Non-Reply From Health Minister’s Aide On IAPT’s Gatekeeping

Last month I asked Dr Coffey, the Health Minister the following questions, in italics I have summarised the responses from an aide. The full text that I received on October 12th 2022 follows.

1.The Government Improving Access to Psychological Therapies (IAPT) Service is experimenting with public, direct access to a Psychological Wellbeing Practitioner. But PWPs are not trained in diagnostics nor are they qualified therapists. Why then are they being given this gatekeeping role?

Best answered by NHS England


2. The IAPT service has cost billions of pounds, since its’ inception in 2008. Why, then has there been no independent audit of the service?

Not answered


3. With regards to physical health the Government is funding Community Diagnostic Centres, with regards to mental health why is there no facility for reliable
diagnosis in IAPT?

Interesting, but diagnosis in mental health  is ‘less straightforward’, it would be too costly, no plans.

4. With regards to mental health there is no evidence that those availing themselves of IAPT fare any better than those attending the Citizens Advice Bureaux? What then is the added value of funding IAPT?

Not answered

5. How is the experiment of making PWPs gatekeepers being evaluated and who decided on the criteria?

Not answered

6. IAPTs claimed recovery rate of 50% has not been independently verified. The independent evidence of an Expert Witness to the Court [Scott (2021) British Journal of Clinical Psychology] suggests that in fact only the tip of the iceberg recover. Is this not grounds for a publicly funded independent audit?


7. How do we know IAPT is value for money?

Not answered

Dear Dr Scott,
 
Thank you for your correspondence of 18 September Improving Access to Psychological Therapies (IAPT) programme. I have been asked to reply.

NHS England has oversight for the IAPT programme, so would be best placed to respond to your queries. However, delivery of IAPT services is the responsibility of local commissioners. Integrated care boards (ICBs) replaced clinical commissioning groups in the NHS in England from 1 July 2022. A list of ICBs can be found at www.nhs.uk/nhs-services/find-your-local-integrated-care-board/.

In response to question 4, people seek treatment through talking and psychological therapies provided through local IAPT services for anxiety, depression and a range of other mental health conditions such as agoraphobia, post-traumatic stress disorder, obsessive compulsive disorders, panic disorders and social phobias. Treatments can include therapies like counselling, cognitive behavioural therapy (CBT) and peer support. In 2021-22, 1.24 million referrals accessed talking therapies through IAPT services.  The recent annual report available at https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-annual-reports-on-the-use-of-iapt-services/annual-report-2021-22 contains information on referrals, waiting times and patient outcomes such as recovery. In addition, the report covers a range of demographic analyses including outcomes for patients of different ages, ethnic group and separately for ex-British Armed Forces personnel.

For your questions relating to Psychological Wellbeing Practitioners, the IAPT workforce consists of low-intensity practitioners and high-intensity therapists who together deliver the full range of NICE-recommended interventions for people with mild, moderate and severe depression and anxiety disorders, operating within a stepped-care model. All IAPT clinicians should have completed an IAPT-accredited training programme, with nationally agreed curricula aligned to the National Institute for Health and Care Excellence (NICE) guidance (or they should have acquired the relevant competences or skills before joining an IAPT service). All clinicians should be accredited by relevant professional bodies and supervised weekly by appropriately trained supervisors.

Many people with mild to moderate depression or anxiety disorders are likely to benefit from a course of low-intensity treatment delivered by a psychological wellbeing practitioner. Individuals who do not fully recover at this level should be stepped up to a course of high-intensity treatment. The NICE guidance recommends that people with more severe depression and those with social anxiety disorder or post-traumatic stress disorder (PTSD) should receive high-intensity interventions first. NHS England’s available at www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdfcontains further detail on the IAPT workforce, including PWPs.

Question 3 raises an interesting point; however, there would be significant challenges to making this approach work for mental health conditions. Diagnosis for mental health is less straightforward and replicating Community Diagnostic Centres would require a significant expansion in numbers of mental health staff, above and beyond what is already set out in the NHS Long Term Plan that there will be additional 27,000 mental health professionals in the NHS workforce by 2023/24. Therefore, we have no plans at present to replicate this model for mental health.

