IAPT’s Clients – Vulnerable Adults With No Protection

Neither NHS England, Clinical Commissioning Groups or BABCP have taken any steps to ensure that there is independent monitoring of the welfare of IAPT’s clients. Such clients suffer a double whammy, not only do they experience the sense of helplessness often accompanying psychological debility, but they are also powerless to say anything about their experience.

The CONSORT guidelines ( see link below) state that randomised controlled trials should address outcomes that are meaningful to the patient. The same should apply to services delivered in routine practice. Changes in psychometric tests scores are not meaningful to clients, whereas no longer suffering from the disorder they were suffering from at the start of treatment is. But IAPT obfuscates its’ true performance by sleight of hand with psychometric test results. Clients are fodder for providing psychometric test data at each session, no matter that there is no certainty that the test is pertinent to what they are suffering, that repeated administration means that they can remember their last score and will want to convince themselves that they are getting better and that the results are interpreted by their therapist, creating a demand effect.

A major feature of the CONSORT guidelines is that treatment should be evaluated by those independent of service provision. There is no opportunity to protest about incompetence or the arbitrary number of session limit. IAPT violates this and every aspect of the guidelines that might be pertinent to routine practice.

Unfortunately Editors of Journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and the Lancet often ignore the CONSORT guidelines or any translation of them into routine practice. Consequently the evidence base for expansion of IAPT into areas such as psychosis in secondary care, is much less than understood by its’ workers.

https://www.dropbox.com/s/vj2hp1q43hz4lh8/CONSORT%202010%20Explanation%20and%20Elaboration%20Document-BMJ.pdf?dl=0

Dr Mike Scott

IAPT – The Need For A Product Recall

In response to David Clark’s blog ‘IAPT at 10’ on the NHS England website, I wrote: ‘If NHS England invited the manufacturer of a pharmaceutical to review the growth and successes of its’ drug over the last decade eyebrows would be raised. Yet this is precisely what has happened in asking David Clark to comment on his baby (IAPT) with whom he has an ongoing commitment and financial arrangement. In terms of publication bias his piece is off the scale.

No Independent Replication

There has never been independent replication of IAPT’s claim to 50% recovery. My own work, which is wholly independent of IAPT and was published in the Journal of Health Psychology   last year (see link below)  suggests a 10% recovery rate.

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Questionnaires Rather Than An Independently Administered Standardised Diagnostic Interview

IAPT relies on questionnaires completed by clients with the full knowledge of the treating clinician, introducing a ‘demand’ element into the proceedings. Further there is in IAPT’s procedures no way of knowing that the questionnaire/s are tapping the disorder/s that are germane to the client. 

No Evidence of An Added Value To IAPT When Compared With Findings Before Its’ Inception

The changes in questionnaire scores observed in IAPT clients are no different to those observed on self-report measures administered to clients going through counselling before the advent of IAPT. The Mullin (2006) findings (see link below) are the appropriate counterfactual and indicate no added value to IAPT.

https://www.dropbox.com/s/8a4qv5r13rotkyy/Appropriate%20Counterfactual%20Mullin%202006.pdf?dl=0

Clients present for therapy at their worst and some improvement with time would inevitably be visible on a questionnaire, IAPT has provided no evidence that clients given simply attention would not have shown the same changes to those observed.

The Jettisoning of Evaluation Guidelines

Entry into Pharmaceutical/Psychological Studies is governed by the administration of a standardised diagnostic interview. Outcome is determined by blind re-administration of the interview at the end of treatment and follow up. In line with this, an international team of Experts [Guidi et al (2018) see link below] have developed evaluation guidelines stipulating the need for blind independent assessment of psychological interventions. All IAPT generated studies have breached these guidelines.

https://www.dropbox.com/s/hizta38yqm4lfh3/Methodological%20Recommendations%20for%20Trials%20of%20Psychological%20Interventions.pdf?dl=0

Countries that do not look at psychological interventions through the lens of such evaluation guidelines will be taken in by IAPT’s marketing prowess. Unfortunately many such countries have shown such gullibility in the last decade.

