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