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Testing For Mental Health Is A Token Gesture Compared to Testing For The Corona Virus

Nobody doubts that testing for the the Corona virus is a necessary part of the treatment planning for those with a fever and persistent cough. However the test alone is not judged sufficient, it has to be complemented by other clues such as the result of X-rays, a CT scan, and consideration of whole range of Covid-19 symptoms before the clinician makes a judgement on diagnosis. This contrasts sorely with the position in routine mental health services where in the Improving Access to Psychological Therapies (IAPT) service the sole arbiter of treatment decision making and judgement of outcome is the PHQ9/GAD7, accompanied by an unbridled clinical judgement. Yet the authors of the PHQ9 [Kroenke et al (2001 )] and GAD7 [Spitzer et al (2006)] insisted that the tests results needed to be interpreted in the context of a diagnostic interview. 

The completion of the PHQ9/GAD7 is mandated by the IAPT hierarchy, but clinicians have little or no interest in the results except that they may be disciplined if there is a pattern of non-recovery on these measures. IAPT Psychological Wellbeing Practitioners were asked to identify potential clients with GAD ( a score of 10 or more on the GAD7 ) for a study Kalpakidou et al (2019) https://doi.org/10.1186/s13063-019-3385-5  comparing the efficacy of CBT (delivered by high intensity therapists) to medication. But they put too few clients (only 12% of those potentially eligible) forward that the trial was cancelled. The take home message appears to be that for clinical purposes PWPS don’t take PHQ9/GAD7 measures seriously and operate on the basis of their own clinical judgement e.g whether a client’s stress is just a  natural reaction to a difficult situation or whether simple psychological first aid is judged sufficient to address difficulties. There appears to be little believe in the importance of stepping up clients and indeed only 10% of clients are stepped up. 

The judgement of PWP’s ( who provide over 70% of IAPT contacts) will likely be influenced by their training, the focus of which is on goal setting and tackling the most important problem see Richards and Whyte (2011) Reach Out 3rd Edition. But PWP’s are painfully unaware that such interviews have no more reliability that the standard open ended psychiatric interview with at most a 1 in 2 chance that different assessors seeing the same interview would agree  on the way forward [see Spitzer RL, Fleiss JL. A re-analysis of the reliability of psychiatric diagnosis. Br J Psychiatry 1974;125(0):341–7]. Essentially judgements are idiosyncratic unless a standardised semi-structured interview such as the SCID, DIAMOND or MINI is included in the assessment. Without such reliable assessments PWPs are operating outside the sphere of evidence based interventions.

Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-1097.

Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-613.

Dr Mike Scott

 

 

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