IAPT 10 NICE Guidance 0

a study by Barkham and Stone https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1899-0 of over 33,000 IAPT cases has revealed high intensity counselling as being the most cost effective, requiring on average just 6 sessions compared to the 9 sessions for high intensity CBT, to achieve the same result. But the NICE Guidance  recommends CBT as the first line treatment not only for depression http://www.nice.org.uk/guidance/cg90 but also the common anxiety disorders. In the 2 years since the published study, IAPT appears not to have considered that there is likely something wrong with its’ data set when it provokes a conclusion at variance with the NICE Guidance. However it is IAPT that has muscle at the coal face, not NICE. The juggernaut of IAPT carries on, paying lip service to NICE Guidelines to placate NHS England and local Clinical Commissioning Groups.

The Barkham and Stone study also suggests that whatever of the 4 trajectories clients take in IAPT: 1. high intensity counselling (9%) 2. high intensity cbt (18%) 3. low intensity cbt followed by high intensity counselling (20%) 4. low intensity cut followed by high intensity cut (53%) there is no difference in outcome, all improve by 6 points on the PHQ9 each starting off at a score of 15. This would suggest that there are no meaningful distinctions between the categories and that the stepped care approach bears no fruit. Yet IAPT continues with stepped care. IAPT fails on quality control, it can provide no meaningful data with regard to treatment integrity i.e a guarantee that an evidence based protocol has been followed for a reliably identified disorder. Nor can it provide any evidence that the observed changes of score would not have happened with the passage of time and attention (an active placebo).

Regrettably IAPT, markets itself superbly with Ontario in Canada being the latest to be conned by the IAPT model, when will people wake up and smell the coffee.

 

Dr Mike Scott

Problem Descriptors – A Confusing IAPT Signpost Leading to Crashes

‘ I think it is social anxiety disorder, from my problem description my manager thinks its’ generalised anxiety disorder’  should treatment be determined by the power holder or should they just spin a coin with a ?50% chance of the client getting the right treatment. Such is the soap opera acted out in IAPT.

IAPT uses problem descriptors to determine what treatment to give to whom. But problem descriptors are a rule of thumb to determine treatment. In randomised controlled trials treatment was based on a reliable diagnosis, which would typically take an hour or more to determine. IAPT has come up with a problem descriptor shortcut of undetermined reliability and which it seeks to legitimate by asking therapist to provide an ICD-10 code.

The IAPT Manual considers it best practice if a service provides an ICD-10 code for at least 80% of cases. Can it be acceptable for up to 1 in 5 people to have rudderless treatment? When clients are assigned an ICD-10 code it is usually a single code and a Manager may advise that a another code is appropriate rather than the one the clinician selects.  Whilst the IAPT Manual advises that more than one code can be appropriate, it also advises that treatment should be dictated by the principle problem, this likely has the effect of making for single awards of ICD-10 codes.

The IAPT Manual claims that ICD-10 codes are the basis of the NICE recommended treatments, but they are not. Most of the mental health trials considered by NICE are based on the more reliable and stricter DSM criteria. Notwithstanding this ICD-10 provide diagnostic criteria for each disorder, but IAPT also contends that it does not make diagnosis. It is therefore difficult to escape the conclusion that IAPT pays lip service to ICD-10 codes for its’ own credibility.  Despite this the IAPT Manual insists that the treatment protocol should follow the identified problem but the protocols have never been matched to problems but to disorders!

Dr Mike Scott

 

IAPT Hoodwinks NHS England

by alleging compliance with NICE recommended evidence-based psychological treatments. But, NICE bases its’ recommendations, largely, on randomised controlled trials conducted on specific disorders, with different protocols for different disorders. It is impossible to implement NICE guidance without reliable diagnosis, but IAPT have never claimed that its’ clinicians make a diagnosis!

Even the notion of a utilising a ‘provisional diagnosis’ was jettisoned in last years IAPT Manual, (see link below) in favour of a ‘problem descriptor’:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

On the basis of a client’s ‘problem descriptor’ the IAPT Manual requires its’ therapists to specify an ICD-10 [International Classification of Diseases 10th edition, World Health Organisation] code for a disorder, which would allegedly indicate the appropriate protocol. However there are 99 codes for Mental and Behavioural Disorders in ICD-10, there is no bridge between a ‘problem descriptor’ and a disorder. If such a leap were possible ICD-10 ( the World Health Organisation) would not have bothered to specify diagnostic criteria for the 99 conditions! Within IAPT clinicians come up with a ‘problem descriptor’ in just 2/3rds of cases, [ Clark et al (2018)] see link below:

https://www.dropbox.com/s/s7var6llzwt1otd/IAPT%20and%20Transparency%20Clark%202018.pdf?dl=0

and usually following a 20-30 minute telephone conversation, it is therefore a matter of ‘plucking a code’ from thin air for administrative purposes,


if the clinician can remember this particular ticking the box exercise.

The Clark et al (2018) study was published in the Lancet, and funded by the Wellcome Trust, and headed ‘Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data’ and states:

‘Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication’.

But there is no mention that the lead author is the leading light in IAPT, and that with one of the other authors, Lord Layard, they were the architects of IAPT. Where is the ‘transparency’ in this? In fairness in this paper they do state that a limitation of their paper is that their data is dependent entirely on client self report, but a conflict of interest stops them going on to say, that there needs to be an independent audit of IAPT, in which the diagnostic status of clients is assessed before and after treatment and at follow up.

My own independent analysis of 90 IAPT clients suggests that, contrary to IAPTs claims of a 50% recovery, just the tip of the iceberg loose their diagnostic status diagnostic status, see link below: https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

NHS England needs to clearly establish whether or not the public is ill served by IAPT and not to rely on the claims of those with a vested interest in providing the Service.

Dr Mike Scott

Routine Psychological Treatment Is Like A Car Being Revved Stuck in Mud

Marija has had OCD for 30 years since adolescence, her treatment included exposure and response prevention at the Institute of Psychiatry, many years ago. Her most recent therapist has suggested she try this again. But closer examination of her notes reveal that she simply felt better for some months after exposure and response prevention. When I asked her did she return to her usual self after exposure and response prevention she said ‘no’, but was 80% better for a while. Whilst exposure and response prevention is a NICE recommended treatment, at most only 50% recover. The NICE guidance can as applied to routine practice create a tunnel vision. She is a classic example of how clinicians stop at the first identified disorder. Whilst she clearly has severe OCD, there is no mention at all in the voluminous records that she has also been suffering from panic disorder, depression and illness anxiety disorder, all of which have gone untreated. Her son commented ‘I always knew there was more than just OCD’.

Marija was relieved that there was some new potentially beneficial therapeutic targets and that a ‘light touch’ with her OCD rather than ‘battling with my thoughts’ might be useful. She entered a different mode when I suggested a) that she had performed an experiment by not completing her rituals when she was asleep and found she came to no more harm than when awake and b) would not ring the local radio station to tell them that everybody must perform her rituals to stop harm coming to their loved ones c) she had performed rituals for a year as a 8 year old but when she gave them up nothing happened.

Marija has gone through a revolving door of mental health clinicians, which could have been stopped by a careful reassessment and history taking using a standardised diagnostic interview.

Dr Mike Scott