Failure to Engage and Treat Clients

IAPT loudly proclaims the very large number of clients that it makes contact with but this is meaningless when their trajectory is considered. Half of those referred to or referring themselves to IAPT   have less than 2 treatment sessions.  The mean number of sessions attended for those who have 2 or more sessions is 6, there is no NICE approved treatment for a psychological disorder that requires just 6 sessions.  It is scarcely credible that IAPT is providing an evidence based treatment on any scale. There is an an independent re-analysis of the IAPT data in the link below

http://therapymeetsnumbers.com/is-iapt-too-big-to-fail/

A Failure of Governance

IAPT is essentially a QUANGO dependent on NHS England, and committed to expansion but without any observance of evaluation guidelines.  NHS England has taken IAPT’s claims at face value, as a consequence Clinical Commissioning Groups focus only on operational matter, numbers, waiting times etc with no focus on clinical matters in their interactions with IAPT. The National Audit Office conducted an inquiry into IAPT but has failed to publish its’ results. There has been a gross failure of governance by public bodies and their representatives.

Only The Voice Of IAPT’s Hierarchy Is Listened To

There has been no attempt by public bodies to independently seek the views of consumers of IAPT services. However an IAPT teacher, Jason Roscoe has publicly made a blistering attack on the service, see link below

https://www.dropbox.com/s/myz53dyn8zqhj13/Has%20IAPT%20become%20a%20bit%20like%20Frankenstein.docx?dl=0

He reflects ‘the gap between what the literature advises and what management allow seems to be widening leaving the patients as the ones who are being given sub-therapeutic, watered-down CBT’ and adds ‘The result? A revolving door where patients return in quick succession for multiple episodes of treatment with a different therapist each time…..not only this IAPT also seems to be making its own workers ill with reports of compassion fatigue and burnout not uncommon’.

The views of the 90 IAPT clients I examined were almost wholly negative and indicated the need to transform IAPT see link below

https://www.dropbox.com/s/zhr1fkg71aqvno0/Transforming%20IAPT.pdf?dl=0

IAPT The Need For Product Recall

There are such serious doubts about what IAPT has delivered over the last decade, that if it were a piece of machinery the product would have been recalled. A decade ago I wrote a book on how CBT can be delivered, with fidelity to evidence based treatment protocols, [Scott (2009) Simply Effective Cognitive Behaviour Therapy, London: Routledge], there is a pressing need to review such provision. In private communication with David Clark I have acknowledged that my approach would make the assessment process more costly. However the evidence of the past decade is that it is not possible to make a real world difference to client’s lives without closely following the procedures involved in randomised controlled trials of CBT. Departure from reliable assessment, diagnosis, advice/treatment results in a failure to translate efficacious treatments to routine practice’.

Unfortunately NHS England only permits upto 1000 character comments on their invited blogs, so essentially only the 1st paragraph of this blog will likely appear.

Dr Mike Scott

Without IAPT, The Same ‘50%’ Recovery Rate – Why Do CCG’s Fund It?

One of IAPT’s criteria for claiming patient recovery is shifting a patient’s PHQ9 score to less than 10. But in a study by Gilbody et al (2015) [ see link below] involving 179 patients undergoing treatment as usual in primary care with an initial diagnoses of depression and PHQ9 scores of above 10, 101, (56%) of patients recovered within 4 months. [ A study of treatment as usual cases by Moore at al (2012) similarly showed a 47% recovery].  IAPT currently claims a 50% recovery rate, the burden of proof is on IAPT to demonstrate that it produces results significantly different to those treatments engaged in before its’ inception.

Even when the metric is an adequate treatment response the differences between IAPT and treatment as usual (TAU) are not apparent. In the study  by Moore et al (2012) [see link below] of 576 TAU cases of depression who completed the PHQ9 twice (mostly within 3 months)  63% showed an adequate treatment response ( a drop of 5 or more points), this is not  discernibly different to IAPT’s findings.

CCG’s want it seems to be seen to be mindful of mental health, as their masters NHS England dictate, but don’t want to engage in effortful thinking in this domain, bypassing it by talking only of operational matters, numbers, waiting times etc.  It is a new political correctness that also permeates the political parties.

The true metric of recovery is returning a person to their usual self ( a minimum component of which is losing diagnostic status, assessed independently), IAPT has studiously avoided  such a hard outcome measure preferring its’ own surrogate. All this despite that the original randomised controlled trials for anxiety and depression insisting on hard outcome measures.

