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BABCP Response - NICE Consultation January 2022

“We can’t tell you what proportion recover, we can only tell you what proportion clinically significantly improve”

This is the bizarre mantra from NHS Talking Therapies digital partner, SilverCloud. The latter platform is based in Ireland and until recently it boasted ‘up to a 70% clinical recovery rate’. I protested to the Irish Advertising Standards that this was fraudulent, and Silver Cloud have since withdrawn any claim as to recovery. I explained to the ISAA that recovery has a clear meaning to a member of the public, as back to their old self or best functioning. As SiverCloud studies have never demonstrated achievement of this metric, it was highly misleading. Its’ new vanguard claim is ‘up to 65% of users achieve clinically significant improvement’. But I wouldn’t change my internet provider if the would be provider claimed an ‘up to particular speed’, I would smell a rat. 

The term ‘clinically significant improvement’ only has meaning if the population being addressed is clearly specified. The mnemonic PICOT is recommended by the NHS and NICE to establish the credibility of an intervention. The ‘P’ stands for population, established with a ‘gold standard’ procedure. But in none of the studies cited by SilverCloud has the ‘population’ been crystallised using a standardised diagnostic interview  nor has outcome , the “O” been determined by a blind independent assessor using a ‘gold standard’ interview. The cited SilverCloud studies lack any credibility. 

It is disingenuous of SilverCloud to now claim ‘up to 80% of participants show improvement in depression and anxiety symptoms’. Once again we have the advertising gimmick of ‘up to’. With no specification of who the ‘participants’ are with regards to the P of PICOT. The platform has not used a credible attention placebo to determine whether any identified changes are any more than regression to the mean. Similarly stating ‘93% users satisfaction’   is no more compelling than restaurant owners saying 93% of customers said they were satisfied when asked, leaving the premises. 

Why does NHS Talking Therapies associate itself with SilverCloud? It offers the alluring prospect of wide dissemination of a service at minimal cost. Quite simply it is fixated on a fantasy, such a state of mind is a recipe for abuse. The time is long overdue for NHS Talking Therapies and NHS Managers to be properly regulated.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

NHS Talking Therapies Under a Cloud

SilverCloud is a computerised CBT programme, which according to the manufacturers supports ‘80%’ of the NHS services. A year ago, I complained to the Advertising Standards Authority (ASA) over its’ claim of, ‘up to 70% clinical recovery rates’, citing my independent evidence, Scott (2018), that only the tip of the iceberg recover.  The matter was passed to the Irish ASAI, under whose jurisdiction it actually falls, and they informed me  (April 27th 2023 ) that the advertised claim has since changed from “up to 70% clinical recovery” to “up to 65% users achieve clinically significant improvement”. For whatever reason there has been a watering down of SilverCloud’s claim. They no longer want to talk about recovery, a concept that most people can easily understand. The ASAI are continuing to address the matter. Unfortunately NHS Talking Therapies, are it seems answerable to no one and there is no indication that they are abandoning their absurd claim of a 50% recovery rate.

The claim that 65% achieve clinically significant improvement, has a scientific aura about it for a member of the public, but with no idea as to what it means in real world terms. They might consider that as ‘77% of volunteers agreed that volunteering improved their mental health and wellbeing’, National Council for Voluntary Organisations survey 2019, this was actually a better investment.  The implication of SilverCloud’s claim is that it is the use of their product that has brought about the ‘significant improvement’ but this has not been demonstrated. The said improvement could represent regression to the mean, patients presenting at their worst and becoming a bit better with time. Equally it could represent the client’s wish to please the therapist and/or to feel that they have not wasted their time. The claim of ‘significant improvement’ because of usage of the product is not evidence-based and is simply a marketing ploy.

NHS Talking Therapies have produced no evidence that its’ therapists using SilverCloud make any added difference to their clients over and above that of those who didn’t use it. see SilverClouds Space for Depression programme   NICE Guidance ‘Space from depression for treating adults with depression’ Medtech innovation briefing published May 7th 2020. Strangely the NICE IAPT Expert Panel concluded that the case for adoption is ‘partially supported’ despite in the body of report noting lower depression scores, at the end of treatment for the clients of therapists who did not use the computer assisted CBT. An example of spin and conflict of interest.

Dr Mike Scott

 

 

 

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BABCP Response - NICE Consultation January 2022

The Extraordinary Claims and Behaviours of IAPT’s Backers

who exhibit power without accountability. They include companies such as SilverCloud and limbic and professional bodies such as the British Association for Behavioural and Cognitive Psychotherapy (BABCP) and the British Psychological Society (BPS).

I reported SilverCloud to the ASA over its claim of ‘up to 70% clinical recovery rates’ for its computerised CBT. Unfortunately they could not act on it as it comes under Irish jurisdiction. The matter has  been passed to the Irish ASA, from whom I have heard nothing. The reach of SilverCloud is extensive, with its’ claim to be “supporting 80% of the NHS Improving Access to Psychological Therapies(IAPT) services”. It is a major financial backer of IAPT workshops. But there has been no independent verification of SilverCloud’s claimed recovery rates.

