IAPT under the microscope, 2018, Marks

Andy

Andy

Retired committee member
Abstract
England’s flagship ‘Improving Access to Psychological Therapies’ (IAPT) service has cost around £1 billion yet Scott’s (2018a) study suggests that only 9.2% of IAPT patients recover. This leaves an enormous gap of 40.8% between the observed recovery rate and IAPT’s claimed recovery rate of 50.0%. The spotlight is on patients with ‘medically unexplained symptoms’ (MUS) and ‘long-term conditions’ (LTCs) such as ‘diabetes, COPD and ME/CFS, yet there is no way of knowing whether IAPT is capable of yielding the promised rewards or English patients are being sold an expensive pup. An urgent independent expert review of IAPT recovery rates is necessary to answer this question.
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Open access at http://journals.sagepub.com/doi/full/10.1177/1359105318781872
 
My emphasis and underlining.

The most common LTC patients who are likely to be seen in new integrated IAPT services are those with diabetes, chronic obstructive pulmonary disease, cardiovascular disease, musculoskeletal problems and chronic pain.
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The new findings of Michael J Scott (2018a) suggest that IAPT review and/or reformulation is definitely warranted. Scott used a robust and rigorous methodology consisting of a standardised semi-structured interview and the Structured Clinical Diagnostic Interview for DSM Disorders, and listened to patients’ own accounts of their interaction with the service. Scott’s results suggest that only the ‘tip of the iceberg’ fully recovers from their disorders (9.2%), leaving an enormous gap of 40.8% between the target and the true situation.
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To fully recover from, for example, diabetes, one would need to become "not diabetic" and all damage done to body tissues would need to be reversed. To fully recover from COPD one would need a new set of lungs. COPD is a progressive disease that slowly destroys the lungs and the damage has never been reversed as far as I know. Cardiovascular disease - as a minimum arteries would need to become unclogged.

No amount of talking therapy is going to achieve the things I've suggested. It simply cannot happen. So, what weird definition of "full recovery" are people invested in IAPT actually using?
 
Probably the type where either

you don' t go back because it does nothing for you and the assumption is that you have "recovered".

Your perception of symptoms has changed - particularly beloved of pain management- to enable you to fill out a questionnaire and magically be " recovered" ....
 
The Editorial linked in the OP of this thread is the first of a group of articles published together in the current JHP edition.

The link to the journal is here:
http://journals.sagepub.com/toc/hpqa/current

Articles on IAPT in the journal are:

Improving Access to Psychological Therapies (IAPT) - The Need for Radical Reform
Michael J Scott
First Published February 2, 2018;

The diagnosis is correct, but National Institute of Health and Care Excellence guidelines are part of the problem not the solution
Sami Timimi
First Published March 30, 2018;

Attempting to reconcile large differences in Improving Access to Psychological Therapies recovery rates
Scott H Waltman
First Published July 14,

Medical approaches to suffering are limited, so why critique Improving Access to Psychological Therapies from the same ideology
James Binnie
First Published April 10, 2018;

Transforming Improving Access to Psychological Therapies
Michael J Scott
First Published June 12, 2018;
 
Arnie Pye said:
To fully recover from, for example, diabetes, one would need to become "not diabetic" and all damage done to body tissues would need to be reversed. To fully recover from COPD one would need a new set of lungs. COPD is a progressive disease that slowly destroys the lungs and the damage has never been reversed as far as I know. Cardiovascular disease - as a minimum arteries would need to become unclogged.

No amount of talking therapy is going to achieve the things I've suggested. It simply cannot happen. So, what weird definition of "full recovery" are people invested in IAPT actually using?
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I think the recovery claims are for depression and/or anxiety only.
 
Arnie Pye said:
So what benefits are there supposed to be for the people with diabetes, COPD, cardiovascular disease etc who are pushed into IAPT therapy?
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From The Improving Access to Psychological Therapies (IAPT) Pathway for People with Long-term Physical Health Conditions and Medically Unexplained Symptoms Full implementation guidance — section 2.2, pp. 13-15:
The impact on the person

Untreated depression and anxiety disorders can lead to a range of adverse psychological, social and employment outcomes for the person. These may include:

• Lower likelihood of engaging with treatment for the physical health problem and reducing the person’s ability to effectively self-manage the problem: coexisting mental health problems can reduce a person’s motivation and energy to follow treatment plans and self-manage. For example, depression is associated with poorer adherence to dietary interventions in people with diabetes.

• Higher likelihood of unhealthy behaviour: mental health problems are associated with higher rates of smoking, alcohol and drug use, poor diets and decreased physical activity.

• Poorer physical health, including premature mortality: people with comorbid mental health problems and LTCs have been shown to have higher rates of functional impairment and a heightened risk of premature morality. For example, in people with COPD,50% more acute exacerbations were reported in those with common mental health problems than those without. Where diabetes coexists with depression, mortality rates are around 38% higher than those with diabetes alone.

• Poorer employment outcomes: there is a higher risk of unemployment in people with coexisting mental and physical health problems and for those in employment a high risk of absenteeism, poorer performance and lower income.

• Poor social outcomes: for instance, people are more likely to experience social problems and stress over the first year of recovery from post-myocardial infarction if they have depression.


The impact on the NHS

Healthcare costs for those with coexisting mental health problems and LTCs are significantly (around 50%) higher. A large proportion of this cost is accounted for by increased use of physical health services (not mental health services). For example:

• depression is associated with increased rehospitalisation rates in people with cardiovascular disease and COPD, compared with the general population

• people with MUS account for up to 45% of primary care consultations and up to 66% of outpatient clinics.