 

Unfortunately mental health charities are often now dependent on IAPT and private agencies seek to ape IAPTs metrics, the upshot is that for the past decade there has been precious little evidence based psychological treatment of the sort I advocated in Simply Effective CBT London: Routlege (2009).

https://www.dropbox.com/s/awwtpdhv0mxbtht/Treatment%20as%20usual%20recovery%20rate%202015%20Gilbody.pdf?dl=0

https://www.dropbox.com/s/mupj14fq14eba4g/Depression%2050%25%20natural%20recovery%20on%20PHQ9%20within%203%20months%20of%20GP%20diagnosis.pdf?dl=0

Dr Mike Scott

Telling It As It Is at IAPT

There is an urgent need for an independent investigation of IAPT. In an earlier blog ‘IAPT half baked’, an IAPT worker commented that it would be ‘hair raising’ for people to learn of his/her experiences. This past week I’ve come across 2 cases that exemplify this,

  1. ‘X’  was given 3 sessions of guided self-help therapy, judged ‘resistant’, treatment was judged unsuccesful on the basis of PHQ 9 and GAD7 results and it was recommended that ‘X’ was stepped up to trauma focussed therapy. But without any specification of what the trauma was or its’ sequelae.  Some months later ‘X’ began a series of 10+ sessions at step 3 for Generalised Anxiety Disorder (GAD) , but during treatment the therapist discovered ‘X’ experienced  a very distressing incident many years ago and was upset when thinking about it. This event became the treatment focus and by the end of therapy ‘X’ was allegedly less distressed by this incident. Treatment was judged successful on the basis of changes on PHQ9 and GAD7 scores, but the therapist discharge letter said ‘ may now need to be re-referred for treatment of GAD!
  2. ‘Y’ saw his/her GP immediately following a needlestick injury was given the IAPT telephone number and a telephone consultation took place within days, PHQ9 and GAD7 scales were completed and the scores were elevated and ‘y’ was scheduled for a face to face treatment 6 weeks later. If you were not distressed/anxious after a needlestick injury you really would be weird, does the GP and IAPT have to collude in this medicalisation of normal distress, is this really a proper use of resources? from a GP’s point of view I can see that it ‘off loads’ a case for a time but really!

My fear is that no one in power really wants to know what is going on at the coal face, it is not helped by the National Audit Offices failure to publish the results of its investigation into IAPT. One can only speculate that the champion’s of IAPT, NHS England have had a gentle word with the Office.  The effect is that a political correctness rules expressing concern about mental health, stigma and the need for more resources, but without getting close to the people effected and really listening to what is going on.

 

 

Dr Mike Scott

The Cost of IAPT Is At Least Five Times Greater Than Claimed

The British Medical Journal has just published the following letter of mine online with the above title:

‘Six years ago a News headline in the BMJ proclaimed ‘Increasing access to psychological therapies will cost NHS nothing’ BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4250, citing a report of Lord Layard  of the Mental Health Policy Group of the Centre for Economic Performance http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp, that claimed ‘after an average of 10 sessions half the people with anxiety conditions will recover, most of them permanently, and half the patients with depression will recover’ .  Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.

The progenitors of IAPT, Clark and Layard in their book Thrive (2015) claim that the cost of treatment in IAPT is £650 per person, for people having attended 2 or more treatment sessions.  This leaves out of account the 40% of its clients who attend only one treatment session [IAPT (2018)] and the costs of the initial assessments which totalled £92 million in 2016-2017, with total costs of £367,219,192 in that period.  This means that the true cost of IAPT is at least 5 times greater than alleged, all without any government funded independent audit. Further average session attendance for those ‘treated’ in IAPT is 6.6 [IAPT (2018)] not the average of 10 sessions that Lord Layard deemed necessary, so that the average patient in fact receives a sub-therapeutic  dose of treatment.

In 2012 Lord Layard claimed ‘the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy’. This claim remains unproven and what limited evidence is available points in the opposite direction. How do Clinical Commissioning Groups justify paying such inflated sums? how can they be sure another agency could not achieve the same for less? how do they know that GPs simply tracking clients with depression and anxiety disorders would not achieve the same outcomes? NHS England should surely advise CCG’s to ask searching questions and organise a long overdue government funded independent audit of IAPT focusing on real world outcomes, such as loss of diagnostic status..

BMJ (2012) ;344:e4250 Increasing access to psychological therapies will cost NHS nothing, says report

Clark, D.M and Layard, R (2015) Thrive: The Power of Evidence-Based Psychological Therapies London: Penguin.

IAPT (2018) Psychological Therapies: Annual report on the use of IAPT services England, 2016-17 Data Tables. NHS Digital: Community and Mental Health Team.

Mental  Health Policy Group of the Centre for Economic Performance (2012) How mental health loses out in the NHS.   http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp.

Scott, M.J (2018) IAPT: The Need for Radical Reform. The Journal of Health Psychology, 23, 1136-1147.

 

Dr Mike Scott