I hope this reply is helpful.

Yours sincerely,

K Jarvis
Ministerial Correspondence and Public Enquiries
Department of Health and Social Care

 

Dr Mike Scott

Has Routinely Collected Outcome Data Assisted In Answering, ‘What Works For Whom?’

 

Over 50 years ago Paul (1967) asked the fundamental question for psychotherapy “What treatment, by whom, is most effective for this in- dividual with that specific problem, under which set of circumstances” (Paul, 1967, p .111). The proud boast of the Improving Access to Psychological Therapies (IAPT) service is of a million referrals a year, with test results for 90% of treatment sessions [IAPT Manual 2019]. But despite the quantity of data IAPT has amassed over the last 14 years, it has been of no help to clinicians in answering this key question. It has simply been an added stress.

What is the function of the IAPT data? Is it to simply bamboozle paymasters NHS England/Clinical Commissioning Groups (CCGs)? Perhaps it is to improve the practice of IAPT staff? Even if this latter were the case, there is no evidence that this translates into an improved outcome for clients that they would recognise.

The irrelevance of the IAPT data set, can be gauged by inspecting the table below:

Treatment

Clinician

Characteristics of the client

Specificity of the Problem

Specificity of Psychosocial Functioning

There is no treatment typology within the service. Simply a claim that most clients get CBT in varying doses.

The service distinguishes deliverers of low and high intensity. But clinicians training varies enormously from clinical psychologists with Ph.Ds  to recent graduates who have done voluntary work.

Clients are not distinguished in terms of whether they may or not have a personality disorder or a neuro developmental problem.

The service has no typology of problems. It does not make diagnoses so cannot specify disorders, albeit that it allocates a diagnostic codes.

There is no framework within which to specify level of functioning

With IAPT’s data there are fuzzies in every column of Paul’s framework,  leaving its’ clinicians rudderless.

 

Dr Mike Scott

Paul, G. L. (1967). Outcome research in psychotherapy. Journal

of Consulting Psychology, 31, 109–118.

 

Clinical Commissioning Groups Decade of Neglect In Auditing Mental Health Pathway

no Clinical Commissioning Group has been compliant with NICE’s (2011) 1.5.1.2 https://www.nice.org.uk/guidance/cg123 injunction for them to audit and review local mental health pathways. Instead, the  CCGs have left it to the Improving Access to Psychological Therapies (IAPT) programme to mark their own homework. NHS England has turned a blind eye. Can there be a better example of institutionalised bias against mental health patients?

The National Institute for Health and Clinical Excellence (NICE) document https://www.nice.org.uk/guidance/cg123 (2011) also advocates a stepped care model that ‘provides the least intrusive  and most effective intervention first’. But this creates a conundrum in that, clearly the least intrusive interventions include, guided self-help, computerised CBT and psychoeducation groups, what would be deemed low intensity interventions in IAPT. However, the NICE recommended treatments for specific disorders, are recommended in a dosage that would be incompatible with a low intensity intervention. It is only the high dosage interventions that have been credibly systematically evaluated in randomised controlled trials. Contrary to the assertion of Boyd et al (2019) https://doi.org/10.1371/journal.pone.0214715 there is not ‘sound evidence for the efficacy of low intensity interventions’.  The methodological quality of the studies that form the basis for NICE’s recommendation for specific disorder treatments is much stronger than the foundation for the low intensity recommendations. Thus to provide ‘the most effective intervention’ first would mean jettisoning low intensity interventions and herald the demise of the stepped care model!

