‘Two thirds of GPs providing specialist mental health support beyond their competence’ this was the headline in Pulse, May 9th 2022. This has been brought about by NHS pressures. With 38% of consultations having a mental health element compared to 25% pre-Covid. But there is no evidence the patients have fared less well than if they had been referred to the Government’s Improving Access to Psychological Therapies (IAPT) business (or secondary care mental health services). In similar vein there is no evidence that those attending the Citizens Advice Bureau with mental health problems do any less well than those attending IAPT [http://www.cbtwatch.com/no-evidence-that-the-improving-access-to-psychological-therapies-iapt-service-does-any-better-than-contact-with-the-citizens-advice-bureaux-cabx]. It appears that IAPT is no better than an attention placebo.
Ideally IAPT would have been subjected to a randomised controlled trial in which clients were alternately assigned to the services ministrations and to a credible placebo intervention. With outcome gauged by blind assessors, using a standardised reliable diagnostic interview. But no such study has been forthcoming or seems likely to happen anytime soon. Though less than ideal comparisons can be made with the trajectory of attendees of GPs and Citizens Advice Bureaus.
The burden of proof is on IAPT to demonstrate that its’ staff have a competence beyond that of GP’s and Citizens Advice Bureau Workers, that makes a real world difference to client outcome. My own research [Scott (2018) https://doi.org/10.1177%2F1359105318755264] suggests that only the tip of the iceberg of IAPT clients recover .
GPs acknowledge the limits of their competence, IAPT staff do not, at least publicly. Unfortunately nobody holds them to account, they are a law unto themselves. We continue to throw away over a £1 billion a year on IAPT, with the National Audit Office, NHS England and Clinical Commissioning Groups showing a radical apathy about the matter.
A year ago the British Journal of Clinical Psychology published my paper ‘Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin’ 60(1), 38. https://doi.org/10.1111/bjc.12264. This month in the Journal there is a further damning indictment by Martin et al (2022) ‘Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?’ 61, 157–174, DOI:10.1111/bjc.12314.
Here are the main points from Martin et als’ BJCP paper:
Improving Access to Psychological Therapies(IAPT)has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged.
Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas.
There view indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands.
Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.
The British Association of Behavioural and Cognitive Psychotherapies (BABCP) ought to look seriously at the promotion of its’ IAPT comic ‘CBT Today’. Interestingly in its’ recent issue it managed to omit that I was one of those who made a submission re: the proposed NICE Guidance on depression. Further, only one of the others who made submissions were given their adjectival title, the leading light in IAPT. The British Psychological Society (BPS) should reconsider its validation of low intensity IAPT courses, in the absence of any credible evidence base on real-world effectiveness.
No matter that the likely cost of the Improving Access to Psychological Therapies (IAPT) service last year was £1.2 billion! There are significant pay differentials in IAPT, starting with Band 5 Low Intensity Psychological Wellbeing Practitioners (PWPs)earning £25,655 – £31,534 a year, qualified high intensity(HI) therapists will likely earn £38,890 (progressing annually to £44,503) but there is no evidence of a difference in effectiveness of low and high intensity therapists. There is a claim that the HI therapists work with the more complex cases but the evidence for this is suspect, resting on claims of higher PHQ9 scores amongst the latter’s clients. But in the British Association for Behavioural and Cognitive Psychotherapies (BABCP) submission (and in my own submission) to NICE, in relation to the proposed guidance for depression, we argued that it was inappropriate to choose a single score on this measure to differentiate levels of severity. If IAPT members were in a Union the latter would cry foul at the pay differentials. But would the NAO continue its selective deafness?
The most common scenario is for an IAPT clients to receive the minimalist, low intensity treatment for which there is an absence of evidence of real-world effectiveness. 48% of treatments are low intensity treatments based on CBT principles and 20% are high intensity treatments, a small minority are stepped up from low to high intensity [Clark (2018)]. But the evidence base for the low intensity interventions derived from randomised controlled trials is weak compared to that for the high intensity interventions. But the National Institute for Health and Clinical Care Excellence (NICE) rubber stamps both, with IAPT staff on NICE panels for computerised CBT. There is not only a problem with the science behind IAPT’s approach, but also no evidence that what it delivers on the ground represents fidelity to NICE approved treatment protocols.
In summary there is no evidence that IAPT delivers what it says on the tin, evidence based treatment for depression and the anxiety disorders. IAPT has failed to monitor treatment integrity, why then should such infidelity be so richly rewarded?
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
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.
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.
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.
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:
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.
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
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.
Layard, R and Clark, D.M ( 2014) Thrive: The Power of Evidenced-Based Psychological Therapies Penguin Limited
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/.
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].
‘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:
Why was a minimalist intervention repeated when the first such intervention had not worked?
Why are the least well-trained clinicians given the power to direct treatment?
Why are the least well-trained clinicians given the power to re-direct treatment?
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?
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.
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.
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.