IAPT shouts eureka at this point, discharges the client and claims the improvement is due to the therapists efforts. It is like declaring that a person who is terminally ill is cured because they have had a good refreshing day gardening. In effect IAPT has gone fishing for flashes in the pan – I make similar points in a forthcoming BBC Radio 4 investigation into IAPT.
But studies of depression and the anxiety disorders e.g Bruce et al (2005) require a 2 month period of symptoms not significantly impairing functioning (see also DSM-5 criteria for recurrence of depression). Bruce et al (2005) point out that anxiety sufferers naturally only have symptoms 80% of the time. With regards to depression Stegenga et al (2012) point out that for 40% of depression sufferers their depression naturally takes a variable course. Without independent assessment of the period for which the person is without significant symptoms talk of remission/ recovery is meaningless. IAPT’s clients have not been assessed using this metric.
Bruce et al (2005) https://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0
Stegenga et al (2012) https://www.dropbox.com/s/k0x2fm0ds01no0k/natural%20course%20of%20depression%20stegenga%202012.pdf?dl=0
If IAPT were a Hospital, operating without any consideration as to whether patients are returned to their usual selves with treatment, they would likely be placed in Special Measures. IAPT has eskewed accepted definitions of recovery.
IAPT’s Meaningless Yardstick
If you are departing IAPT (or wish to commit professional suicide!) tell your IAPT manager/supervisor the psychometric test results are not measuring anything meaningful, they are simply impositions from above! IAPT claims that the psychometric tests it uses (PHQ9 and GAD7) measure clinically significant change/ recovery. But this is not true.
The validity of clinically significant change criteria relies crucially on whether the test used taps the same construct as the identified disorder1. IAPT’s use of the PHQ9 and GAD7 violates the requirement for construct validity, specifically as IAPT make no standardised reliable diagnosis it is a lottery as to whether the psychometric test matches the diagnostic status of the client. A client could be suffering from for example variously, no recognised disorder, an adjustment disorder, OCD, panic disorder, the changing scores on the PHQ9 and GAD7 would say nothing at all about the outcome of an intervention for these disorders. To compound matters in the IAPT set up it is not possible to know when these measures are actually tapping depression or generalised anxiety disorder in a particular client.
IAPT’s Idiosyncratic Use of Tests
IAPT have never stipulated any criteria for enduring improvement. Therapists discharge clients as soon as their scores dip below casenness on a self-report measure, neglecting to consider that what is being observed is likely natural variation than any return by the client to their usual self. Matters are compounded because clients can complete the questionnaires to either please the therapist (particularly likely if completed in front of the therapist) and/or convince themselves that they have not wasted time in investing in therapy.
IAPT Training At Fault
CBT therapists per se are not trained in methodology – there is rarely any understanding of concepts such as construct validity, reliability, the limitations of psychometric tests, bias introduced into such tests by the ways in which they are administered or of accepted criteria for recovery. The deeply flawed IAPT training has arisen without a murmur of protest from the British Psychological Society and BABCP hierarchy. The rationale appears to be so long as IAPT secures increased monies for mental health services that is all that matters, this is a dereliction of care to both clients and therapists.
How Outcome Should Be Assessed
The passage of depressed clients through IAPT has never been judged by accepted definitions of response, remission and recovery2, 3.
Response is defined as a clinically
meaningful improvement in depressive symptoms that has continued for a
sufficient length of time (3 consecutive weeks) to protect against
misclassification owing to symptom variation or measurement error2. Response
is typically operationalised as an improvement
of ≥ 50% over pre-treatment scores.
Remission relies on a definition of
an asymptomatic range, defined as the presence of no or very few symptoms. A
person can be judged to be in the asymptomatic range only if neither of the two
essential features of depression (sad mood and loss of interest or pleasure) is
present and fewer than three of the additional core symptoms of depression are
present2. Remission requires that the person remains in this range
for at least 3 weeks, again to protect against factors such as natural symptom
variation.