The mnemonic PICOT has been advocated by NHS England (2013) Finding the Evidence https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwj5_-fAhbn0AhXDiVwKHSgdDnYQFnoECBgQAQ&url=https%3A%2F%2Fwww.england.nhs.uk%2Fwp-content%2Fuploads%2F2017%2F02%2Ftis-guide-finding-the-evidence-07nov.pdf&usg=AOvVaw3-7g7wSw9WFJhtWaS-gBdX to help clinicians distinguish what is an evidence-based treatment and  what is not. The P refers to the  patient/problem/population studied, I the intervention/exposure of interest, C the comparison condition, O for outcome and T the time frame. The low intensity interventions fall at each hurdle. With regards  to P the patient population is poorly specified, with reliance on a self-report measure rather than a ‘gold standard’ diagnostic interview. The intervention used, I, is fuzzier in low intensity interventions with no indication as to how it is adapted to the needs of the individual. The comparison conditions, C are invariably waiting list controls in low intensity interventions, but patients on waiting lists do not expect to get better, the appropriate comparison is an active control group e.g attendance at a shyness group to learn from each other what works best for them. The outcome, 0, in low intensity interventions is always a change on a self-report measure, it is never complemented by an independent evaluation of the diagnostic status of the person. Finally T, there is no indication in the low intensity studies of the duration of gains i.e what proportion of those who have recovered go on to maintain their gains. Whilst not all rct’s of  high intensity interventions clear the PICOT hurdles about half do and these interventions merit a strong recommendation. These studies are qualitatively different to the low intensity studies.

 

 

It is a source of concern that the manufacturers of Silver Cloud, a computerised CBT programme, is the sponsor of a recently publicised IAPT training day. 

 

Dr Mike Scott

 

Fundamentalism and The Improving Access To Psychological Therapies (IAPT) Service

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

 

 

‘Low Intensity’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.

  1. 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.
  2. 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.

 

Dr  Mike Scott

It’s A Myth That The Improving Access to Psychological Therapies (IAPT) Service Pays for Itself

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:

  1. 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.
  2.  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

 

  1. 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.
  2. Layard, R and Clark, D.M ( 2014) Thrive: The Power of Evidenced-Based Psychological Therapies Penguin Limited

Dr Mike Scott

 

Decrypting the Improving Access to Psychological Therapies (IAPT) Code

IAPT communications have an agenda, their focus is on persuading their source of revenue, local Clinical Commissioning Groups (CCGs) to expand funding, to cover staffing costs of £0.5billion by 2024.  To achieve this goal it uses language that is familiar to the GPs that comprise CCGs, ‘NICE compliant’, ‘recovery’ and claiming a comparability of outcome to those in randomised controlled trials. But CCG’s are themselves under orders from NHS England, who have never critically appraised IAPT’s claims.

The secret to breaking the IAPT Code, is strangely its’ use of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s code is to gloss over that IAPT’s interventions are based, not on diagnosis but on ‘problem descriptors’. The silent assumptions are that:

a) there would be reliable agreement (reliability) between clinicians about what would constitute a clients main problem and

b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility.

But there is no empirical evidence for either a) the reliability or b) the clinical utility. 

IAPT operates its’ own coding device, akin to the Enigma machine used by the Germans in World War 2, and it has as a result ill-served millions. NHS England and CCG’s have totally failed to recognise its’ operation, believing instead IAPT’s public broadcasts e.g a 50% recovery rate, when independent assessment indicates a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264.

Dr Mike Scott

Improving Access to Psychological Therapists (IAPT) or Care Assistants?

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/.

Dr Mike Scott

IAPT’s Hidden Agenda

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:

  1. Why was a minimalist intervention repeated when the first such intervention had not worked?
  2. Why are the least well-trained clinicians given the power to direct treatment?
  3. Why are the least well-trained clinicians given the power to re-direct treatment?
  4. 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?
  5. 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.

 

Dr Mike Scott

 

 

NICE Mental Health Guidance Fails To Address Real World Cost Effectiveness

The National Institute for Health and Clinical Care Excellence (NICE) rightly considers the results of randomised controlled trials in advocating particular psychological therapies, but has not assessed whether, as implemented, they represent an added value compared to previously available therapies. Consider a new drug that is of proven efficacy in randomised controlled trials, NICE would understandably look positively at it, but before recommending it would want to know about side effects and the proportion of people discontinuing use. However NICE seems blissfully unaware that for the psychological treatments that they recommend, when delivered in routine practice, only one half of people tolerate more than one treatment session [Improving Access to Psychological Therapies (IAPT) Annual report 2019-2020 https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf,.  But they do know that there is no independent evidence of greater remission since the inception of IAPT – their silence on this point is deafening. 

