More Treatment But No Less Disorder: What Is Going on Here?

 

a soon to be published study by Ormel et al https://doi.org/10.1016/j.cpr.2021.102111 highlights the increased access to psychological therapies but notes that the population prevalence of disorder has not decreased. The authors term this the ‘treatment-prevalence paradox’ (TPP) and although their focus was on depression, it likely applies to all the common mental disorders. They consider that the most likely explanations are that:

(a) the published literature overestimates short- and long-term treatment efficacy,

(b) treatments are considerably less effective as deployed in “real world” settings, and

(c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases.

 

Efficacious treatments are it seems, likely lost in a fundamentalist translation that preserves the reputation of service providers. Independent corroborative evidence of effectiveness is non-existent.

In the event of the statistically likely, ‘real world’ failure of a psychological treatment how should a clinician respond? With dismay, if he/she is an IAPT therapist enjoined to demonstrate a 50% recovery rate. The pressure to manipulate test results will be great, ‘on item x did you really mean…’ . The therapist might protest that any one case is ‘complex’, but such a claim is likely to be given short shrift, with repeated vocalisations.  A suspicion of ‘incompetence’ lurks, which may be at least temporarily assuaged, by agreeing to go for further training. But the dice are it seems loaded in favour of burnout, this New Year.

There is no IAPT protocol for treatment failures.  In a spirit of apparent openness A GP may be invited to re-refer  if ‘appropriate’. The latter might just do this if badgered by the patient at some future point. But given that the same assessment and treatment procedures will be in place, another spin around the revolving door is the most likely outcome. IAPT in effect puts most client’s in a waste-paper bin, some are recycled to no avail.

 

The TPP will continue until service providers enable therapists to ask ‘who, needs what treatment?’. Following the mnemonic PICOT, the ‘who’ is determined by  asking which population (P) is this person representative of? There are ‘gold standard’ semi-structured diagnostic interviews to clarify the best fit between a person and a patient population. The use of short-cuts (heuristics) such as solely relying on a test result or highlighting a particular symptom of a disorder, leads to mis-diagnosis and an inappropriate intervention – the I of PICOT. The I should follow  a published treatment manual that specifies the treatment targets and matching treatment strategies for the particular identified disorder. But a treatment protocol lacks credibility if its efficacy was not assessed by comparison (the C) with an active control condition. Similarly outcome studies (the O) lack credibility if they did not involve blind independent assessors. T refers to the duration of follow-up, all conditions wax and wane, so assessment at any one point can simply be ‘ flash in the pan’, enduring change is the mark of recovery.

Service providers, such as IAPT should ensure that they make therapists aware of  the quality of the foundation for the chosen intervention, but this is rather like getting turkey’s to vote for Christmas! Courses run by Academic Institutions for IAPT dare not risk biting the hand that pays them. 

 

Dr Mike Scott

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