The IAPT Pathway for People with Long-term Physical Health Conditions and MUS. Full implementation guidance.

Esther12

Esther12

Senior Member (Voting Rights)
"The Improving Access to Psychological Therapies (IAPT) Pathway for People with Long-term Physical Health Conditions and Medically Unexplained Symptoms. Full implementation guidance"

https://www.rcpsych.ac.uk/docs/defa...implementation-guidance.pdf?sfvrsn=de824ea4_2

This looks as bad as you'd expect considering people like Rona Moss-Morris and Michael Sharpe are part of their expert reference group.

Looks like this is likely to have a big impact on patients, and lead to the creation of a lot more professional with a vested interest in protecting biopsychosocial approaches to MUS.

Their MUS definition:

Persistent and distressing bodily symptoms characterised by functional disability that cannot
wholly be explained by a known physical pathological cause; psychological processes are often involved in the presentation of MUS. Examples include: chronic fatigue syndrome, chronic pain and irritable bowel syndrome.
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I'm sure I was recently reading someone saying that they found a lot of figures like these were spun:

people with MUS account for up to 45% of primary care consultations [37, 40] and up to 66% of outpatient clinics. [41]
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37
Burton C, McGorm K, Richardson G,
Weller D, Sharpe M. Healthcare costs
incurred by patients repeatedly referred to
secondary medical care with medically
unexplained symptoms: a cost of illness
study. Journal of Psychosomatic
Research. 2012;72:242-47.

40
Konnopka A, Kaufmann C, König H,
Heider D, Wild B, Szecsenyi J, et al.
Association of costs with somatic
symptom severity in patients with
medically unexplained symptoms. Journal
of Psychosomatic Research. 2013:370-75

41
Nimnuan T, Hotopf M, Wessely S.
Medically unexplained symptoms: an
epidemiological study in seven specialties.
Journal of Psychosomatic Research.
2001;51:361-67

They've already been adding staff for this, and expect to need another 4,500:

It is expected that 4,500 more clinicians will be
required to support the expansion of IAPT-LTC services.
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The key skills required to deliver psychological therapies effectively for people with LTCs and MUS are outlined in the Competence Framework for Psychological Interventions with People with Persistent Physical Health Conditions 47 (see Figure 5 ) .
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47
Roth A, Pilling S. A Competence
Framework for Psychological Interventions
with People with Persistent Physical
Health Conditions. London: UCL; 2016.

Figure 5 is on page 21 and does not inspire confidence. It's things like this as 'Core Knowledge': "Knowledge of a generic model of MUS".

Shows how important NICE have been for promoting this stuff:

4.1
Existing NICE guidance
A wide range of NICE guidance is available for the treatment of depression and anxiety disorders in the general population, for LTCs and for specific diagnostic groups of MUS, including irritable bowel syndrome and chronic fatigue syndrome.
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It's hard to remember which quack-ridden expert advisory group is which with the MUS stuff:

4.1.1 Recommendations of an expert advisory group
With this in mind an expert advisory group was convened by NHS England c to review d existing NICE guidance for the use of psychological therapies for the treatment of depression and anxiety disorders in the context of LTCs and for the treatment of MUS
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c
NHS England IAPT Education and Training Group
(ETG).
d
It should be noted that ‘review’ in this context does
not mean appraising the guidance with a view to
updating it because of potential new evidence,
but rather assessing whether psychological
therapies recommended for people with
depression and anxiety disorders are suitable for
people who also have LTCs and who have
MUS.
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So what's recommended for CFS and MUS, and why?:

Chronic fatigue
syndrome

Graded exercise therapy, CBT
*
NICE guideline:
CG53
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MUS not
otherwise
specified
CBT
*
Informal consensus
of the ETG
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There's no mention of the CFS guidelines being updated although they say "Note: NICE depression guidance currently being updated."
 