 

The NICEimpact mental health document (2019) asserts, p4 ‘The IAPT programme offers NICE-recommended treatments’  for common mental health disorders in adults. No it does not and what is worse still is that NICE have never bothered to check. NICE has been simply the voice of the power holders in mental health and not the consumers.

The usual metric employed by NICE is Quality Adjusted Life Years (QUALY), as a general rule of thumb new interventions are recommended if the cost of one QUALY does not exceed £20,000. But a QUALY can only be assessed against the benchmark of the previous standard drug/service i.e there is a presumption that this is reliably known. However NICE has operated without this data, as such its recommendations on mental health and in particular on depression and the anxiety disorders are blind. Yet organisations such as IAPT (Improving Access to Psychological Therapies)   establish their legitimacy to paymasters (NHS England and Clinical Commissioning Groups) by claiming the NICE seal of approval.  NHS England and CCG’s prefer to nod to this ‘seal’ rather to enquire about IAPT’s claims, much less to set up an independent body to address the veracity of claims. This is not too surprising as there is a semi-permeable membrane between the Department of Health and service providers. Conflicts of interest have not been addressed. 

 

Determining a QUALY with regards to mental health is not easy, but one QUALY could reasonably be interpreted as the cost of achieving the absence  of meeting diagnostic criteria for a recognised psychiatric disorder for a year for a client, following say an IAPT intervention, this would be compared with the typical cost of achieving this goal with the same type of client in pre IAPT services. But no follow up of IAPT clients has been conducted that independently tracks diagnostic status. NICE is saying more than it knows, but at whose behest?

Dr Mike Scott

IAPT’s Processes Contribute Towards Death or Injury

transcripts of tape recordings of client’s first contacts with the, UK Government funded, Improving Access to Psychological Therapies (IAPT) service, analysed by Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 reveal not only steadily increasing access,  but a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’

Drew et al (2021) give an example of this surrounding risk assessment:

PWP: So just with regards to question nine, okay so we have a duty of care to yourself or others? .hhh.erm (.) > are we okay just to< have a bit of a chat around.hh what those thoughts might be for you at the moment. ‘Cos you’ve scored a one there haven’t you’ Pause 3 secs
 
PWP: Are you having current thoughts of wanting to hurt yourself or end your life? Pause 3.5 secs
 
Pat: No, may. hh Pause for 3.5 secs
 
Pat: It’s – It’s just feels like a really weird (.) week this week because –
(18 lines omitted in which the patient talks about the pressure they are under; only minimal responses and attempts to close from PWP)
 
Pat: I still feel like I – I’m not doing anything and not accompanying anything tearful/tremulous
 
PWP: Mm, mm, okay? .huh
 
Pat: MHHHH HHH [ and it’s tearful/tremulous]
 
PWP: Are you having any thoughts of wanting to be better off dead or off wanting to better off dead or hurting yourself
 
Dangerously The PWP is all at sea  – a disaster waiting to happen, there will be a death. The above exchange shows
 
the therapist unable to move beyond repeating question 9 on the PHQ9, like a broken record, without any reliable
 
exploration of suicide risk. But then the IAPT Manual provides no guidance in this respect, baldly stating risk
 
assessment is part of good assessment.
 
In the exchange above the PWP ignores the client’s story. Assessment and treatment are necessarily built on sand 
 
if the client’s narrative is not first distilled.  Making IAPT’s claim of a 50% recovery rate  beyond belief. [The average
 
session was 44mins for assessment and 33 mins for first treatment]. 

It is bad enough when a friend or relative will not listen to your troubles, but when a Government Agency does it routinely, that is unconscionable. Drew et al (2021) draw attention to the ubiquity of the problem which suggests that it is systemic. However Drew et al (2021) content themselves with recommending that IAPT’s assessors need to ask more open-ended questions at the start of their interviews. The authors claim no conflict of interest, but many of the authors have had previous privileged access to IAPT data, research data may not be so forthcoming if they take a more critical view of IAPT. In this respect they do not question IAPT’s recovery rate or cite data which may disconfirm it Scott (2018) https://doi.org/10.1177%2F1359105318755264.

 

Dr Mike Scott