Would you invest in a company simply on the basis of its proclaimed profits? But that is exactly what successive governments have done every year, for the past fifteen years. At a cost of £752 million in the year 2021 for adult Mental Health Services, £922 million on child and adolescent mental health (excluding funding for eating disorders £73 million). Making a grand total of £1.75 billion [Figures from the National Audit Office (NAO ) Report of February 2023] for 2021-2022. The NAO re-iterates, uncritically, IAPT’s claim of a 50% recovery rate for the Adult mental health service, neglecting to say that there has been no independent verification of this. Further there is not even a claim to the effectiveness of Child and Adolescent Mental Health services!
The NAO is unphazed by the haemorrhaging of clients from the NHS Talking therapies for Adults. It notes, without comment, that 46% of its clientele drop out before treatment, were treatment is defined as attending 2 or more treatment sessions. So that the much vaunted 50% recovery rate, applies only to those who complete treatment!
My own work Scott (2018) on 90 clients going through NHS Talking Therapies predecessor IAPT, was that only the tip of the iceberg recovered.
After 15 years of the Service and £10 billion spent on it, we still do not know! If ever there was a matter for Health Ministers, the Office of Budget Responsibility and the Nation al Audit Office, this is it. To date NHS Talking Therapies have only ever taken their own snapshots of clients, discharging them as soon as their scores fall below ‘casenness’ on a psychometric test. But the natural course of anxiety and depression is a waxing and waning. A photo at any one point is next to meaningless, particularly if it is taken by a party with a vested interest in declaring recovery.
In a 2 year naturalistic study, of depressed, anxious and depressed plus anxious patients in the Netherlands, Penninx et al (2011) the criteria of recovery was at least 3 months free of symptoms as assessed by a diagnostic interview. This metric ensured that they were looking at how long it took to what could be taken as a real-world change. [A far cry NHS Talking Therapies studies]. With half of depressed patients recovering within 6 months. Half the anxious group recovered by 16 months and half the combined group by 24 months. Of those who remitted a quarter relapsed. Approximately half the population had psychological treatment and they fared no better than those who didn’t. There is no evidence that NHS Talking Therapies clients fare any better than those in the Netherlands or than those attending the Citizens Advice Bureaux.
In my capacity as an Expert Witness to the Court I reviewed 90 cases Scott (2018), some of whom had NHS Talking Therapies treatment before a personal injury and others who were treated afterwards, whichever was the case only the tip of the iceberg recovered. I called for a a publicly funded independent assessment of the Service, 5 years on, nothing, just a rebranding of IAPT earlier this year.
The latest published studies of NHS Talking Therapies clients, Thew et al (2023) and Watkins et al (2023) offer no evidence that the interventions delivered are superior to a credible attention placebo condition. It beggars belief that: a) the National Audit Office has not investigated whether spending over £1bn on the Service is justified and b) it has evaded the scrutiny of the Care Quality Commission.
The authors of the Thew et al (2023) study suggest that the 6-week internet delivered CBT package for PTSD, is beneficial and may be deliverable by Psychological Wellbeing Practitioners. But there was no control condition. No diagnostic interview was conducted, there were no blind independent assessors and just 5 clients.
The primary outcome measure in the Thew et al (2023) study was the PCL-5 but Bovin and Marx (2023) have pointed that reliance on this test leads to both a missing of those with a disorder and the unnecessary treatment of those without a disorder. Their findings were that cut-offs varied with the particular population addressed and the prevalence of the disorder in the particular community. Without attention to these details, clients will be misdirected. Bovin and Marx (2023) suggest that the PCL-5 should only be used as an adjunct to a diagnostic interview (but NHS Talking Therapies clients do not make diagnoses) and should involve a discussion with the client as to the meaning of each item. Given that NHS Talking Therapy clinicians have to achieve a 50% recovery rate their ‘discussions’ on the PCL-5 are likely to be particularly biased.