IAPT Guidance document - foreword said:
Improving Access to Psychological Therapies (IAPT) services are transforming the treatment of depression and anxiety-related disorders in England. Now established in every clinical commissioning group, the services are providing a course of NICE-recommended psychological therapy to over half a million people each year. A new session-by- session outcome monitoring system captures the clinical outcomes of 98% of these individuals, with around half meeting criteria for a full recovery and two thirds showing clinical improvement. This is what we would expect to see in a clinical trial.....
Professor David M. Clark CBE, National Clinical and Informatics Advisor for IAPT
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I feel the urge to quote Kim Joy yet again.
https://www.s4me.info/threads/bake-...orking-in-nhs-mental-health.6918/#post-124940
She is always careful not to come across as critical, and never more so than when she talks about her work. “I love the NHS. I really want to work in the NHS, but I’m at a point where the clinical side of mental health isn’t for me.

You do a questionnaire with each person when they come in. So they tell you how many times that week they’ve felt low, which is a really weird question. It’s not real. Professionals need it for their data, to see who’s recovering.

A lot of people just make up their answers, because they want to sound like they’re feeling better.”
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It's a shame that Kim Joy isn't the National Clinical and Informatics Advisor for IAPT.

I guess the irony of Professor Clark's comment "This is what we would expect to see in a clinical trial" would be lost on him. But it is indeed exactly what we would expect to see in a BPS trial - subjective measures of success artificially inflated by biased clinicians and sick people desperately wanting to be well.
 
Having skimmed that document, it is clear that getting CBT and GET out of the NICE Guidance for ME/CFS will be as easy as moving a very large mountain. The expansion of the IAPT industry relies on the assumption that CFS, and MUS in general, are mental health conditions that can be corrected by psychological therapies.

Guidance document said:
Irritable bowel syndrome*
Chronic fatigue syndrome*
Chronic pain (in the context of depression/anxiety disorders)*
MUS not otherwise specified*

* Denotes a mental health problem that is new to the IAPT programme as it is being introduced in the context of IAPT-LTC services.
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6.5 Establishing a business case
Commissioners should work with providers and wider stakeholders to determine shared objectives and develop service models that support the delivery of integrated pathways. Proposed models should be driven by evidential data and best practice, as detailed in NICE guidelines and NICE quality standards (see Section 4).

Where plans to roll out IAPT-LTC services require additional investment, commissioners should use a logic model to demonstrate a robust business case. This should illustrate how IAPT-LTC pathways can help to achieve other national and local strategic priorities,
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We need to counter the misinformation that passes for evidence of success from IAPT approaches.
 
This whole thing makes me feel sick.

So I'm now to be told I have MUS, that it's a mental health condition, and I should be offered CBT/GET implemented by a generalist IAPT practitioner who will probably hastily look up what the special version of CBT is for CFS when I'm allocated to him/her, and try to tell me I have to exercise more. And assess my progress with a depression scale and the Chalder Fatigue Questionnaire.

Mind you, I suspect my GP thinks I have a mental health condition anyway and is just humoring me when I explain about pacing.
 
Esther12 said:
There's no mention of the CFS guidelines being updated
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ME/CFS guidelines.

Michael Sharpe has been saying more and more that he doesn't think ME and CFS are the same, and that PACE was on CFS (although the literature would suggest otherwise).

A big one for NICE then..........if they are including CFS under MUS, does that include ME?

Or indeed Michael Sharpe; does he think ME is an MUS?

eta: where the hell are the charities on all this?
 
