Improving Access to Psychological Therapies (IAPT) - The Need for Radical Reform, 2018, Scott

L

Londinium

Senior Member (Voting Rights)
http://journals.sagepub.com/doi/full/10.1177/1359105318755264#articleShareContainer (Free full text - mentions PACE)

Abstract


Improving Access to Psychological Therapies is a UK government-funded initiative to widen access to the psychological treatment of depression and anxiety disorders. The author has had the opportunity to independently assess 90 Improving Access to Psychological Therapies clients, using a standardised semi-structured interview, the Structured Clinical Diagnostic Interview for DSM Disorders (SCID) and to listen to their account of interaction with the service. The results suggest that only the tip of the iceberg fully recovers from their disorder (9.2%) whether or not they were treated before or after a personal injury claim. There is a pressing need to re-examine the modus operandi of the service.
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PACE cited in the introduction, as an example of dubious trial:

The PACE (pacing, graded activity, and cognitive behaviour therapy: a randomised evaluation) trial of the effectiveness of cognitive behaviour therapy (CBT) and graded exercise for chronic fatigue syndrome came in for fierce criticism in this journal on the grounds that when objective measures of outcome were used the effectiveness of CBT disappeared (Geraghty, 2017; Vink, 2017). The authors of the PACE trial relied on subjective self-report measures to ‘promote’ the cognitive behaviour therapy and graded exercise therapy protocols that they themselves had developed. This cast into doubt the wisdom of spending £5 million of the taxpayer’s money on the trial (Marks, 2017).
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A little hard to follow, but definitely interesting and useful in challenging the claimed efficacy of IAPT and similar treatment modalities. Basically IAPT is failing to prove that they are helping patients, especially in a meaningful manner (versus some dodgy uses of questionnaires), and the limited data reviewed by the author suggests that even those numbers have been badly inflated.
 

"However, the UK Government’s Improving Access to Psychological Therapies (IAPT) programme has similarly relied on subjective outcome measures (Layard and Clark, 2014) offering little by way of accountability for the £1 billion pound spent on IAPT since its inception."
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wow

And he suggests they arent even doing a good job getting the diagnosis right as a prerequisite for selecting the right method
 
It's a government policy decision made so they can claim more people with mental illness are being treated than ever before. While at the same time closing down inpatient facilities for those with really severe mental illnesses which are much more expensive.

Result - prisoners and rough sleepers with serious mental illness who need good inpatient mental health care, and lots of under-trained 'therapists' messing with the heads of mildly to moderately anxious and depressed folk and people with physical 'MUS' illnesses who shouldn't be fobbed off with CBT.
 
While loving any critical reference to PACE, and sceptical of the overall value of IAPT, I'm not sure about this paper.

How was the sample selected?

It sounds like it's different from what is reported for IAPT elsewhere:

The rate of recovery in this sample of 24.0 per cent is substantially less than the recovery rate of 40.0 per cent of clients that is claimed by IAPT (Gyani et al., 2013).
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This was mentioned, but I didn't see any details on exactly how the sample was selected:

Limitations
This audit is limited to a sample of IAPT clients whose difficulties have been triggered or exacerbated by some trauma, and as such, the sample may not be representative of all IAPT clients
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I thought that the arguments presented which criticised the way IAPT worked out assessed outcomes were stronger than the alternative data presented here. Without more information on how the participants were selected t's difficult to interpret the results.

This was a bit interesting:

Table 4 indicates that litigation makes no difference to recovery rates. It may be anticipated that the recovery rate post personal injury claim would be less as litigants may have a vested interest in exaggerating debility but inspection of Table 4 does not support this. Further it could be argued that litigants would minimise their distress prior to the personal injury claim and if they had had treatment before exaggerating how useful it had been i.e. that recovery rates would be higher before than after but Table 4 does not support this
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I didn't read the testimony in the appendix.
 
Professor Ken Laidlaw (UEA) discussing the aims of the IAPT programme with Kevin Jarman, IAPT Programme Manager 2008-15 and Work and Health Joint Unit DWP/DH Lead:

Kevin Jarman: '...we moved very quickly into roll out. In fact, to be honest, the evaluation of IAPT at those Newham and Doncaster services wasn't actually published until 2010, by which time we were at least two years into the roll-out of the programme, which er, if you look at I suppose improvement science, that's not probably the best way of doing it. But we were fortunate that the original erm the original er way the programme was set up and the sort of original results were so positive that people thought and policy makers thought that it was worth going forward into the next roll out phase.'

https://www.uea.ac.uk/medicine/depa.../-about-iapt-and-the-history-of-the-programme
 
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Transforming Improving Access to Psychological Therapies

Abstract
The three commentaries on my paper ‘IAPT – The Need for Radical Reform’ are agreed that Improving Access to Psychological Therapies cannot be regarded as the ‘gold standard’ for the delivery of psychological therapy services. Furthermore, they agreed that Improving Access to Psychological Therapies should not continue to mark its ‘own homework’ and should be subjected to rigorous independent evaluation scrutiny. It is a matter for a public enquiry to ascertain why £1 billion has been spent on Improving Access to Psychological Therapies without any such an independent evaluation.