• people with MUS who were not offered psychological therapies as part of their care were found to have a higher number of primary care consultations, than those who were; similarly, people with COPD who were not offered psychological therapies as part of their care were found to have a higher number of urgent and emergency department admissions than those who were.
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[PDF] https://www.rcpsych.ac.uk/pdf/IAPT-LTC _Full_Implementation_Guidance.pdf
 
"depression is associated with increased rehospitalisation rates in people with cardiovascular disease and COPD, compared with the general population"

But surely that's because 'the general population' don't have COPD and cardiovascular disease or am I reading this incorrectly?

"people with MUS who were not offered psychological therapies as part of their care were found to have a higher number of primary care consultations"

again, that's obvious to me. They want to know WTF is wrong with them! and if the GP keeps fobbing them off.............then they are sent along to a therapist who will at least listen to them for a while.
But I bet that once they've finished the psychological therapy they wouldn't bother going back to the GP as they know they won't do anything..........so bingo they're cured.........until they end up in A and E with something serious.
 
Sly Saint said:
"depression is associated with increased rehospitalisation rates in people with cardiovascular disease and COPD, compared with the general population"
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Or maybe, just maybe, severe COPD can leave you feeling depressed.

Or maybe having severe COPD just makes you tick more items on a depression scale, so you're more likely to "look" depressed? I wonder how many items examine fatigue, concentration, sleep, all of which may be compromised in COPD? I bet its never occurred to anyone to have a look at the scales they use, and check they are valid for use with the chronically ill.
 
NelliePledge said:
bet its that pile of poo Chalder Fatigue scale they use
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The depression symptom measure is, I think, always the PHQ-9 irrespective of condition. Anxiety/MUS symptom measure depends on the so-called problem descriptor, but is GAD-7 for several problem descriptors. In the case of MUS referrals, it depends on the condition.

In CFS it would be PHQ-9 for depression (despite no requirement for depression to refer) and the Chalder Fatigue Scale for MUS, with GAD-7 if the CFQ measure is missing.

Woolie said:
I bet its never occurred to anyone to have a look at the scales they use, and check they are valid for use with the chronically ill.
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The PHQ-9 (for instance) will certainly register answers that are given as a result of loss of function, wellness, and quality of life as indicative of depression.

Sly Saint said:
again, that's obvious to me. They want to know WTF is wrong with them! and if the GP keeps fobbing them off.............then they are sent along to a therapist who will at least listen to them for a while.
But I bet that once they've finished the psychological therapy they wouldn't bother going back to the GP as they know they won't do anything..........so bingo they're cured.........until they end up in A and E with something serious.
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Exactly right.
 
"The Cost of IAPT Is At Least Five Times Greater Than Claimed

8th August 2018

Published in BMJ
‘Six years ago a News headline in the BMJ proclaimed ‘Increasing access to psychological therapies will cost NHS nothing’ BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4250, citing a report of Lord Layard of the Mental Health Policy Group of the Centre for Economic Performance http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp, that claimed ‘after an average of 10 sessions half the people with anxiety conditions will recover, most of them permanently, and half the patients with depression will recover’ . Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.

The progenitors of IAPT, Clark and Layard in their book Thrive (2015) claim that the cost of treatment in IAPT is £650 per person, for people having attended 2 or more treatment sessions. This leaves out of account the 40% of its clients who attend only one treatment session [IAPT (2018)] and the costs of the initial assessments which totalled £92 million in 2016-2017, with total costs of £367,219,192 in that period. This means that the true cost of IAPT is at least 5 times greater than alleged, all without any government funded independent audit. Further average session attendance for those ‘treated’ in IAPT is 6.6 [IAPT (2018)] not the average of 10 sessions that Lord Layard deemed necessary, so that the average patient in fact receives a sub-therapeutic dose of treatment."
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full letter here:
http://www.cbtwatch.com/category/iapt/
 
It is interesting to see how most of the people involved in this debate, including Scott, shy away from the elephant in the room - that the evidence for psychotherapy is not good enough. Scott criticises PACE on selection criteria but fails to point out that the study tells us nothing about effectiveness of CBT even in the patients treated.

What I seem to see here is as much as anything jostling for a piece of the cake amongst the psychology fraternity.
 
Sly Saint said:
"The Cost of IAPT Is At Least Five Times Greater Than Claimed

8th August 2018

Published in BMJ


full letter here:
http://www.cbtwatch.com/category/iapt/
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Here's the BMJ Rapid Response: https://www.bmj.com/content/344/bmj.e4250/rapid-responses

It was attached to the 2012 BMJ article.

I don't trust the official IAPT recovery figures, and they seem likely to really exaggerate the true 'recovery' rate, but I'm not sure about Scott's 10% figure either.

Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.
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He only looked at 90 cases, and we don't know how representative these cases were of those who attended IAPT so I don't have much confidence that the 10% figure will hold up.
 
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Didn't know where to put this; comments on CBT Watch:

".....we do need good quality talking therapies but we have not got them, rather we have a 10% recovery rate for those undergoing treatment with IAPT http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264.
I very much doubt that IAPT or anyone has an evidence based psychological treatment for a person with bipolar disorder and it would be disingenuous to pretend we have.

Nevertheless IAPT has trespassed into providing treatment for medically unexplained symptoms, which is an unfortunate precedent for claiming more than we can deliver."

"Will IAPT reform itself before it is too late? There is a glimmer of hope, in that I did not meet with open hostility recently when I suggested that it needs reconfiguring to ensure reliable assessment.

But the economic argument for IAPT will be in tatters after a new paper is likely published in the coming months, which will show what the National Audit Office has signally failed to make public – a matter for the House of Commons Public Accounts Committee."

http://www.cbtwatch.com/
 
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