This needs an across charity rebuttal- all LTC like Parkinson's MS etc
Letters to MPs with cc to local Chairs of CCGS, Joint Strategic Commissioning Committees and Local Community Health Engagement and Partnership organisations being told this is bad.
This is a RCPsy power grab with Government drive to save money.
IAPT likely to be group sessions( cheap) which will allow the CCGS to save the new £££ as per announced by NHS England this week.
https://www.hsj.co.uk/policy-and-regulation/ccg-admin-budgets-to-be-cut-by-a-fifth/7023898.article

  • NHS England told CCGs they must reduce admin budgets by 20 per cent
  • Cuts designed to save £320m a year nationally
  • “Administration” limits to be introduced for each CCG in the next financial year
Clinical commissioning groups will have their administration budgets cut by 20 per cent in a push to save money and spread integrated care systems.


https://www.hsj.co.uk/policy-and-re...ant-investment-to-healthwatch/7023886.article
 
The IAPT-LTC Full Implementation Guidance was published towards the beginning of this year. The original LTC/MUS Pathfinder sites were launched in 2012.

There are another couple of PDF documents allied to the full implementation guidance :
https://www.rcpsych.ac.uk/improving-care/nccmh/care-pathways

NHS England refers to LTC/MUS IAPT as 'IAPT-LTC', presumably in keeping with the MUS Positive Practice Guide recommendation not to tell patients they are being diagnosed with MUS.

IAPT timeline:
http://www.tiki-toki.com/timeline/entry/592316/History-of-IAPT/

UEA is a course provider for qualifications allied to the IAPT programme, so there is a repository of IAPT documents on UEA's website. I'm not sure that this is being maintained, however.

https://www.uea.ac.uk/medicine/depa...oural-therapy-training/iapt-and-cbt-resources
 
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I've recently been reading some of the early MUS-papers and it's very much Simon Wessely who has pushed this concept and term in the early 2000s (see studies below). Sharpe followed soon with some studies of his own (and he would soon get the help of Chris Burton). These MUS-studies seemed to follow their famous publication “Functional somatic syndromes: one or many?” . So it’s seems like we as ME/CFS patients have the honour: it’s our researchers who have developed the MUS-term (sorry IBS- and fibro-patients).

It’s funny to read some of the comments to their introduction of this term. Julius G Mendel for example wrote: “Unfortunately the important paper by Dr Page and Professor Wessely (May 2003 JRSM1) has served to widen the gulf between UK and USA physicians. Just as we have struggled to acquaint our non-psychiatric colleagues on the spectrum of conversion, hypochondriasis, somatization and factitious disorders as described in the DSM IV we are now presented with a new acronym MUS [medically unexplained symptoms]. US psychiatrists and medical colleagues would not know a MUS from a mouse so I would respectfully urge we stick to the terminology we all understand.”


https://www.ncbi.nlm.nih.gov/pubmed/8081582

https://www.ncbi.nlm.nih.gov/pubmed/10553745

https://www.ncbi.nlm.nih.gov/pubmed/11282861

https://www.ncbi.nlm.nih.gov/pubmed/11448704

https://www.ncbi.nlm.nih.gov/pubmed/11448704

https://www.ncbi.nlm.nih.gov/pubmed/10623778

https://www.ncbi.nlm.nih.gov/pubmed/12724431

https://www.ncbi.nlm.nih.gov/pubmed/11872517
 
This paper also looks interesting, although I Have not yet gained full access

Volume 354, Issue 9182, 11 September 1999, Pages 936-939

Review
Functional somatic syndromes: one or many?
Author links open overlay panelProfSWesselyMDaCNimnuanMB BSaDrMSharpeMRCPsychb

It talks of dimensional categorisation, rather than categorical, and makes much of cost implications.

I still think that the disappearing of Abnormal Illness Behaviour as per Pilowsky is connected to all this.
 
I thought we had been told ME could t be lumped under MUS? Or were we asking for that. This seems to be an area to lobby on. I think Rona MM is totally unqualified to be writing waffle about my illness, which she lumps in with IBS and over plays psychological factors.

The latest I saw from her field of research was claiming menopausal night sweats could be eased through CBT targeting beliefs or something. If brexit causes a further financial squeeze I hope that the departments of health psychology see their funding halved.
 
Esther12 said:
And also, how anything like 'CBT to help adjust to the condition' in the new NICE guidelines will leave people like Moss-Morris with power over how patients are treated.
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We need someone on the NICE committee to push for this to be explicitly ruled out in the new NICE guideline due to lack of evidence.