What is interesting is that nocommentary has been forthcoming from the UK Improving Access to Psychological Therapies service nor have they shared a platform to discuss these issues. It is regrettable that the UK Government’s National Audit Office has chosen, to date, not to publish its own investigation into the integrity of Improving Access to Psychological Therapies data. Openness would be an excellent starting point for the necessary transformation of Improving Access to Psychological Therapies.
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Paywalled at http://journals.sagepub.com/doi/abs/10.1177/1359105318781873
 
A nice abstract. I will presumably be able to get at this through college but it takes me a while to get through the system. This is presumably what David Marks flagged up as imminent a week or so ago.

I thought the figure must be getting somewhere near a billion. With my 96 year old mother waiting in A/E again this evening I am unimpressed.
 
A quote from this new paper

The current IAPT organisation bears all the hallmarks of a fundamentalist group, with its own idiosyncratic interpretation of sacred texts (RCTs and NICE Guidance) that brooks no disagreement, with expansionism as its creed, where staff are fodder for its ‘mission’, and never employing quality control to ensure that clients are actually receiving an evidence-based psychological therapy. Essentially, there is no accountability for the expenditure of vast sums of public money combined with hype and hyperbole in the place of evidence of effectiveness.
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Ouch.
 
A nice paper. I see Indigo has got theURL for everyone to see.
Basically it shows that IAPT is hopeless for the conditions that CBT is supposed to be standard for. It does not even mention MUS or ME or the problems of PACE.

But it is worse than that. Although the author is clearly being usefully critical I get the impression he still believes that randomised controlled trials (note the absence of double blind) for these therapies can give reliable results. He argues with others who seem even less critical than him but they are still arguing over evidence that is basically no use. And he talks of tailoring treatment to the patient, which sounds sensible but clearly cannot be evidence based.

The bottom line for me is that this really is the worst case scenario. The whole business is voodoo in comparison to normal medical science. I now see why referees of my own paper wanted me to cut out comments that might make it look as if rather a lot of clinical psychology trials might be useless. As the author of this paper concludes, the Emperor really has nothing at all.

That said, inasmuch as you can get useful evidence in this context, the author here seems to have done a very good job. He has produced figures that clearly do make some sense. Simon Wessely was right. If you do trials that suggest that there is a curative recipe, a whole lot of incompetent people will be brought in to provide a service that is of no use to anyone.

It's bit like when we got people in to look at how bad the dry rot was in the downstairs bedroom window frame. They told us that the upstairs bedroom floor had no joists left and asked when we last went into that room.
 
"‘Around half are likely to be completely cured’ was the proud boast of Alan Johnson, Secretary of State for Health, on 10 October 2007 at the inception of Improving Access to Psychological Therapies (IAPT). It is tempting both in research and public policy to redefine the original hypothesis when the findings do not support the prediction."

Fifty per cent recovery rate was more than a prediction by Alan Johnson. It was a mandated standard.

The Mandate
A mandate from the Government to NHS England: April 2014 to March 2015
Presented to Parliament pursuant to Section 13A(1) of the National Health Service Act 2006

https://mentalhealthpartnerships.com/resource/nhs-mandate-2014-to-2015/

p. 15: "3.7 This will also involve extending and ensuring more open access to the Improving Access to Psychological Therapies (IAPT) programme, in particular for children and young people, and for those out of work. NHS England has agreed to play its full part in delivering the commitments that at least 15% of adults with relevant disorders will have timely access to services, with a recovery rate of 50%. They will also begin planning for country wide service transformation of children and young people’s IAPT. NHS England will work with stakeholders to ensure implementation is at all times in line with the best available evidence."

p. 5: "7. NHS England is legally required to pursue the objectives in this document.3 However it will only succeed through releasing the energy, ideas and enthusiasm of frontline staff and organisations. The importance of this principle is reflected in the legal duties on the Secretary of State and NHS England as to promoting the autonomy of local clinical commissioners and others."

This standard was reiterated in the 2015/16 and 2016/17 NHS Mandates.


NHS Service Standards

https://www.england.nhs.uk/mental-health/adults/iapt/service-standards/

"Access standard
Access: IAPT services should be providing timely access to treatment for at least 15% of those who could benefit (people with anxiety disorders and depression.

"Recovery standard
Recovery: At least 50% of people who complete treatment should recover."
 
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