An Impotent Approach to Psychological Therapy (IAPT)

there is no evidence that routine psychological therapy, as delivered in the Improving Access to Psychological Therapies (IAPT) programme either, resurrects a person or  returns them to their best functioning. As such IAPT is impotent.

Most of those entering the IAPT programme undergo low intensity cognitive behaviour therapy (LICBT). This latter involves a reduction of the multifaceted protocols from randomised controlled trials to single elements of those protocols eg avoidance or cognitive restructuring, in the belief that this may resolve client’s difficulties. But over a decade on, there is no evidence that this minimalist approach makes a real-world difference.  It is still unknown ‘what, if any, low intensity intervention works with whom?’. 

The problem with reductionism is that it fails to acknowledge that  the whole is more than the sum of its parts. The multifaceted CBT protocols distilled for randomised control trials likely work because of the synergistic interactions of components, delivered by a particular type of agent (therapist). Simply providing ‘an agent’ or ‘a technique’ is not evidence based.

A recent debate in the Journal Psychological Medicine, has focused around a paper by Read and Moncrief (2022)Moncrieff, J., & Read, J. (2022).[ Messing about with the brain: A response to commentaries on ‘Depression: Why electricity and drugs are not the answer’. Psychological Medicine, 1-2. doi:10.1017/S0033291722001088 https://www.cambridge.org/core/journals/psychological-medicine/article/messing-about-with-the-brain-a-response-to-commentaries-on-depression-why-electricity-and-drugs-are-not-the-answer/C93997DBF4D174D9807D0F65BD994999] highlighting the problem of reductionism when applied to antidepressants and ECT. Both treatments are based on the postulate that there is particular dysfunction in the brain largely responsible for depression, which these intervention rectify. However the search for such an organic deficit has been unsuccessful. These authors point that such interventions are no more effective than enhanced placebo for depression.  

Interestingly Read and Moncrief (2022) pin their hopes on psychological therapies by appealing to the results of randomised controlled trials of CBT for depression. However they are over-stepping the mark. The routinely provided CBT by IAPT has none of the hallmarks of CBT in the trials: the dosage of sessions is sub-therapeutic, no fidelity checks have been conducted to check that individuals actually receive appropriate CBT, there have been no independent assessors of outcome.

In their paper Read and Moncrief (2022) were quite specific about the population they were addressing ‘depressed patients’ but there is no such specificity about the populations treated in routine practice. IAPT clinicians do not make reliable diagnoses, (albeit that they have the temerity to ascribe a diagnostic code). Whilst it is comparatively easy to guarantee that an antidepressant or ECT has been administered, guaranteeing that an appropriate CBT protocol has been imparted, requires independent fidelity checks. No such checks have been applied to IAPT’s ministrations. Read and Moncrief (2022) may well be right, that psychological therapy is the best hope, but the way to hell is paved with good intentions. Currently IAPT is impotent.

Dr Mike Scott

Mental Health – Propaganda For IAPT and Antidepressants Far Outstrips Evidence of Effectiveness

a just published editorial in Psychological Medicine 1–10. https://doi.org/10.1017/S0033291719003295 indicates that it is  doubtful that antidepressants exert a clinically significant effect compared to being on a waiting list for depressed patients. Strangely the editorial goes on to recommend IAPT as an addition to antidepressants. But there are major problems with this a) the effect of IAPT has never been compared to a waiting list b) IAPT clinicians do not make a diagnosis, so that it is unknown whether IAPT makes a difference for depression c) there has never been an independent evaluation of IAPT. In fairness to the writers of the editorial they do suggest halting the embrace of IAPT until the Service demonstrates that it has a long term effect.  NHS England and Clinical Commissioning Groups should at least heed this latter point. 

here is my 5 minute interview with BBC TV, https://vimeo.com/316124732

and a link to the waiting list  investigation by BBC Radio 4 last week:

https://www.bbc.com/news/health-50658007

the main points of my interview are:

  • only the tip of the iceberg of those attending IAPT fully recover https://journals.sagepub.com/doi/10.1177/1359105318755264 this contrasts with the Organisations claim of a 50% recovery rate
  • IAPT has only ever marked its’ own homework, despite over £3 billion being spent on it in the last decade. There has been no independent assessment of outcome, of the quality that would be expected were the effectiveness of a drug was being evaluated
  • IAPT fails to effectively engage and treat people. The IAPT Annual Report (2018)/2019] see link below, reveals that a third (31.2%) of new referrals drop out before treatment and approximately two thirds (61.1%) do not complete a course of treatment (using IAPT’s liberal definition of treatment as attending 2 or more session) with almost a third (29.54 %)  attending only one treatment session.

    https://www.dropbox.com/s/hwn9ncuuyds8qfa/IAPT%20Annual%20Report%202018-2019.pdf?dl=0

  • the most common gateway into IAPT is via a 20-30 minute telephone assessment with the most junior members of staff who are trained to signpost people via problem descriptors they do not make diagnoses
  • most IAPT clients do not get psychological therapy rather they are given either guided self help, computerised cbt or invited to attend a class/group i.e they receive low intensity interventions which are without the evidence base of the psychological therapies (high intensity)

Dr Mike Scott