Edit: And because it undermines ME/CFS as a standalone illness with its own NICE guideline.
 
https://ebmh.bmj.com/content/18/4/97.full
PDF

Perspective
App-based psychological interventions: friend or foe?
Free

    • Simon Leigh1,2,
    • Steve Flatt3
Author affiliations
    • Lifecode Solutions, Liverpool, UK
    • Liverpool Health Economics, Management School, University of Liverpool, Liverpool, UK
    • Psychological Therapies Unit CIC, Liverpool, UK
The potential
Given the documented limited success of IAPT in stemming the rising tide of unmet need within mental health,4 an alternative approach may be necessary, that can extend care to those with the greatest need, without imposing substantial pressures on already scarce mental healthcare funding.11 Online and app-based self-delivered treatments for mental health disorders are a novel and increasingly popular method12–14 of service delivery, and as such, may be the solution the NHS is looking for. To date, a number of mental health apps have demonstrated effect sizes comparable to the conventional standard of care,13 ,14 while circumventing financial barriers to treatment including a lack of available trained professionals, waiting lists and the indirect costs of seeking treatment.13 ,15 ,16

Research has shown that user engagement, rather than the modality of therapy is the key to achieving successful outcomes,17 ,18 and given that just 50% and 13% of patients currently have a choice of when and where they receive therapy,5 apps may not only be equally effective as some forms of traditional psychotherapy,19 but also provide a flexible and pragmatic means of increasing patient access, through removing barriers to treatment that do not respond to financial impetus. Such barriers may include a negative perception of psychological treatments, impaired access to health services and personal difficulties such as low mental health literacy13 ,15 ,16 and stigma, commonly observed within the armed forces20 and adolescents,2 and all of which impacting the effective reach of the current standard of psychological care.

 
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It may be useful to start dialogue with the other chronic disease charities and organisations about the impact this will have on them. I'm sure they'll want to avoid any association with a stigmatized illness, solidarity isn't a big thing unfortunately, but this will have a huge impact on many of them and they have no idea what's coming their way.

ME is the prototype and they are now consolidating on their delusional project of psychologizing all chronic illness. It will probably take a while until they understand that their fate is aligned with ours, but whether they catch on to this before it's too late or long after, they will come around so might as well open dialogue.

Not sure how, it would have to come from professionals.
 
From my reading of this (which was admittedly a quick skim some hours ago) I read it as dividing their clients into 3 distinct categories:

1.People with mental health problems like anxiety or depression and no chronic physical illness where the CBT is aimed at alleviating the mental health problem.

2. People with well recognised chronic physical illnesses who also have anxiety or depression, possibly as a consequence of living with chronic illness who will get supportive CBT to help them cope. In other words, as an adjunct to their main medical treatment of their physical illness. They will still have access to the appropriate medical treatment for their physical illness.

3. People with MUS, including CFS and IBS, which they classify as mental health conditions and for which there are specific CBT/GET based treatments aimed at treating the condition itself, not as an adjunct, and as the only treatment offered.
..................................

I don't think people with conditions like MS or Parkinsons' who are offered CBT would see a problem with it, because it's not claiming to treat their condition, only the comorbid anxiety or depression. So we don't really have common cause with them in fighting this.

Even among the group of syndromes and symptoms they classify as MUS we are in a unique position, in that the GET part of the package actually causes serious physical harm.
 
Trish said:
People with well recognised chronic physical illnesses who also have anxiety or depression, possibly as a consequence of living with chronic illness who will get supportive CBT to help them cope. In other words, as an adjunct to their main medical treatment of their physical illness. They will still have access to the appropriate medical treatment for their physical illness.
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In practice, I suspect long-term conditon patients who are 'frequent attenders' or are thought not to be managing their condition appropriately (but do not have anxiety or depression) are also likely to be referred.
 
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