The Bell Tolls for IAPT if NICE Has Its’ Way

according to the BABCP’s submission BABCP response – NICE consultation draft  to the National Institute for Health and Clinical Excellence (NICE ). Implementation of the latter’s proposed guidance would mark the end of the Improving Access to Psychological Therapies (IAPT) service. 

Interestingly BABCP recommend that assessment should begin with a reliable diagnostic interview and acknowledges that IAPT’s Psychological Wellbeing Practitioners (PWPs) are not equipped to do this. Further BABCP recommend that outcomes should be assessed from the client’s perspective but do not specify how. Ironically some of BABCP’s own recommendations undermine the functioning of its over-induIged prodigy, IAPT. BABCP are alarmed that the proposed guidance would, in their view, herald the end of stepped-care.

BABCP are aghast that NICE have not included studies by IAPT related personnel in determining the way forward. In defence of IAPT, BABCP cite the Wakefield et al(2021) https://doi.org/10.1111/bjc.12259 study published in the British Journal of Clinical Psychology but fail to mention my rebuttal paper Scott(2021) https://doi.org/10.1111/bjc.12264 published in the same issue of the Journal. Quite simply NICE does not consider studies that are based on agencies marking their own homework as having any credence. This is thoroughly reasonable.

The BABCP have rightly pointed out to NICE that in recommending group interventions as the starting point for offering clients help, they have not properly looked at the context of the group studies. As I pointed out in my submission to NICE COMMENTS ON PROPOSED GUIDANCE (and simultaneously submitting via BABCP as a stakeholder), there are considerable hurdles in engaging clients in group therapy, see Scott and Stradling (1990)Group cognitive therapy for depression produces clinically significant reliable change in community-based settings Behavioural Psychotherapy, 18: 1-19 and Simply Effective Group Cognitive Behaviour Therapy Scott (2011) https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiph5Hlvbb1AhWKX8AKHRSJDZ0QFnoECAUQAQ&url=https%3A%2F%2Fwww.amazon.co.uk%2FSimply-Effective-Cognitive-Behaviour-Therapy%2Fdp%2F0415573424&usg=AOvVaw0nam02gszlQ0HqCktSCB0s. 

In fairness, I think Prof Shirley Reynolds from BABCP has done a great job in reviewing the extensive documentation provided by NICE and collating the individual submissions, all within a very brief period of time. I understand from her that these matters will feature in the next issue of CBT Today and whilst I was happy to have my name noted as having submitted, there are important aspects of the submission on which I wish to dissent.

NICE make its’ formal recommendations in May, interesting times

 

Dr Mike Scott

IAPT and The Rogue Driving Instructor

Imagine the would-be driving instructor for your son/daughter, has on public record, that for every person attending 2 or more lessons there is one person who attends just once. Warning lights would flash . But the latest IAPT data, for September last, https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services/september-2021-final-including-reports-on-the-iapt-pilots-and-quarter-2-data-2021-22 show just such poor engagement, with 39,734 having only one treatment appointment and 56,972 having two or more treatment sessions. Further, just as many people fail to follow up their referral (self or GP) , 43,258 as have one or two or more treatment sessions. This suggests that IAPT is not high in the public credibility stakes. The driving instructor may claim a 50% pass (recovery) rate but would you believe them without independent verification? IAPT’s self-proclamation of such a recovery rate lacks credibility.  

IAPT claims 7.9 sessions of treatment per referral, but can this be regarded as sufficiently potent when NICE recommended treatments are typically twice this length? On December 9th 2021 NHS Digital proclaimed that the ‘Improving Access to Psychological Therapies (IAPT) is run by the NHS in England and offers NICE-approved therapies for treating people with depression or anxiety’. Yet neither NICE nor IAPT have provided any evidence of treatment fidelity. Both display what the Chair of the Hillsborough Independent Panel has termed ‘the patronising disposition of unaccountable power’ [ ‘Justice for Christ’s Sake’ by James Jones SPCK (2021)]. The Panel also highlighted 3 necessities for further public enquiries, empathy, equality and candour. It would be empathetic to ask  IAPT clients ‘are you back to your old self with the treatment you have received or alternatively are you back to your best?’. Equality  would mean giving precedence to the client’s definition of their situation, and not an organisational device {PHQ9 and GAD7) administered in such a way as to protect the reputation of the Service. Candour would be allowing IAPT therapists to tell it as it is, no longer too fearful to speak out or having to use such measured tones that the central meaning of what they have to say is lost. 

Dr Mike Scott

 

New NICE Menu for Depression

The proposed Guidance, published last month, excludes consideration of assessment. Recommendations are  therefore built on sand. Depression can occur in a variety of contexts and alongside other disorders, NICE’s response is that it doesn’t matter so long as there is a high score on a depression psychometric test. The clinician, not the client holds the menu, the former takes them through the options in a set order. For ‘less severe’ depression group CBT is to be canvassed first with clients, next in line is group behavioural activation. Despite the fact that the latter group modality has not been assessed with blind independent assessors.

