Clinical Commissioning Groups, IAPT’s Fairy Godmother

bestowing their munificence without any audit by GPs of local benefit, at a cost nationally of billions of pounds. Yet it should be a simple matter for any GP to interrogate the practice database of IAPT ‘beneficiaries’ and ask the patient the basic question ‘are you back to your usual self since seeing IAPT’? and to further determine whether recovery is stable and reliable by asking ‘for how long have you been back to your usual self?’ Then to integrate the responses with any recent record of functioning in the record of Consultations. Such data can then be presented to the local GP reps on the CCG’s to decide whether the local IAPT is value for money.

CCG’s need to move beyond simple operational matters of numbers of patients seen and waiting times, to a determination of the percentage of people recovering. The randomised controlled trials of cognitive behaviour therapy for depression and the anxiety disorders have suggested a 50% recovery rate when there has been blind assesment of patients. This was the original justification for IAPT. The suspicion is from my independent analysis of 90 IAPT cases that in routine practice the recovery rate is about 10% see link below

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

However when IAPT marks its’ own homework it miraculously comes up with a 50% recovery rate and has seduced CCGs with its own data. The response of most GPs to this is ‘give us a break, but I am nevertheless grateful for a respite from the patient if they are seeing someone else, so I can get on with my core tasks’. We need to move on to a point where GPs are to a degree advocates for their patients, if they don’t do it no one else will. Without such advocacy mental health patients become not just Cinderellas compared to patients with physical problems but confined to their own personal asylum.

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It is perfectly possible transform IAPT so that it properly translates the findings of rcts into routine practice, see my trio of Simply Effective Cognitive Behaviour Therapy books published by Routledge and my last book Towards a Mental Health System that Works (2017) London; Routledge. But we need to wake up and smell the coffee.

Dr Mike Scott

Action Line Needed For Those Failed By Mental Health Services

It is 2 years since the Manchester Arena bombing, Cheryl has been absent from school since, despite 5 sessions of counselling at a well known Children’s Hospital. She and her Aunt (also a victim of the bombing) were invited to consider variously that Cheryl may be autistic, her difficulties may be a product of her mum’s childhood stressors, she may have PTSD and they need family therapy. All of which I found to be total rubbish.

The limited counselling she had only occurred because the Manchester Hub (set up to simply signpost people in the aftermath of the bombing) made regular contact with the Hospital. In fact all she was suffering from was panic disorder with agoraphobic avoidance and illness anxiety disorder. Within 2 sessions she has already made rapid progress.

Her aunt has had twelve sessions with an IAPT service followed by group therapy which she dropped out of. She was never offered any diagnosis. Two years on she is still struggling. Neither Cheryl or her Aunt have had anywhere significant to turn to to protest (the Hospital has made a half apology about being short staffed). But for both children and adults it is not just a question of money, the quality of service is woeful.

There is a pressing need for an action line for those failed by Mental Health Services.

Two years ago I wrote the book ‘Towards a Mental Health System That Works’ London, Routledge, the system is no better, just that some agencies are highly skilled at self-promotion and thereby expansion, MPs have been taken in by this and like to be seen to be on the side of mental health.

Dr Mike Scott

Mental Health Systems Not Fit For Purpose

The promise of evidence based CBT treatments and antidepressants seems not to be realised in practice, an editorial in the current issue of the Canadian Journal of Psychiatry notes:

‘Despite a 3- to 4-fold increase in the use of antidepressant
medications, the prevalence of depression and anxiety dis
orders in Australia, Canada, the United Kingdom, and the United States has remained unchanged over the past .1 20 years In the absence of compelling evidence that the incidence of these disorders is on the rise, a natural conclusion is that depressed or anxious patients who could benefit from treatment are still not identified and treated, or that the duration of illness has remained unchanged in those who are treated. This is a striking and troubling finding, considering the known efficacy of antidepressants and psychotherapies. It emphasizes both a well-delineated treatment gap, whereby many patients with depression or anxiety do not receive treatment, and a quality gap whereby those who are treated either do not need to be treated or do not receive effective 2-7 treatment’. Click link below for full editorial: https://www.dropbox.com/s/kbmly9awq9diflb/Collaborative%20Care%202018%20mediocre%20usual%20care.pdf?dl=0

  1. Jorm AF, Patten SB, Brugha TS, et al. Has increased provision
    of treatment reduced the prevalence of common mental disorders?
    Review of the evidence from four countries. World Psychiatry.
    2017;16(1):90-99.
  2. Jorm AF. The quality gap in mental health treatment in Australia.
    Aust N Z J Psychiatry. 2015;49(10):934-935.
  3. Lin EH, Katon WJ, Simon GE, et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp
    Psychiatry. 2000;22(2):78-83.
  4. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in
    primary care: a meta-analysis. Lancet. 2009;374(9690): 609-619.
  5. Simon GE, VonKorff M, Wagner EH, et al. Patterns of antidepressant
    use in community practice. Gen Hosp Psychiatry. 1993;15(6):399-408.
  6. Kendrick T, King F, Albertella L, et al. GP treatment decisions
    for patients with depression: an observational study. Br J Gen
    Pract J R Coll Gen Pract. 2005;55(513):280-286

But the editorial posits that greater collaboration between services would usher in the promised land. Whilst this might be helpful, a failure to understand what constitutes a faithful translation of the positive results of randomised controlled trials for depression and the anxiety disorders [see Scott (2017) Towards a Mental Health System That Works London: Routledge https://www.amazon.co.uk/Towards-Mental-Health-System-Works/dp/1138932965/ref=sr_1_1?ie=UTF8&qid=1547819366&sr=8-1&keywords=Towards+A+Mental+Health+System] into routine practice will continue to nullify any actions. Unfortunately in the UK, IAPT continues to pursue its own fundamentalist translation of the randomised controlled trials, despite evidence that it doesn’t work, with just a 15% recovery rate [ Scott (2018) see link below:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Further IAPT has extended its’ empire well beyond the borders of reliable evidence based outcome studies e.g to medically unexplained symptoms. Staff are frightened to speak out publicly. It is difficult to escape charging IAPT with imperialism. Theirs is a dominant narrative in BABCP, British Psychological Society and in journals such as Behaviour Therapy and Research.

Dr Mike Scott