Audit of Secondary Care Psychological Therapies Fails Clients

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.

Dr Mike Scott

 

IAPT’s Below Intensity CBT Revolution

IAPT’s low intensity CBT should be re-branded ‘below intensity CBT’, as all the methodologically rigorous CBT outcome studies were conducted  on full dose CBT.  Guided self-help (GSH) interventions were first recommended by a NICE committee in 2007 and 2009 for depression and the anxiety disorders. In its’ wake IAPT enthusiastically adopted GSH such that by 2018, 70% of clients were being given it. But recently therapists have been told not to use the term ‘GSH’ but talk to clients instead of ‘low intensity CBT’. This re-labelling appears to have occurred because of the difficulties of engaging the public in this more obviously cheap option (see previous post).

But NICE did not conduct a systematic review of the outcome literature, rather its’ recommendations were simply the advice of its’ committee. It failed to acknowledge that there were no studies of ‘guided self-help (GSH)’ with a hard outcome measure i.e studies involving an independent blind assessor using a standardised diagnostic interview. Thus there was no evidence that the man/woman in the street would recognise that the GSH had returned them to normal functioning. However the recommendation of NICE was that the low intensity interventions had to be matched to the particular depression or anxiety disorder. But IAPT took what it wanted from the NICE guidance, jettisoned making a diagnosis and proclaimed that appropriate treatment could follow a problem descriptor, without any empirical evidence for the latter.  The upshot is that for a decade IAPT clients have largely been subjected to ‘below intensity cbt’.

There has been a decade of ‘the below intensity CBT’ revolution and it has failed. This is not to say that there may not be cheaper effective options for service delivery such as group CBT, but the scope for such interventions is limited to depression and some anxiety disorders and much more methodologically rigorous outcome studies are necessary to confirm its place.

Dr Mike Scott 

Populist Mental Health Myths

poor psychological therapy services are as much about populist mental health myths, as underfunding. Drill down beyond IAPT and NICE and you enter a sub atomic world very different to that of the orchestrators.

In the microscopic world people are concerned with:

‘will I get back to my old self with this therapy?’

‘what proportion of people like me, get over this with therapy?’

‘are the effects of therapy temporary or permanent?’

‘are you interested in and committed to me, or am I just a number?’

Moving up to the macroscopic world, real world outcomes are replaced by surrogates ‘a change on a questionnaire’ but without any certainty the questionnaire is measuring anything pertinent to what the person is suffering from! There is no independent assessment of outcome of routine practice.

Myth One: IAPT and NICE are at one

IAPT insists that it is NICE compliant, i.e its treatment protocols match the identified condition. But IAPT clinicians do not diagnose, instead they make a judgement using ICD 10 diagnostic codes, this weak surrogate ignores that NICE Guidance assumes a reliable diagnosis and advocates the DSM criteria not ICD10!

Myth Two: IAPT is credible because of its’ advocacy of NICE Guidelines

The NICE guidelines have called for a decade, for an evaluation of low intensity CBT vs counselling vs treatment as usual, which would include observer rating. Such is its’ ongoing uncertainty as to the value of low intensity CBT.

Myth Three: The value of low intensity CBT has been demonstrated

Not if one insists on methodologically strong studies involving independent outcome assessors.

Myth Four: CBT is the answer

NICE points out that even where there is the strongest evidence in favour of the use of CBT in depression the effects are ‘modest’. It also notes that there are comparitively few studies of Behavioural Activation (BA) and NICE makes a clarion call for more head to head research between BA and CBT. But stresses the need for inclusion of observer rated assessment in such a study, they also may have added that there is a need also for an attention control group. There is a need for more humility in IAPT about the contribution of CBT.

Myth Five: Approval by NICE equals evidence of efficacy

Not so, NICE guidelines are the fruits of a committee’s deliberations, about primarily, the results of randomised controlled trials, but there is no assessment of those rcts using the Cochrane risk of bias, which includes requirements such as observer rated outccomes.

Myth Six: IAPT never departs from NICE

With regards to ‘Medically Unexplained Symptoms (MUS) not otherwise specificied’ the recommended specialised form of CBT is entirely a product the IAPT Education and Training Group (ETG). The ETG is also a reference source for the specialised form of CBT for irritable bowel syndrome and chronic pain, albeit that 2 NICE guidelines are also referred to.

Myth Seven: IAPT is becoming more robust in evaluation

Not according to its’ recent forays into disorders like chronic fatigue syndrome were reliance is placed on a psychometric test the Chalder Fatigue scale of doubtful relevance to the CFS construct and without any independent observer rating.

Myth Eight: Real world change can happen without hospitality and commitment

Hospitality is notably absent in client’s first contact with IAPT , therapists are focussed on not becoming the subject of sanction. In the real world initial formulation of client’s problem/s is often in need of significant modification, the time constraints on therapists rarely cater for the necessary adaptations and the importance of persistence on the part of the therapist.

Myth Nine: It is ok to discharge a client as soon as their score hits recovery

For 40% of people experiencing depression, their disorder takes a variable course, whilst for the anxiety disorders, sufferers are only affected 80% of the time. Thus discharging at the first signs of a low score is simply capitalising on chance, there can be no certainty that lasting meaningful change has occurred. The stage is set for a revolving door.

This list of myths is by no means exhaustive, please feel free to add your own. However the microscopic and macroscopic worlds are different universes it seems.

Dr Mike Scott

The diagnosis is correct, but National Institute of Health and Care Excellence guidelines are part of the problem not the solution

This is the title of a Commentary on my paper ‘IAPT – The Need for Radical Reform https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/ published in the Journal of Health Psychology, by Sami Timimi the link is: Article first published online: March 30, 2018

https://doi.org/10.1177/1359105318766139 

 

Two further commentaries are in the pipeline, with my commentary on the commentaries to be published in the Summer, in a Special issue of the Journal. Timimi’s comments/data on Childrens and Young Persons IAPT are particularly interesting.

Special thanks to Donna Botomley for all the help she has given in the construction and maintenance of this site and she is retiring from this role. As many of you might know technology, particularly social media is not my forte, any comments always welcome.

Regards

 

Mike Scott

‘IAPT -The Need for Radical Reform’ 3 Commentaries

The Journal of Health Psychology has just published the 1st of 3 Commentaries on my paper ‘IAPT- The Need for Radical Reform’ https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/ , the other 2 commentaries will be published online in the next week or two. I will be writing a commentary on the commentaries.  The 1st of the Commentaries is by Sami Tamimi (see below):

‘The diagnosis is correct, but National Institute of Health and Care Excellence guidelines are part of the problem not the solution’

Mike Scott’s study provides data demonstrating that the national Improving Access to Psychological Therapies project is not leading to improved outcomes or value for money. I present further data from both the adult and children and young people’s versions of Improving Access to Psychological Therapies that lends supports to this conclusion. However, while Scott argues in favour of better compliance with National Institute of Health and Care Excellence guidelines and greater model expertise, I argue that it is this ‘technical’ focus that is part of the problem not the solution.

1Lincolnshire Partnership NHS Foundation Trust, UK
2Health Education England, UK
3University of Lincoln, UK
Corresponding author:
Sami Timimi, Lincolnshire Partnership NHS Foundation
Trust, Trust Headquarters, Lincoln LN1 1FS, UK.
Email: stimimi@talk21.com

Interesting that similar findings in Children and Young Person’s IAPT.

Dr Mike Scott