The IAPT Double Myth of Economic and Clinical Utility

 

The impetus for the Improving Access to Psychological Therapies (IAPT) service was derived from a) economic considerations and b) an assertion that the positive results of randomised controlled trials of, primarily CBT, for depression and the anxiety disorders would be realised in routine practise.

 

 

A Money-Saver?

In 2006 the Centre for Economic Performance stated that “the total loss of output due to depression and chronic anxiety is some £12 billion a year-1% of our total national income ”. The contention was that investment in psychological therapy would pay for itself by a reduction in such costs. But currently IAPT costs over £1 billion a year, where is the evidence of a substantial reduction in the loss of output? Where is the evidence that IAPT constitutes a no-cost talk therapy?

 

Poor Performance at the Coal-Face

In the randomised controlled trials on average 50% of clients lost their diagnostic status as assessed by independent blind assessors. But no such unbiased assessors have ever gauged the impact of IAPT’s ministrations. IAPT has always marked its own homework. Rather than the claimed recovery rate of 50%, the best available evidence suggests that only the tip of the iceberg recover, Scott (2018).

Each myth means that the other is not carefully examined and IAPT advocates can deftly switch the focus from one to the other under critical scrutiny – a politician’s dream.

 

Psychological Therapy – a history of exaggerated claims

T.S Eliot wrote ‘Humankind cannot bear very much reality’ this applies particularly to looking at the effects of mental heath treatment. In 1751 the scientist and Quaker, Benjamin Franklin petitioned the Pennsylvania colonial assembly for funds to build a hospital on the grounds that ‘it has been found , by the experience of many years, that above two thirds of the Mad People received into the Bethlem Hospital in England  and there treated properly , have been perfectly cured’. He was reiterating claims made in published books by English doctors. Fast forward over 260 years, to 2012 and an editorial in the prestigous journal Nature declares IAPT ‘represents a world-beating standard thanks to the scale of its implementation and the validation of its treatments’ (p. 473)’.  A decade later, NHS England echoes this declaring ‘the Improving Access to Psychological Therapies (IAPT) programme began in 2008 and has transformed the treatment of adult anxiety disorders and depression in England. IAPT is widely-recognised as the most ambitious programme of talking therapies in the world and in the past year alone more than one million people accessed IAPT services for help to overcome their depression and anxiety, and better manage their mental health’ and recommends the IAPT Manual (2021). In 2019, Pickersgill examined the proliferation of IAPT by canvassing the views of professionals and professional bodies, noting that IAPT fellow-travellers were in the ascendancy. But in this evangelisation for the in vogue psychological interventions nobody has asked the consumer or considered the operation of vested interests.

The Absence of Open Discussion

Psychological disorders are ubiquitous and can negatively impact the course of coexisting physical conditions. Since the days of Benjamin Franklin, UK data on mental health treatment, has been used to foster the belief that UK treatments are a ‘world beater’. But independent evidence to support this contention is lacking. There is not just a gap between the psychological treatments delivered in randomised controlled trials and what comes to pass in routine psychological services, such as the Improving Access to Psychological Therapies Programme (IAPT) service, but a chasm. Efforts to have a meaningful debate on the issue have been met with a deafening silence. In the silence, the scope of psychological treatments has gradually been expanded, beyond the initial focus of depression and the anxiety disorders to include patients with long term physical conditions – a psychological imperialism. The power-holders definition of the outcome of routine psychological treatment reigns.

 

Dr Mike Scott

Nature (2012) Editorial: Therapy deficit. Nature 489(7417): 473–474.

Pickersgill M. (2019). Access, accountability, and the proliferation of psychological therapy: On the introduction of the IAPT initiative and the transformation of mental healthcare. Social studies of science49(4), 627–650. https://doi.org/10.1177/0306312719834070