The Watkins et al (2023) study focuses on internet CBT for depression. They repeat the NHS Talking Therapies mantra of a 50% recovery rate for their intervention, but made no comparison with a credible attention control condition. But they claim to have used the depression module of the SCID for diagnosis but present no results on this pre or post treatment. Whether or not, the SCID was not intended for use with a pre-determined module.
NHS Talking Therapy studies are de facto spin for the organisation. Researchers delight in the ease with which they can access subjects from it. Well-meaning people want to believe their efforts have not been in vain and this trumps seriously listening to those affected.
What the CQC would discover
If the CQC bothered to investigate they would discover a revolving door.
Recently I saw a lady who had had an accident at work. She was distressed at being physically unable to return to the job. This lady had 12 sessions with IAPT (NHS Talking Therapies predecessor) she found the therapist very understanding. But she couldn’t identify what she had learnt and said she was given no diagnosis. At the end of the sessions she was told she could re-refer if she needed to, which she did. The new male therapist seemed uninterested, and after 10 mins or so was making an appointment for a further session. She dropped out but returned to IAPT with a new male therapists, sessions were similarly very brief and she found him ‘ignorant’ in that in the video link he would disappear from the screen, and she could hear him busy in the kitchen. Again she dropped out. She had unidentified and untreated mild PTSD and depression from the accident.
If that hasn’t been a waste of the taxpayer’s money I don’t know what is.
So why is the UK Government spending a £1 billion a year on NHS Talking therapies? NHS Talking Therapies raison d’etre is that it has a 50% recovery rate [IAPT Manual (2019)], based principally, on a change of score on the PHQ-9 from above caseness, (a score of 10 or more) to below 10, from 1st to last assessment. But in a study of a sample of GP patients (n=100) [ Gilbody et al (2015)] given usual care, 56% recovered within 4 months and 60 and 61% recovering by 12 and 24 months respectively, using the PHQ-9 as the outcome metric. [Albeit that 13% accessed IAPT (the predecessor of NHS Talking Therapies]. Similarly, Moore et al (2012) found 47% recovering within 3 months. Whence the added value of NHS Talking Therapies?
The null hypothesis is that NHS Talking Therapies are no better than treatment as usual. Funding of the Service cannot be justified without studies demonstrating the superiority of these interventions to a credible attention control condition. But no such studies have been forthcoming. NHS Talking Therapies Outcome studies have ignored the placebo response. Most recently, Strauss et al (2023) in a comparison of 2 forms of low intensity guided self-help, claiming the superiority of mindfulness guided self-help over CBT guided self-help, despite reductions in mean PHQ-9 scores from 14-15 to 6-7 in 16 weeks in both arms of the study. No mention that similar results would likely be obtained with an attention placebo, nor comment that 25% dropped out of each form of self-help. Instead, Strauss et al (2023) call for an expansion of guided self-help beyond the 100,000 current recipients a year, preferably mindful because it was cheaper!
The Size of The Placebo Response
In a review by Motta et al (2023) the average response and remission rates in placebo groups (across all anxiety disorders including PTSD and OCD) were 37% and 24% respectively. [Motta LS, Gosmann NP, Costa MdA, et al. BMJ Ment Health 2023;26:1–8]. Those diagnosed with GAD and PTSD had larger placebo response estimates than those with PD, SAD and OCD. These figures were calculated by a within group Standardised Mean Difference, the average within subject placebo effect size was -1.1. By comparison the mean average placebo effect size in depression is 0.37. [Furukawa TA, Cipriani A, Atkinson LZ, et al.2016:3:1059-66} Placebo response rates in antidepressant trials: a systematic review of published and unpublished double-blind randomised controlled studies Lancet Psychiatry 2016;3:1059–66].
Recovery in NHS Talking Therapies
The service claims a 50% recovery rate but I found that only the tip of the iceberg recover, Scott (2018). My finding is consistent with the reported recovery rates in the above placebo studies, given that the NHS Talking Therapies population is most likely a mix of people suffering predominantly anxiety or depression.
