stepped care mental health Archives

NICE Rubber Stamps Business as Usual

despite the fact that the main provider of psychological services, the Improving Access to Psychological Therapies (IAPT) Service is ‘An Abject Failure’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/. It is all about cost, with no regard for evidence. It is recommended by the National Institute for Health and Care Excellence (June 29th) that clients are offered 11 possible interventions for depression, presenting the least costly first, guided self-help, group cognitive behavioural therapy (8 sessions) progressing up to the 11th option, short term psychodynamic psychotherapy. With Psychological Wellbeing Practitioners (PWPs) providing the assessment and the least costly interventions. But PWPs are not trained therapists and the IAPT Manual states that its’ employees do not make diagnoses and they are not trained to diagnose. Yet bizarrely NICE states that assessors must be competent to make a reliable assessment of depression! A pig’s ear of monumental proportions.

There is no empirical evidence that 8 sessions of group CBT delivered by PWPs makes a real world difference to client’s lives as assessed by a blind assessor. Nor that the recommended 8 sessions of individual CBT for depression, presumably delivered by a high intensity therapists, constitutes a therapeutic dose of treatment.

The revision of the Draft Nice Guidance on Depression https://www.nice.org.uk/guidance/ng222 now recommends a stepped care approach to depression and sees Psychological Wellbeing Practitioners as contributing to treatment. This has brought a ‘hurrah’ from BABCP (British Association for Behavioural and Cognitive Psychotherapy), as it is exactly what they lobbied for https://babcp.com/About/News-Press/Revised-NICE-Guideline-on-Depression-in-Adults post the Draft guidelines. Dr Andrew Beck the BABCP President proclaims in the press release ‘the guidedInes highlight the amazing value of PWPs’. In addition antidepressants and CBT in combination are seen as the treatment choice for severe depression.

But these recommendations and changes are eminence-based not evidence-based. A paper published in the Journal of Psychiatric Research last year by Bartova et al (2021) https://doi.org/10.1016/j.jpsychires.2021.06.028 showed a 25% response rate for those who had antidepressants and manual-driven psychotherapy (mostly CBT), no better than antidepressants alone. This compares with a 31% response rate in those given a placebo Rutherford and Roose (2013) https://doi.org/10.1176%2Fappi.ajp.2012.12040474

Before BABCP issued the press release, I raised the following issues with its’ author Professor Reynolds:

I can find no randomised control trials of low intensity interventions that are methodologically robust enough to lead to the conclusion that such interventions should be the initial treatment of choice for less severe depression.

I can find no evidence that as a result of stepped care, the trajectory of clients with depression Is meaningfully better than if they were not treated in a stepped care model.
There was criticism of the initial draft for the ‘marginalising and undervaluing of PWPS’. However, it appears that under pressure from BABCP, PWPS are now to be lauded. But there is an absence of evidence of what PWP treatment works for whom and in what circumstances. As such their interventions are not evidence- based. Further they are not psychological therapists.

NICE have apparently indicated that the IAPT database may be used to inform the next set of guidelines. But this database tells us nothing of the course of any client’s disorder as the service does not make diagnoses or engage in long-term follow up.

I asked that my dissent from BABCPs press release be publicly noted, and was told simply that it would be passed to the BABCP Board. At the same time the comments of IAPTs lead, Professor Clark. on the importance of including relapse prevention in treatments, would be included in the press release and it was. An in-group clearly operates. I am reminded that when I submitted an article to the BABCP comic, CBT Today on IAPT, the article was rejected not by the editor but by the past (Prof Salkovskis) and current (Dr Andrew Beck) Presidents of BABCP. The matter was never addressed by the Board despite an assurance from Dr Beck. If ever there was a clique. Unholy alliances rule.

Dr Mike Scott

The Bell Tolls for IAPT if NICE Has Its’ Way

according to the BABCP’s submission BABCP response – NICE consultation draft to the National Institute for Health and Clinical Excellence (NICE ). Implementation of the latter’s proposed guidance would mark the end of the Improving Access to Psychological Therapies (IAPT) service.

Interestingly BABCP recommend that assessment should begin with a reliable diagnostic interview and acknowledges that IAPT’s Psychological Wellbeing Practitioners (PWPs) are not equipped to do this. Further BABCP recommend that outcomes should be assessed from the client’s perspective but do not specify how. Ironically some of BABCP’s own recommendations undermine the functioning of its over-induIged prodigy, IAPT. BABCP are alarmed that the proposed guidance would, in their view, herald the end of stepped-care.

BABCP are aghast that NICE have not included studies by IAPT related personnel in determining the way forward. In defence of IAPT, BABCP cite the Wakefield et al(2021) https://doi.org/10.1111/bjc.12259 study published in the British Journal of Clinical Psychology but fail to mention my rebuttal paper Scott(2021) https://doi.org/10.1111/bjc.12264 published in the same issue of the Journal. Quite simply NICE does not consider studies that are based on agencies marking their own homework as having any credence. This is thoroughly reasonable.

The BABCP have rightly pointed out to NICE that in recommending group interventions as the starting point for offering clients help, they have not properly looked at the context of the group studies. As I pointed out in my submission to NICE COMMENTS ON PROPOSED GUIDANCE (and simultaneously submitting via BABCP as a stakeholder), there are considerable hurdles in engaging clients in group therapy, see Scott and Stradling (1990)Group cognitive therapy for depression produces clinically significant reliable change in community-based settings Behavioural Psychotherapy, 18: 1-19 and Simply Effective Group Cognitive Behaviour Therapy Scott (2011) https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiph5Hlvbb1AhWKX8AKHRSJDZ0QFnoECAUQAQ&url=https%3A%2F%2Fwww.amazon.co.uk%2FSimply-Effective-Cognitive-Behaviour-Therapy%2Fdp%2F0415573424&usg=AOvVaw0nam02gszlQ0HqCktSCB0s.

In fairness, I think Prof Shirley Reynolds from BABCP has done a great job in reviewing the extensive documentation provided by NICE and collating the individual submissions, all within a very brief period of time. I understand from her that these matters will feature in the next issue of CBT Today and whilst I was happy to have my name noted as having submitted, there are important aspects of the submission on which I wish to dissent.

NICE make its’ formal recommendations in May, interesting times

Dr Mike Scott