 

NICE advocates different pathways for ‘less’ and ‘more severe’ depression, advocating a cut-off of 16 on the PHQ-9. De facto the authors rubber-stamp the widely held practice, reflected in the Improving Access to Psychological Therapies (IAPT) Service, of routing high scorers on a depression psychometric test (e.g PHQ-9 score 10 or greater) to treatment for this condition. But patients with a wide range of disorders including, panic disorder, PTSD, obsessive compulsive disorder and adjustment disorder have elevated depression scores. Nevertheless, NICE signals a diversion along a depression pathway with one fork for ‘less severe’ and another for the ‘more severe’. Clinicians and clients are likely to be equally bemused by the ‘road signs’. The upshot is likely to be misguided treatment.NICE have invited the public to Comment on their intended guidance https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0725/consultation/html-content-3 on the treatment of depression. Commentary has to be submitted specifying the particular paragraph that any comment is about, so it is somewhat tedious, and you may well decide to write your Christmas cards instead. 

 

Generalising from Low Quality Studies

In assessing the outcome studies NICE do not take seriously the concept of minimally important difference (MID) i.e what change would a a patient see as the minimum requirement necessary for them to say treatment has made a real-world difference. There is no evidence that they would regard a change of score on a psychometric test as conferring a real-world difference. But they would recognise being back to their old self or best functioning and possibly no longer suffering from the disorder, so that loss of diagnostic status would be a reasonable proxy for a MID. However only a minority of studies furnish this data with the use of blind assessors. Inferences can therefore only be properly drawn from this sub-population of studies, which exclude the low intensity studies. As an exemplar see the comparison of group CBT and group behavioural activation at the end of this document.

 

Pseudo-preferences

 

Under the proposed Guidance client’s preferences are paramount.  If the client is judged as having ‘less severe’  depression and volunteers no treatment preference, they are to be taken through  a menu of options in a set order starting with first group cognitive behavioural therapy, second group behaviour activation, third individual CBT and on to the 11th option short-term psychodynamic therapy.  For ‘more severe’ depression top of the league is individual CBT plus antidepressants, in 2nd place individual CBT, and in 3rd place individual behavioural activation and in last and 10th place is group excercise. The ‘more severe’ route is more labour intensive and there is likely to be congestion as approximately half those entering IAPT have mean scores of 15 or more on the PHQ-9 [Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173]. Unwittingly the Guidance spells the end of low intensity interventions because none of the top of the league options are low intensity! But 70% of clients entering the IAPT service are given a low intensity intervention first. However there is nothing to prevent a Service Provider declaring that ‘unfortunately none of the top of the league options are currently available’ and recourse has to be made to options in danger of relegation.

Psychometric Test Results Can only be Considered in Context

 

The NICE guidance assumes that psychometric test results speak for themselves but they are only meaningful when described in context. To my knowledge there is no study of the reliability of the PHQ-9 in UK routine mental health services compared to a ‘gold standard’ diagnostic interview. Rather data on the PHQ-9 has been extrapolated from from US studies of psychiatric outpatients, in a population with a high prevalence of depression, but not using a ‘gold standard’ diagnostic interview [The Prime MD was used instead, with insufficient distinction between this interview and the questions on the PHQ-9]. It is the author’s experience that in the UK the PHQ-9 gives a large number of false positives compared to a reliable diagnostic interview, such as the SCID.

 

The Need to Contextualise Outcome Studies

NICE has a ‘blind spot’ about context. In its’ analysis of outcome studies it lumps together ‘depression studies’ that were wholly reliant on self-report measures with those that included the results of a diagnostic interview as an outcome measure. Outcome is assessed in terms of statistical differences between either different modes of service delivery e.g stepped v non-stepped or between different treatments e.g CBT v waiting list. There was no attempt to try and discern what proportion of clients in each arm of a study would have regarded themselves as back to their normal selves or best functioning post treatment [ or in lieu of this, lost their diagnostic status] and the duration of those gains. Rather than patients being asked to cite preferences over treatments they largely have no knowledge of, they would be very interested as to the likelihood of treatment making a real-world difference to their lives i.e a difference that they would care about.

 The Need to Consider Effectiveness Studies Not Just Efficacy Studies

NICE’s failure to look at context is highlighted in the top league place it gives to group CBT for less severe depression. No mention that in our study [Scott and Stradling (1990)https://doi.org/10.1017/S014134730001795X ] of individual and group CBT for depression in Toxteth, Liverpool the invitation to group CBT went down like a ‘lead balloon’ and we had to change the protocol to include up to 3 individual sessions in the ‘group’ arm. Entry was determined by independent diagnostic interview, but mean entry Beck Depression scores were around 28, so the population was likely ‘more severe’ in NICE terms. NICE also fails to critically appraise the Group Behavioural Activation studies, having previously called for BA studies to include observer rated assessments. They may have also added the need for credible attention control comparisons. NICE is content with statistical sweeps at large data sets rather trying to discern what is happening at the coal face.