The burden of proof is on NHS Talking Therapies to demonstrate that it produces a clinically relevant effects beyond placebo. But I do not think it will attempt this anytime soon, it would be like turkeys voting for Christmas.
NHS Talking Therapies is the only NHS service that it is not independently assessed. Costing £2 billion a year for adult and child services, it has escaped the scrutiny of both the National Audit Office and the Care Quality Commission. It is also, it seems, the only NHS service were staff are not in a public pay dispute. What is going on?
It deftly keeps below the radar, so that ‘value for money’ questions are not asked. The other string to its’ bow is ‘gas-lighting’, the repeated repetition of a claim, absorbed by its familiarity. Its’ much vaunted ‘50% recovery rate’, has warmed the cockles of the hearts of politicians, Integrated Care Boards and the media, who have all readily and willingly accepted the lie [see Scott (2018)] in the name of political correctness – to be seen to be on the side of mental health. In Mental Awareness Week the powerholders need educating that functioning does not equal working. The Annual reports of IAPT (NHS Talking Therapies previous embodiment) portrays its functioning: numbers seen, waiting times and self-determined targets met. But with no evidence that it is working – no independent assessment of the proportion of clients who are back to their old self and remain so post treatment. There is no credible listening to the client by a Red Cross-like body.
The Citizens Advice Bureaux are a nationally recognised and valued body. Many of their clientele have mental health problems, but there is no evidence that they are any the less served than if they had attended NHS Talking Therapies. The added value of this NHS service has not been demonstrated. Perhaps NHS Talking Therapies staff dare not consider strike action because they are afraid nobody would miss them. GPs may miss the brief respite that may come with off-loading to NHS Talking Therapies, some perhaps even believing or at least wanting to believe NHS Talking Therapies fairy tale. They may be complicit in marketing the tale to patients.
Unsurprisingly the surveyed integrated care board (ICB) mental health leads and mental health trusts tell the NAO what a great job they are doing. The NAO also interviewed mental health stakeholder organisations such as the BPS and BMA. On this basis, the NAO [“Progress in improving mental health services in England”] declared last month, that ‘the government has achieved value for money’. The yardstick used by the NAO was whether the surveyed bodies ‘met ambitions to increase access, capacity, workforce and funding for mental health services’. No attempt to access the voice of the people.
Interestingly the NAO did not even attempt to make the claim of the prime movers in IAPT Layard and Clark (2015) that the Service costs nothing, due to savings on welfare benefits and physical healthcare costs! The response of the great and the good in mental health (the NHS Confederation, SANE and Mind) has been, that the report highlights the need for increased funding, to recruit and retain more staff. No awareness that more of the same is unlikely to make any difference to patients.
The report reveals that £752 million was spent on NHS Talking Therapies predecessor, IAPT, in 2021-22. But when the NHS acquired IAPT earlier this year no audit of the latter was conducted. No business would behave in this way. Yet the NAO report re-iterates the target of ‘at least 50% achieve recovery across the adult age group’. No mention that there is no independent evidence that this has ever been achieved. With the best evidence Scott (2018) suggesting that only the tip of the iceberg recover. What sort of auditors are the NAO? Under their watch acquisitions can be made without credible scrutiny.
In 2018 the NAO jettisoned an enquiry into the Improving Access to Psychological Therapies (IAPT) Programme. In response to a Freedom of Information request, the NAO responded on February 17th 2020 ‘We commenced work on the IAPT programme in 2017-18. However, the work on this programme was curtailed in June 2018 by the Comptroller and Auditor General (C&AG) of the time in response to changing priorities. The alterations to the work programme were made so that the C&AG could respond quickly on important topical issues, such as work on the UK’s exit from the European Union, the government’s handling of the collapse of Carillion, and on significant NHS spending increases in 2017- 18 on generic medicines in primary care’.
‘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.