Constant Breaches of Conflict of Interest By IAPT and NHS England

 

the latest example comes from Saunders et al  (2021) in the Journal of Affective Disorders 294 (2021) 85-93 https://doi.org/10.1016/j.jad.2021.06.084. None of the 9 cited authors acknowledge any conflict of interest. But the database they draw upon is from the Improving Access to Psychological Therapies (IAPT) treatment programme, 2 of the 9 work for iCope an IAPT service, as well as being part of a research network of IAPT and academics, 4 others are also part of the IAPT Service Improvement and Research Network (SIRN). Their paper is titled ‘Older adults respond better to psychological therapy than working age adults: evidence from a large sample of mental health service attendees’.  The authors note that their finding runs counter to other studies that have suggested interventions for depression are equally effective when comparing older to working age adults and even that older adults suffering from anxiety disorders have worse outcomes than working-age patients. They are curiously blind to the possibility that the IAPT database is suspect, that it does not measure what it purports to  do so. There is a clear operation of allegiance bias. Readers and Journal editors have a right to be alerted to the possibility of allegiance bias by a transparent declaration of conflicts of interest. I wrote to the Journal Editor about this but he declined to publish my letter.

 

1. Earlier this year I wrote a blog on  a study by Barkham et al (2021) https://doi.org/10.1186/s12888-018-1899-0 which involved comparison of person-centred counselling and cognitive behaviour therapy (cbt) in a high intensity therapy service delivered by IAPT. Curiously patients were screened for the study using the Clinician Interview Schedule Revised but neither this nor any standardised diagnostic interview was used as an outcome measure. Further Barkham et al (2021) chose to adopt the Improving Access to Psychological Therapies (IAPT) primary outcome measures the PHQ-9 [Kroenke et al (2001)] and GAD-7 [Spitzer et al (2006)], without any discussion. There is no comment that these are self-report measures, subject to demand characteristics and that changes are impossible to interpret without comparison to an active placebo treatment. Why such apparent blindness? The answer is apparent reading the declaration of conflicts of interest, the authors are either devotees of person-centred counselling or have links with IAPT. Their take home message is that person centred counselling might be better than CBT for depressed patients. But there is no attempt to address the question of what proportion of patients lost their diagnosis status and for how long, as determined by an independent blind clinical assessment using a standardised interview. Service-users interests are ill-served by this type of study which additionally ignored data that suggest the recovery rate in IAPT is just 10% [Scott (2018)]https://doi.org/10.1177/1359105318755264 .
2. IAPT is the biggest provider of group psychoeducation and it was given a boost by a Dolan et al (2021) study all authors declared no conflict of interest. But the corresponding author for the Dolan et al (2021) study is a programme director of IAPT and another of the authors has IAPT involvement.Dolan, N., Simmonds-Buckley, M., Kellett, S., Siddell, E., & Delgadillo, J. (2021). Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis. The British journal of clinical psychology, 60(3), 375–399. https://doi.org/10.1111/bjc.12288

 

3. In March 2021 the British Journal of Clinical Psychology published my Commentary ‘Ensuring IAPT Does What It Says On The Tin’ I wrote ‘In the Wakefield et al. (2020) paper all the authors declare ‘no conflict of interest’. But the corresponding author of the study, Stephen Kellett, is an IAPT Programme Director. The study is therefore open to a charge of allegiance bias. It is therefore not surprising that Wakefield et al. (2020) fail to make the distinction between IAPT’s studies and IAPT studies. By definition, the former have a vested interest, akin to drug manufacturer espousing the virtues of its psychotropic drug. Whilst an IAPT study is conducted by a body or individual without a vested interest, in this connection Wakefield et al. (2020) have implicitly misclassified this author’s IAPT study, Scott (2018). In their study, Wakefield et al. (2020) make reference to the Scott (2018) study with a focus on a subsample of 29 clients (from the 90 IAPT clients) for whom psychometric test results were available in the GP records. But in Scott (2018) it was made clear that concluding anything from such a subsample was extremely hazardous. The bigger picture was that 90 IAPT clients were independently assessed using a ‘gold standard’ diagnostic interview, either before or after their personal injury (PI) claim. Independent of their PI status, it was found that only the tip of the iceberg lost their diagnostic status as a result of IAPT treatment. Wakefield et al. (2020) were strangely mute on this point. They similarly failed to acknowledge that the ‘IAPT’s studies’ involved no independent assessment of IAPT client’s functioning and there was no use of a ‘gold standard’ diagnostic interview.’

 

Failure to declare conflicts of interest is not confined to Journals but also operates in NHS England who direct Clinical Commissioning Groups. IAPT staff are employed by NHS England, the latter has no independent body overseeing IAPT and it is therefore unsurprising  that the expansion of the service is given wholesale backing.

 

Dr  Mike Scott