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.
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.
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!
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.
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.
I recently asked the National Audit Office to restart it’s investigation into IAPT. I am expecting their reply in the next week or two. There has been no independent scrutiny of IAPT. They have been answerable only to Clinical Commissioning Groups, which have consisted largely of GPs and allowed IAPT to mark its’ own homework.
But the accountability gap also extends downwards, where is the evidence that front line staff or clients have been consulted or involved in decision making? Most recently IAPT has offered webinars, for its staff on helping those with long term COVID. There is a tacit assumption that this will be within the expertise of IAPT therapists just as helping those with long term physical conditions such as irritable bowel syndrome. But the IAPT staff working with LTCs were never consulted, before this new foray. Client’s with LTCs were never asked whether they were back to their old selves (or best functioning) before this proposed further extension of IAPT’s empire.
In the forthcoming issue of the British Journal of Clinical Psychology I have challenged IAPT’s account of its ‘performance’ see ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264. There is a reply in rebuttal see ‘The costs and benefits of practice-based evidence: correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’ https://doi.org/10.1111/bjc.12268 that reveals a breathtaking level of conflict of interests. IAPT and its’ fellow travellers should be held to account. But importantly they also need to account to their therapists and clients. [ The original IAPT paper is available at https://doi.org/10.1111/bjc.12259]
and we have ‘no plans to revisit work’. This was the National Audit Office’s response to a Freedom of Information Request to my colleague Joan Crawford on February 18th 2020 http://FOI-1298. The NAO’s response continues our ‘purpose was to establish the relevant facts’ with regards to waiting times. The NAO adds it was these concerns expressed by an NHS staff member that first led to the NAO inquiry. Curiously the NAO then says it was planned to describe the responsibilities of different health sector bodies ‘in assuring and overseeing the accuracy and integrity of the reported data’ but the NAO has never addressed the ‘integrity’ of the data. The NAO has failed to tell anyone that the unit of analysis in IAPT’s own data set, the proportion of people who recover, is suspect. Whilst IAPT claims a 50% recovery rate my own independent analysis submitted to the NAO suggests it is just 10%. The NAO curtailed its’ investigation in June 2018 because of ‘changing priorities’, leaving its’ findings unpublished and duties undischarged. There is a pressing need for independent audit.
On the same day as the FOI response, the Government announced that it will spend £2.6 billion over 6 years on flood defences and that every £1 spent will save £8. However the UK Government has failed to ensure that the NAO furnishes it with similar data. Without such data there is no real world accountability.
and suffers a depressive reaction. I was preparing a desktop report for Ms X just as a National Audit Office (NAO) Report into the DWPs procedures was announced. It revealed that the DWP were investigating 69 cases of suicide following cessation of Personal Independence Payments (PIPs). The NAO observed that the true extent of suicide in this context is unknown. It is time to put the mental sequelae of DWPs decisions on the agenda.
Extensive documentation on Ms X reveals recurrent depressive disorder, autism and adult ADHD, together with years of contact with secondary care mental health services. Despite this the DWP assessor indicated that she had 0 problems communicating and interacting with others! Reading his letter of justification he relied entirely on his perception of how she presented at interview. He gave a total Summary score of 0 which is simply preposterous, whether or not she had sufficient points to meet the PIPs criteria. I have written to the DWP for a review of the case. I have also suggested that not only should suicides be subjected to an Internal Process Review but all Claimants who are judged to have scored 0. Such a change in PIP score is near miraculous as people are awarded PIPs initially because of enduring functional impairment. But IPR’s are not open to public scrutiny and the NAO pointed out that it is not known whether such reviews have led to any change in practice: There is a need for transparency, I await with interest the DWP’s response to my letter.
Unfortunately the DWP’s assessor has adopted the style of most mental health professionals, reliance primarily on a single source of data (IAPT on self report measures of doubtful relevance ) or the clinicians take on the client’s story with an open ended interview. This results in missed diagnosis, mistreatment and misleading statements about the client’s diagnostic status.
The National Clinical Audit of Anxiety and Depression (NCAAD) has just been published https://www.rcpsych.ac.uk/members/your-monthly-enewsletter/january-2020-enewsletter/anxiety-and-depression-report?dm_i=3S89,13323,2H3J22,3SCFB,1 but it is impossible to gauge from it what proportion of those with anxiety or depression recovered with psychological treatment. There was no reliable methodology employed to determine what constituted a ‘case’ of anxiety or depression and there was no independent evaluation of outcome.
No evidence is provided that psychological therapy made a real world difference to client’s lives. The authors reported that 75% of service users agreed that their therapy helped them to cope with their difficulties, with 88% agreeing they were treated with empathy, dignity and kindness. The average number of treatment sessions attended was 13. Having made such a time investment clients are unlikely to be critical of the service they received particularly, as was usually the case, the therapist was judged a nice person.
The report opines that 65% of service users were receiving a type of therapy in line with NICE Guidance for their disorder. But given that diagnostic status was not reliably determined there can be no certainty that an appropriate NICE protocol was used. There is nothing in the report to indicate that treatment records were reviewed (or capable of review) in such a way as to determine matching treatment targets, strategies and disorder. This makes one sceptical of the authors claim that the main intervention was CBT, it is alleged CBT. With just over a half completing the planned number of sessions. With a further 1 in 3 people receiving a type of treatment that was not NICE compliant even by the standards of the authors of the report.
The authors call for an increased use of psychometric tests (no test was used in more than 15% of cases) and a reduction of waiting times (almost half waited over 18 weeks). Doubtless these are laudable aims but of themselves are unlikely to make any real world difference to client’s lives.
There is a legitimation of current practice, with implicit claims for more funding and better training, all horribly reminiscent of the failed IAPT service. The National Audit Office needs to not only re-ignite its’ inquiry into IAPT but also determine whether secondary care psychological therapy is value for money – the NCAAD provides no evidence of the latter.
but the NHS has taken no steps to stop the haemorrhaging of clients and money. A quarter (25.3%) of IAPT’s expenditure in 2017-2018, £75.58 million, was devoted to clients who were either not assessed or were not put in any care cluster (groups of diagnoses), according to the National Schedule of Reference costs see link https://www.dropbox.com/s/3xlu6tipaeguk2c/FOI%20IAPT%20data.xlsx?dl=0
which I acquired through a Freedom of Information Request. Curiously only 15.2% of IAPT’s expenditure, £45.68 million in 2017-2018 went on common mental health problems of low severity, whilst £176.86 million (58.99%) was spent on non-psychotic disorder.
For those with common mental health problems of low severity there were 214,863 high intensity contacts compared to 378,617 low intensity contacts. Thus low severity often appears to necessitate high intensity contacts, this raises questions about the reliability of ‘common mental mental health problems of low severity’ category.
For non-psychotic disorders 1.075 million high intensity contacts were delivered and almost as many low intensity contacts, 0.876 million. Assuming that the those categorised as a having a non psychotic disorder are more functionally impaired than those with common mental health problems of low severity, why are they having so many low intensity contacts? Sticking plasters for serious injury! It is time for the National Audit Office to restart its’ inquiry.