Recovery is defined as an extended length of time in remission, which has been operationalised as at least 4 months4.
The passage of anxious clients through IAPT has never been judged by accepted definitions of recovery4. In the Bruce et al (2005) study of the trajectory of anxiety disorders a participant was considered to have recovered from anxiety disorder if he/she experienced 8 consecutive weeks at psychiatric status ratings of 2 or less (Table 1). Subjects who met this condition were virtually asymptomatic for 2 consecutive months.
Table 1
2. Residual The patient claims not to be completely his/ her usual self, or the rater notes thepresence of symptoms of no more than a mild degree (for example, mild anxiety in agoraphobic situations).
1. Usual self The patient is returned to his/her usual self, without any residual symptoms of the disorder. (The patient may have significant symptoms of some other condition or disorder; if so, a psychiatric status rating should be recorded for that condition or disorder.)
References
1.Fisher PL and Durham RC Recovery rates in generalized anxiety disorder following psychological therapy Psychological Medicine 1999; 29, 1425-1434
2. Dobson KS, Hollon SD, Dimidjian S, Schmaling KB, Kohlenberg RJ, Gallop RJ, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. J Consult Clin Psychol 2008;76:468–77
3. Dombrovski AY, Lenze EJ, Dew MA, Mulsant BH, Pollock BG, Houck PR, et al. Maintenance treatment for old-age depression preserves health-related quality of life: a randomized, controlled trial of paroxetine and interpersonal psychotherapy. J Am Geriatr Soc 2007;55:1325–32
4. Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, Shea MT and Keller MB (2005) Influence of psychiatric comorbidity on recovery and recurrence in generalised anxiety disorder, social phobia and panic disorder: A 12 year prospective study. Am J Psychiatry 162:1179-1187.
The list of those with a vested interest in consciously or non-consciously muddying the waters of mental health outcomes (fake news) is staggering and include Charities, IAPT and Independent Practitioners. Consumers, Businesses and Clinical Commissioning Groups beware!
Most client’s of mental health services are glad of the help proferred, they find them ‘soothing’ but this is a far cry from recovery from identifiable disorder. I’ve just put ‘Voltarol’ on my sprained ankle it is soothing, less of a burning sensation, but it doesn’t actually speed up the rate of recovery or increase gait velocity (improvement). Recovery would be back to what I was before I crumpled getting out of the taxi. Blurring the distinction between soothing, improvement and recovery is good for the marketing of a product, analgesic/wares of a mental health service provider, but the ‘injured’ are not well served and ill equipped to protest. As a consequence the juggernaut of existing services continues. There is a pressing need to go beyond expressions of client satisfaction.
E-cigarettes look like a good way of helping people giving up smoking cigarettes, but the long term effects are unknown, a Parliamentary Committee has just been appointed to look at the matter. There is an understandable wariness about wide dissemination in the abscence of evidence. But there is no such critical awareness when it comes to mental health.
If you are undergoing a medical procedure this is a pressing question. Curiously, psychological therapists create an aura in which clients are disuaded from asking this question, with responses that amount to ‘we don’t like to use labels, just complete questionnaires to see how you go’, masking a wholesale distrust of the medical model. Clients are intimidated from voicing their basic concerns, when asked whether they were given a diagnosis usually the response is ‘no’ or “they said I had ‘x’ symptoms” either way they do not feel on solid ground. Invalidating a person/client’s nascent question whether it be the ‘meaning of life’ or the likelihood of treatment that makes a socially significant difference is direspectful.
IAPT obscures the answering of this question by a sleight of hand, using changes on 2 psychometric tests to indicate recovery, with no blind, independent assessment of outcome and no use of a ‘gold standard’ diagnostic interview. But this obscurantism is not confined to Government funded psychological therapy services, in private practice there is an equal failure of diagnostic accuracy and comprehensive evaluation at both initial assessment and at the end of treatment. However at least in the private sector one can search out a therapist who can deliver, no such option is available within IAPT.
