be carefully monitored.

It goes without saying that we all need a more caring society nationally, for example assisting those who have been self-isolating for over a year to gradually venture out.  From an international perspective we should be giving a £1bn a year to fund the provision of vaccines in poorer countries. The need for compassion is never redundant.  But political correctness about mental health can obscure fully engaging with those in most need. 

Dr Mike Scott

On What Basis Are Talking Therapies Out Of Bounds To The Care Quality Commission?

The Care Quality Commission (CQC) has just called the Government to task for blanket Do Not Resuscitates (DNRs) applied at the start of the pandemic. But the CQC is not allowed to investigate the quality of the Improving Access to Psychological Therapies (IAPT) services for those with mental health difficulties. Could there be a more glaring example of the disparity between physical and mental health services?

 

The IAPT service has had a decade of going under the radar of independent public scrutiny, despite Government expenditure of over £4billion. Strangely the National Audit Office (NAO) has no intention of mounting an audit (see recent post), citing preoccupation with Covid and its’ earlier preoccupations with the collapse of Carrillion and the provision of generic medicines. IAPT is responsible to NHS England but staff at the Department of Health also have key positions in IAPT. NHS England are likely to claim that they are ‘too busy’ to address trivial matters like conflicts of interest, reacting like the NAO. The Government will likewise claim preoccupation to avoid addressing sensitive matters.

The CQC can investigate whether the needs of those in Care Homes are being served and can champion the plight of residents, who is to champion the needs of those with mental health difficulties. Organisations such as Mind often have funding arrangements with IAPT. The  British Association for Behavioural and Cognitive Therapies (BABCP) and the British Psychological Society (BPS) regularly give pride of place to IAPT luminaries with rare opportunities for opposing views to be expressed.  The result is a groupthink within these organisations. 

Dr Mike Scott

 

National Audit Office Offers No Evidence That The £0.5 Billion, Per Year, Spent on Talking Therapies Is Value For Money

The £4 billion plus spent on the Improving Access to Psychological Therapies (IAPT) programme over the last decade could have been better spent improving the lot of Nurses. On March 6th 2021, I received a reply from the National Audit Office (NAO), ironically from the Director of the Health value for money Team, saying that it had no intention of mounting an investigation into UK Government’s, Improving Access to Psychological Therapies (IAPT) programme. The Director adds ‘but you raise important issues – around data quality, levels of performance, outcome measurement, and what has been achieved for the spend – that would be important to cover in any report we consider on mental health services’.  

The Director informed me they have been preoccupied with the effects of Covid!  In 2017 the NAO  initiated an investigation into IAPT  but a year later it was discontinued because of ‘Brexit, the collapse of Carillion and concerns about spending on generic medicines’. The NAO never published their findings.  It seems that the NAO will always have an excuse to kick a focus on IAPT into the long grass. But in 2016 it had asked the Department of Health  to investigate why  IAPT was exempt from Care Quality Commission scrutiny.  The DOH made no response – friends in high places?

There appears to be an implicit assumption that just throwing money at mental health must be good. The NAO has signally failed to manage the public purse. At a time when this purse is near empty, and there are clearly pressing needs amongst Care and Nursing staff, this is appalling. 

Dr Mike Scott

 

Unnecessary Treatment Is The Rule In IAPT – Due Diligence?

 

The UK Government, Improving Access to Psychological Therapies (IAP) only uses psychometric test screening measures  to assess clients, most commonly the  PHQ9 ( a measure of the severity of depression) and GAD7 (a measure of the severity of generalised anxiety disorder), but other measures are advised for other disorders, such as the PCL-5 for PTSD. A study by Zimmerman and Matia (2001) [The Psychiatric Diagnostic Screening Questionnaire: development, reliability and validity. Comprehensive psychiatry, 42(3), 175–189. https://doi.org/10.1053/comp.2001.23126 ] showed that questionnaire measures that reflect DSM criteria have a roughly 90% sensitivity across major depressive disorder, PTSD, panic disorder, social phobia and GAD, i.e it correctly identifies 9 out of 10 of those who do have one of these disorders. But it identifies only about 60% (specificity) of those who do not have the disorder and for GAD only 50%.  However many more people do not have a particular disorder than have one, leading to unnecessary treatment for many. The National Audit Office should take note of this and re-instate its’ investigation, where is the due diligence with regards to IAPT? £4billion has been given to IAPT!

Depression

In the Zimmerman  and Mattia (2001) study 47.9% of the psychiatric outpatients had major depression. Assuming psychiatric outpatients are a reasonable approximation to the IAPT population, then in a sample of 100 patients approx. 50 would have depression and 50 would not. Of the 50 with depression, 45 would have been correctly identified and treated. However of the 50 who did not have depression only, 30 would have been correctly identified leaving 20 as false positives, candidates for inapropriate treatment. Thus roughly for every two depressed cases appropriately treated one would be inappropriately treated. For depression the appropriate/inappropriate ratio is 2/1 – pretty wasteful.