Ignoring the Pandemic

NICE puts group interventions as top of the league for less severe depression, but ignores the context of the pandemic, realistically how possible will it be two get 2 therapists together with 8 clients for 90 minutes a week for 8 weeks, all face to face. with masks? The logistics and effectiveness of conducting it online is a venture into the unknown. NICE appears to operate without contextualisation of findings.

 

Failing to Pay Attention to the Detail of Group Interventions

In 2019 Kellett et al published a paper in Behavior Therapy, 50 (2019) 864–885 the abstract advocates Group Behavioral Activation for depression as a front line treatment. The abstract also claims a moderate to large effect on depressive symptoms. NICE appears not to have read further than the abstract, but closer inspection reveals the conclusions are deeply flawed.

In passing the abstract mentions that the standardized mean difference (SMD) between group BA and waiting list was 0.72. This would cause few people to question the findings, but actually it means the results are of doubtful clinical relevance, as it actually means there is less than one standard deviation in outcome between the treated group and the waiting list. If a group of depressed patients had a mean Beck Depression Inventory Score of 28 at the start of treatment, [assuming that the spread of the results was 7, the standard deviation – taken from the Scott and Stradling (1990) study Behavioural Psychotherapy, 18, 1-19 ] a mean score of 23 at the end of treatment would produce an SMD of 0.71, i.e about the same as in the University of Sheffield analysis. Thus the average person experiencing this change of score is unlikely to feel that they are back to their normal selves, and are likely to view it as part of the normal cycling of mood, influenced by positive events e.g the company/support of fellow sufferers for a time in a group. In none of the Group BA studies was there an independent assessor determining whether clients were still depressed or the permanence of any change. Unsurprisingly the authors found that the Group BA was no better than any other active treatment (i.e controlling for attention and expectation), and make an implicit plea for the Dodo verdict ‘all therapies are equal and must have prizes’.

In the body of the BA paper the authors acknowledge that the Group BA studies are of low quality, save one and that analyses were on treatment completers as opposed to the more rigorous intention to treat. But there is no indication anywhere as to what proportion of people recover from depression with any permanence.

In 1990 Steve Stradling and I had published [Behavioural Psychotherapy, 18, 1-19] a study of depressed clients comparing, group CBT, individual CBT and a waiting list condition. For Group CBT the initial mean BDI was 29.0 and end of treatment score was 6.2 whilst for individual treatment the comparable scores were 28.21 and 11.53. However those on the waiting list also improved from 25.89 initially to 20.26 at the end of waiting list. Thus, it is far from clear that the results from the University of Sheffield analysis on Group BA are actually better than those of putting people on a waiting list.

Dr Mike Scott

 

 

 

 

 

IAPT and NICE Compliance – panic disorder a case study in infidelity

the infidelity starts with IAPT’s emphasis on psychometric tests to determine treatment. NICE (2020) http://pathways.nice.org.uk/pathways/panic-disorder, observes there are no appropriate screening instruments for panic disorder. The guidelines highlights the importance of a) detailing a timeline for the emergence of various symptoms and b) clinicians being aware of the common comorbidities of depression and substance abuse. But it is doubtful that this can be done within the typically 30 mins IAPT telephone triage assessment by Psychological Wellbeing Practitioners, the least well qualified of all IAPT staff. NICE suggests the monitoring of the frequency and severity of attacks as an outcome measure. But in IAPT notes I have never seen this systematically recorded. 

IAPT is non-compliant with NICE recommended dosages:

  1. Low intensity treatment is likely as the first step in panic disorder treatment. NICE recommends that brief CBT be around 7 hours and integrated with structured self-help materials. But Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 found that the average client in the Improving Access to Psychological Therapies  (IAPT) low intensity therapy has 3 sessions ( a mean of 2.85 sd 2.81). Thus over 84% of those in low intensity CBT receive less than the than the number of NICE recommended treatment  sessions for brief CBT.  But Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803 have defined low intensity treatment as consisting of 6 hours or less therapist contact. Thus IAPT’s low intensity therapy is of such low dosage that it would not qualify for NICE’s brief CBT. 
  2. For high intensity treatment NICE recommends 7-14 hours of treatment, involving weekly sessions of 1-2 hours and completed within 4 months. But IAPT clients in high intensity treatment typically receive 5 sessions Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 ( a  mean 4.79 sd 5.51)]. 

IAPT has never systematically monitored compliance to NICE protocols. There is no evidence that IAPT has obeyed NICE’s guidance that ‘CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols’.

IAPT pays lip service to adherence to NICE protocols for funding purposes. But this is unacceptable, the NICE guidance is important, for example it warns that benzodiazepines are an inappropriate treatment for panic disorder. The NICE guidance is a means of challenging not only the inappropriateness of pharmacological treatment but also of psychological therapy. 

 

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

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

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