We Rejoice In Reliable Cancer Screens But Accept The Incompetence Of Mental Health Screens – Time To Sue

Nobody would accept unreliable cancer screens, but mental health screens are conducted in IAPT (Improving Access to Psychological Therapies) by Psychological Wellbeing Practitioners (PWPs), the least well qualified practitioners and conducted over the telephone in a 20-30 minute ‘assessment’.


Tell me this is ok:

  1. Ms B underwent a telephone assessment after which her GP was informed that she had a PHQ9 score over 10 and GAD7 score over 8 and was being placed on a waiting list f or a psychoeducational group at step 3. No indication of what she apparently screened positive for, nor what evidence based treatment was proposed for the said condition/s.
  2. 5 months later the GP writes in her notes that Ms B did not attend IAPT and is worrying about everything and added ‘tried counselling doesn’t feel useful’
  3. 15 months after her initial telephone assessment she has another IAPT telephone assessment, by a PWP from the Screening Team and the GP is informed that her PHQ9 is 19 and GAD7 is 9. Further she has suicidal thoughts but no plans and the GP is reminded that she took an overdose years ago. The PWP added that they were going to put her on a waiting list for a face to face assessment and had given her the phone number of the Samaritans.

If a patient had telephone consultations with a GP over an unexplained lump, with no face to face assessment or treatment conducted in 15 months, there would be outrage. A Personal Injury claim would likely be mounted, yet this is accepted without a raised eyebrow in the mental health sphere. I don’t think anything will change until someone sues IAPT.

Dr Mike Scott

Better Than CBT?

‘Metacognitive therapy (MCT) is a new evidence based psychotherapy that is proving to be more effective than than CBT’ so runs the advert in the April 2019 issue of the Psychologist, promoting an MCT Conference at the end of next month. Inspection of the referenced supporting literature indicates that there is just one, to be published study, by Adrian Wells et al, on Generalised Anxiety Disorder, suggesting MCT outperforming CBT. In MCT their is allegedly a 70-80% recovery rate compared to average 50% in CBT.

But great care has to be taken in evaluating efficacy studies, those relating to GAD are an exemplar. Studies conducted only by the originator of a therapy (Adrian) are necessarily suspect, there needs to be at least one independent study by researchers without an allegiance to the therapy and in which there is blind assessment of outcome using a standardised diagnostic interview. Further the results should include blind rater assessments not merely self-report. Whilst Adrian’s work has not yet cleared this hurdle, a methodologically rigorous analysis of the CBT for GAD studies paints a less convincing picture than most CBT devotees would imagine. A review of CBT for GAD studies by Zhu and colleagues, found just 12 studies as worthy of consideration and commented:

‘Despite having blinded rater, in half the the studies the main outcome depended on the self-rating….The overall risk of bias was considered high in 8 of the 12 studies. And using the rigorous GRADE criteria the overall level of evidence was classified as ‘moderate’, which indicates that further research could change the widely accepted conclusion about the effectiveness of CBT. Thus the results in favor of CBT are strong, but not definitive’. Dropbox link to full article below:

https://www.dropbox.com/s/cng09hehty9qo02/GAD%20Meta-analysis.pdf?dl=0

When it comes to studies of CBT for long term physical conditions, the evidence is much weaker than that for GAD which raises the interesting question of ‘why IAPT is treating long term physical conditions’. This very question is to be addressed by a Psychological Welbeing Practioner at an IAPT PWP Conference on June 26th. Interestingly the Workshop is titled ‘Step 2 Support for long term conditions’. But there is surely a gross mismatch between a low intensity intervention and a long term physical condition! It rather looks like distinction between low and high intensity interventions is being blurred, not before time. However a colleague of mine working in high intensity has been trained in treating LTC’s but is restricted to 6 sessions! Despite none of the efficacy studies in this area offering just 6 sessions, I am off to a home for the bewildered and bemused.

Dr Mike Scott