Generalised Anxiety Disorder

In the Zimmerman Mattia Study 17.5% pf the psychiatric outpatients  had GAD. Thus in a sample of 100 patients approx. 18 would have GAD, of whom 16 would have been correctly identified and treated. But 82 would not have GAD but 50% of them would have been regarded as having GAD meaning that 41 would have been inappropiately treated. Thus for GAD the appropriate/inappropriate ratio is 16/41, so that for every one GAD client treated appropriately 2-3 others are treated inappropriately.

Post-traumatic Stress Disorder

In the Zimmerman and Mattia study 10.5% of the psychiatric outpatients had PTSD. Thus in a sample of 100 clients approx. 11 would have PTSD with 9 being correctly classified and treated. However 89 would not have PTSD of these 62% (55) were correctly classified, meaning that 34 were false positives. Thus the ratio of appropriately treated/ inappropriately treated is approximately 1/4 , for every one treated appropriately 4 are treated inappropriately.

IAPT’s Preposterous Claim On Recovery

Given the ubiquity of unnecessary treatment in IAPT, its’ claim of a 50% recovery rate [IAPT Manual (2019)] is preposterous.  I found a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264, which is much more likely if a body relies simply on a screening instrument.

The Need To Translate Research Methodology Into Routine Practice

Ehlers et al. Trials (2020) 21:355 https://doi.org/10.1186/s13063-020-4176-8 have used the PDSQ to screen for cases of PTSD in their study of therapist assisted treatment for the condition, but have followed the screen up by using a standardised semi-structured interview the SCID to then diagnose PTSD. In this study they have kept a screen in its place and not allowed it free rein as in IAPT.  The IAPT Manual p25 states ‘To ensure that all relevant problems are identified, it is recommended that assessments include systematic screening for each of the conditions that IAPT treats. Standardised commercial screening questionnaire that cover the full range of problems and that can be completed by people before they attend an assessment can be considered ‘ and cites the  PDSQ as an example. But sole use of any screening instrument is very wasteful.

Ehlers et al (2020) have sought to establish whether no more than 4 hours therapist time can make a real world difference to PTSD sufferers lives, a consummation devoutly to be wished, these authors could be well employed helping IAPT get its’ own house in order.

 

Dr Mike Scott

Following NICE Guidance On Covid Treatment Threatens To Overwhelm Mental Health Services

Yesterday NICE issued guidance on the management of Covid post 12 weeks (long term) https://www.nice.org.uk/guidance/ng188 and recommends that those with mild anxiety or mild depression are referred to mental health services, with severe cases of anxiety/depression referred to psychiatrists. IAPT (Improving Access to Psychological Therapies) has already been conducting webinars for its’ Step 3 staff, within which concerns were expressed about possibly overwhelming services and the pathologising of normality. Despite this further webinars are planned for the low intensity (Step 2) staff. Buoyed by its’ success in attracting monies for psychological therapies for long-term conditions (LTCs), such as chronic pain, irritable bowel syndrome, IAPT sees an opportunity to extend its’ reach to those affected by Covid. Those with long term Covid are likely to suffer the same fate of those with Chronic Fatigue Syndrome of not being really listened to. 

Given that according to NICE the most common features of long term Covid are fatigue, ‘brain fog’ and breathlessness, and that ‘symptoms of anxiety and depression’  are presented as possible symptoms of Covid at any stage, how is it possible to make an additional diagnosis of anxiety and depression? With the exception of the few, Covid patients who may be suicidal the distinction between the physical and psychological symptoms is fraught with difficulties. One response is to ignore the distinction, ignore the science and claim that all with Covid need a psychological therapist, but there is no scientific evidence for this – albeit that it suits the purposes of service providers to make such a claim. If you were not feeling ‘mildly anxious or depressed’ when you contract Covid that is probably very worrying!

An editorial in the British Medical Journal http://dx.doi.org/10.1136/bmj.m4425 bemoans the medico-political contexts that has hampered scientists expressing their concerns over the evidence base for handling Covid. But such a medico-political context has operated for years with regard to IAPT. There has been no independent evidence that IAPT’s work with sufferer’s from LTC’s has led to the resolution of accompanying psychological disorders. There has been no comparison with an active placebo or with the fate of LTC sufferers before the advent of IAPT.  The National Audit Office was allowed to suspend its’ investigation of IAPT in 2017, with no check on the appropriateness of having spent £4 billion of the public purse on the Service. Matters have been compounded by the BABCP’s (the lead organisation for cbt) unwavering support for IAPT and the British Psychological Society’s endorsement of IAPT training. Despite any evidence that the competence of therapists trained relates to client outcome Liness et al (2019) https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0.

2021 can only get better, one needs hope, I think that this is the message of Christmas.

Dr Mike Scott