IAPT – Discrimination and Incredulous Claims

Dr Michael Kelleher, a Consultant Addictions Psychiatrist, interviewed in next months Psychologist has claimed ‘some IAPT services exclude patients that use or have used alcohol until they are many months post abstinent. This is contrary to positive practice guidelines that the National Treatment Agency brought out’ . He continues ‘if people get detoxed they shouldn’t have to wait an arbitrary length of time to be sober before they can have psychological therapy. They should be able to flow into an anxiety or depression programme straight away once a detox is completed’.

IAPT data on 16,723 clients in the North East of England, Boyd, Baker and Reilly (2019), see link below, suggests that the Organisation is superb at spurning those with an alcohol problem,

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

over a 4 year period the proportion of clients treated with ‘a mental and behavioural disorder due to alcohol use’ never rose above 0.1%, ( 1, 1, 4 and 3 people in successive years). By contrast the proportion with ‘mixed anxiety and depressive disorder’ was 26.8%, 30.5%, 30.1% and 39.6% over the four years.

Dubious Recovery Rate

The North East IAPT service claims a recovery rate of 40-49%, depending on which years are considered. With between a quarter and half of clients categorised as ‘mixed anxiety and depressive disorder’. However the IAPT Manual cautions against the use of the ‘mixed anxiety and depressive disorder’ label thus:

‘The ‘mixed anxiety and depression’ problem descriptor (ICD-10 code) should not be used unless the person’s symptoms of depression or anxiety are both too mild to be considered a full episode of depression or an anxiety disorder. Inappropriate use of the ‘mixed anxiety and depression’ problem descriptor may mean that patients do not receive the correct NICE- recommended treatment. For example, if someone has PTSD and is also depressed they should be considered for trauma-focused CBT as well as management of their depression, but this may not happen if they have been identified as having ‘mixed anxiety and depression’.

Given the common usage of an unreliable ‘mixed anxiety and depression’ label, is it at all credible that the recovery rate should approach IAPT’s claimed national average of 50%? It looks like massaging of data for public consumption.

Choose The Right Clients For Performance

The IAPT Manual published a year ago, see link below:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

clearly and rightly, states that it would be inappropriate for IAPT staff to provide therapy for clients who arrive at a session intoxicated. But delaying treatment once detoxified, smacks of special selection so the agencies performance figures look good – akin to a school selecting the brightest pupils in the area.

Studies generally show that the prevalence of depression and adjustment disorder are about the same, and psychiatrists diagnose them as often as each other, but curiously over half of IAPT clients in the Boyd et al (2019) study are declared to have depression but the prevalence of adjustment disorder doesn’t rise above 0.6% in any year! Either IAPTs population is incredibly skewed or there is no reliability at all in their diagnostic labels, such that therapists don’t have a clue what they are treating!

Non-Declaration of Conflict of Interest In IAPT Studies

IAPT staff have a penchant for not declaring conflicts of interest in published papers, in the Boyd, Baker and Reilly (2019) paper it is written ‘The authors have declared that no competing interests exist’ , but the lead author presenting at a Conference in Amsterdam in May 2016 is described thus:

Lisa Boyd, IAPT service, Tees Esk and Wear Valley Mental Health Trust, UK Impact of a Progressive Stepped Care Approach in an Improving Access to Psychological Therapies Service: An Observational Study

Dr Mike Scott

Organisations Bias Diagnosis and Treatment Pathways

Organisations find the diagnosis they were set up for, creating a label that is passed on without critical re-appraisal – ‘sticky labels’. Resulting oftentimes in inappropriate treatment. Culprits are not only the obviously dedicated services such as those  for Autism Spectrum Disorders (ASD) but missionaries of monopoly training bodies such as EMDR and IAPT. The danger is that the Organisations do not seriously consider a contradictory diagnosis.

 

Recently I saw a 14 year old, two years ago a panel decided that he met criteria for ASD. No individual clinician in the ASD pathway had been definitive about an ASD diagnosis, and the possibility had only been raised when he was aged 11. His social communication was in fact good, interrupting mum appropriately in the Consultation. He clearly had behavioural problems, but there had been no consideration of a possible alternative DSM-5 diagnosis of ‘conduct  disorder with limited prosocial emotions’, instead the Panel concluded ‘will need to be taught social skills methods which suit his ASD needs’ but this has never happened in the intervening 2 years. When Panel decisions are made there is a need to be wary as they make riskier decisions (groupthink). His GP has now suggested that he be guided to a general counselling service for adolescence. No chance it seems of CBT appropriate to his and/or his mum’s needs!

In similar fashion EMDR therapists find PTSD everywhere and IAPT finds a mix of anxiety and depression ubiquitous resulting in poorly targetted treatment.

Dr Mike Scott

Brief Assessments Are The Norm And Invariably Wrong

Work on the assumption that the assessments of others are wrong because they have probably operated on some idiosyncratic  rule of thumb to save time. My cynicism about the assessments of colleagues was heightened recently, two years ago I saw a lady who had a phobia about driving and travelling as a passenger in a car and needed CBT. I’ve just discovered that her GP has decided she has PTSD and she is consequently, about to undergo 12 sessions of CBT.

In a previous post I talked about the importance of ‘Watching and Waiting’ but if this is done without the appropriate measuring instrument, a standardised reliable diagnostic interview all is in vain. My suspicion is that the GP, like many clinicians has in mind a ‘cardinal symptom’ of PTSD such as flashbacks and/or nightmares and uses this rule of thumb (heuristic) to determine treatment. The advantage of heuristics is that they are quick, the disadvantage is that they are usually wrong

see Daniel Kahneman’s book, resulting in a waste of resources and the client likely defaulting from CBT

Dr Mike Scott.

 

Dire Consequences Of Unchallenged Diagnostic Labels

‘Angela’ lost access to her 3 children, because a psychiatrist said she had an ‘Emotionally Unstable Personality Disorder’. When challenged he claimed 4 other clinicians had said the same! It is a classic example of the dire consequences of ‘sticky labels’, the passing on of a diagnosis without rigorous critical appraisal.

In submission to the Court I challenged the psychiatrist’s diagnosis thus ‘he seems unaware of the operation of ‘Diagnosis momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries (patients, paramedics, nurses, physicians), what might have started as a possibility gathers increasing momentum until it becomes definite, and all other possibilities are excluded’ [ Crosskerry, P (2003) The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78, 775-780]. Further the category of Emotionally Unstable Personality Disorder, Borderline Type is never used for research purposes, because to my knowledge there are no studies of its’ reliability [i.e the level of agreement (kappa) amongst a group of clinicians independently viewing the assessment of the same person] instead use is made of the comparable Borderline Personality Disorder in DSM-5 which has very explicit diagnostic criteria and requires assessment of each symptom in a criteria set, in my book Towards a Mental Health System That Works (2017) London Routledge I reviewed evidence that the kappa for DSM defined Borderline Personality Disorder is 0.54 making it a reliable set of symptoms, further when I assessed ‘Angela’ using the DSM criteria for Borderline Personality Disorder she did not meet the criteria’.
In the event the Expert Witness appointed by the Court agreed with me that the psychiatrist had got it wrong, and neither he or his like-minded clinicians had utilised agreed criteria. But all this did not happen until Social Services looked at ‘Angela’s’ behaviour entirely through the lens of Emotionally Unstable Personality Disorder depriving her of a family life.

Dr Mike Scott