IAPT workshops are also now funded by limbic ‘An A. I. assistant for clinical assessment in IAPT – improving access, reducing costs and freeing up staff time’. Recently the British Psychological Society Journal the Psychologist devoted an article to the claims of the CE0 of limbic. I protested, and furnished a critique which the Editor declined. I note that in the current issue of the American Journal of Psychiatry that there is a paper by IAPT researchers Delgadillo et al 2022 JAMA Psychiatry. 2022;79(2):101-108. doi:10.1001/jamapsychiatry.2021.3539 published online December 8, 2021 in which they have been unable to substantiate the claims of limbic.

But Delgadillo et al (2022) do claim a 7% increase in the likelihood of recovery if IAPT therapist use the limbic algorithm i.e inputting data on depression, anxiety, history etc to determine whether the particular clients needs are better met by IAPT standard stepped care or by a stratified procedure where clients are allegedly better matched to high or low intensity CBT initially. However they do observe that the apparent difference could be due the therapists involved in stratification devoting more time to clients!

Delgadillo et al (2022) accept without question IAPT’s definition of recovery, a change of score on a self-report measure, the PHQ9, to below caseness. They fail to point out that their metric does not a) involve independent assessors to counter the demand characteristics involved in usage of a self-report measure i.e the focus on this measure in client-therapist interactions b) the IAPT data provides no indication that clients see the claimed changes as clinically meaningful, i.e back to old self or best functioning c) symptoms of depression and anxiety wax and wane, so that any improvement on a self-report measure can be simply a flash in the pan, particularly when people present initially at their worst. It has to be determined that any change is lasting e.g at least 8 weeks. It appears that Delgadillo et al (2022) simply rejoice in the large data set furnished by IAPT, it is a case of ‘never mind the quality, feel the width’.

When the power holders collude in this way, it is difficult make headway. I think limbic should also be reported to the ASA and BABCP and BPS should be asked to justify their commitment to Psychological Wellbeing Practitioners (PWPs), the deliverers of low intensity CBT – it looks suspiciously like cronyism, however unintentional.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

My black cloud, revolving door and IAPT

‘I found Silvercloud ineffective, generic and not tailored to my personal situation. It wasn’t engaging or helpful and as such I didn’t engage with the website very much. Consequently, the following weekly call with the IAPT therapist  were sometimes made difficult by the fact I hadn’t completed the same questionnaire as the week before or read through articles. I wanted to talk about my situation, my feelings and find out why I was feeling the way I was, but I felt I was just being led back to using the online Silvercloud resource.

‘It was in 2017 that my doctor suggested I try Silvercloud online CBT with telephone support and in September 2017, I started speaking to another IAPT counsellor. He seemed to be a very nice man. After a few weekly calls, he stated that he didn’t believe I was depressed and so he changed the original Silvercloud course I had started and reset it back to a new series of 6 sessions. The weekly calls lasted between 20 minutes to an hour depending on what we discussed, but always concluded with him asking me to log onto Silvercloud and work my way through the programme before our next call. After the requisite 6 sessions finished in February 2018, that was it! No answers, no tools to help me cope, just signed off, discharged, but told I had 12 month access to SilverCloud. I haven’t used the resource since.

I had a very poor experience of counselling through IAPT around 2013. I had been scheduled 6 sessions, these hour long sessions were so ineffective and pointless I can hardly recall anything that was discussed. I may have missed a couple of sessions due to work, but once the 6 sessions expired, I was discharged even though I may have only seen the counsellor 4 times. All I can recall is going over the initial questionnaire about my mood over the previous week which I had been told to monitor through photocopied pictures and graphs which I was told to keep in a file and bring to each appointment’.

 

 

The above is the anonymous report of a depressed client of mine, who is responding very well to my cbt treatment. Not only is she scathing about her IAPT treatment but also about her treatment from her GP:

‘At its height, I was being prescribed 200mg sertraline, 80mg of propranolol. I went to see my doctor for something routine, when she commented on my ‘low mood’ and suggested increasing my antidepressants. I told her I was already taking the maximum dosage and said I didn’t want to take more prescription medicine. I was already taking 200mg of setraline and 80mg of propranolol at that time. My prescriptions had been increased over a period of time without much investigation. In a short 5-10 minute appointment, my ‘low mood’ was usually commented upon and an increase in antidepressant and/or beta blocker was almost automatically prescribed.
In early 2018, I went to see my doctor and insisted that we work together to reduce my medication as I felt so unwell and was sure that the amount of medication I was taking was actually making me feel worse rather than better’.

There is no substitute for really listening.

Dr Mike Scott