Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified, 2020, Geraghty and Scott

Andy

Andy

Retired committee member
Background
Improving Access to Psychological Therapies is a UK Government funded initiative to widen access to psychological treatment for a range of common mental health complaints, such as depression and anxiety. More recently, the service has begun to treat patients with medically unexplained symptoms. This paper reports on a review of treatment protocols and early treatment data for medically unexplained symptoms, specifically the illness myalgic encephalomyelitis/chronic fatigue syndrome.

Main text
A series of seven core problems and failings are identified, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.

Conclusions
There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients’ physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.
Click to expand...
Open access, https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-020-0380-2
 
Added line breaks for readability purposes.
Conclusions
IAPT has a mandate to improve access to psychological therapies in the UK NHS. Most health professionals support this service, particularly for common mental health complaints, where there is considerable unmet need. However, IAPT is now seeking to treat chronic medical conditions and medically unexplained illnesses.

First, given the vast number of patients with possible MUS, this will not be feasible. Second, conditions that fall under the MUS label, such as ME/CFS or IBS, are not exclusively medically unexplained. There is considerable emerging evidence elucidating the pathophysiology of ME/CFS as a possible neuro-immune disease. The IAPT treatment rationale for MUS rests on a weak and contested cognitive behavioural model that is promoted by IAPT advisors. Many patients with MUS conditions, particularly ME/CFS, are unlikely to benefit from attending IAPT.

This leads us to ask whether IAPT should be seeking to expend considerable scarce resources on treating MUS. IAPT therapists are not equipped to manage patients with complex medical conditions. High rates of misdiagnosis observed to date are unlikely to be corrected by IAPT therapists. High drop-out rates are to be expected and many patients may return to GPs feeling distressed by inappropriate referral for CBT. IAPT needs to improve its reporting mechanisms and overhaul its formula for determining improvement and recovery in MUS. Current methods inflate recovery statistics. IAPT services could benefit from independent oversight and auditing.
Click to expand...
 
Very good paper with some interesting information:
DSM-5 states ‘It is not appropriate to give an individual a mental disorder diagnosis solely because a medical cause cannot be demonstrated’
Click to expand...
It appears that the problem is maybe not with psychiatry but with some zealots that have strong but unproven ideas on unxplained symptoms.

Deary et al. is cited as the seminal paper for MUS treatment by Kellett et al. in their review of MUS IAPT service performance (section 5) [23]. However, Deary et al. do not offer a robust analysis of the evidence for MUS treatment. Deary et al. write, “There are varying degrees of evidence for each of the components of this model. What is lacking is solid proof of their interaction in vicious circles, although all the models reviewed assume this interaction” [13]. Essentially, their model of MUS is speculative, and the cycle used to frame their model remains theoretical.
Click to expand...

Essentially, it is possible to fantasize about how patients make themselves worse with their thoughts and behaviours and they just accepted that as truth even when there's no evidence this is actually occurring.

Deary et al. also state:

“What makes the CBT model so difficult to test may also be one of its chief strengths: it is in many ways a meta-model, providing a skeleton structure to join the dots of whatever factors each patient presents…This means that every client will have, in effect, their own model, making the testing of a generic CBT MUS model impossible” [13] p788.
Click to expand...
An admission that testing of a generic CBT MUS model is impossible.

the MUS treatment model is derived from theory and research in ME/CFS.
Click to expand...
As the PACE trial shows, this line of research failed to produce any credible results.

IAPT therapists will not be equipped to discern true or false cases of MUS. Patients referred to IAPT may have legal grounds to bring claims against the NHS if misdiagnosed.
Click to expand...
In other words, psychotherapists have no medical training and many illnesses are not easy to diagnose even by those with the training.
In the Deary et al. [13] model of MUS, the patient is to be challenged on the origins of symptoms such as pain or fatigue - the patient is said to perpetuate their own illness by holding on to beliefs in an ‘organic’ illness (ME/CFS caused by infection for example). The notion patients’ beliefs perpetuate illnesses such as ME/CFS, IBS or Fibromyalgia, is based more on speculation than evidence. In contrast, there is considerable growing evidence showing ME/CFS is indeed linked to biological dysfunction following infection [34, 35]. The IAPT model of MUS may put CBT therapist and patient on a collision course – far from Beck’s collaborative journey. To what extent will the CB Model of MUS be disclosed to patients remains to be seen [41]. We speculate many MUS patients will be told very little about the therapies they will receive in IAPT, before agreeing to participate. We further speculate that if the rationale behind CBT is disclosed to MUS patients, many will reject treatment or withdraw from treatment – we see high dropout rates in early IAPT provider data [23].
Click to expand...
Not disclosing the treatment rationale to patients would seem to exclude genuine collaboration. It would therefore not be CBT as intended by its inventor.
 
strategist said:
Not disclosing the treatment rationale to patients would seem to exclude genuine collaboration. It would therefore not be CBT as intended by its inventor.
Click to expand...
And would not be informed consent? So, especially if harm occurred, then they may well be on dodgy legal grounds, although no doubt their argument would be they were working on the basis of the best evidence that they had available to them.
 
But they had no evidence for the correctness of the model, and no credible evidence for efficacy of the treatment either (see PACE trial debate).

What is happening here is that a story was made up to facilitate selling CBT. It's a fraud.

It's no different from making up a story of how eating yak butter cures unexplained symptoms, and then selling it to the healthcare system. Well, the difference is different levels of skepticism by society. A healthy amount for claims involving yak butter and similar, but a childish credulousness when it comes to claims of psychogenic illness and psychotherapy.
 
Last edited:
strategist said:
But they had no evidence for the correctness of the model, and no credible evidence for efficacy of the treatment either (see PACE trial debate).

What is happening here is that a story was made up to facilitate selling CBT.
Click to expand...
I don't disagree with anything you write but the people delivering IAPT treatment for "MUS" would be able to use the "best evidence available" defence. The ones who made up the "evidence" will, most likely, never have to defend themselves.
 
The biggest problem with MUS from my point of view is that it assumes doctors are perfect diagnosticians who never make mistakes. The patient is assumed to be lying or attention-seeking or drug-seeking or deluded or to have various other problems. The doctor can't be wrong, can they? And let's face it, a mistaken diagnosis of MUS never causes the doctor any suffering. It is always the patient who suffers. It is this which makes MUS the most sadistic treatment idea that anyone ever came up with and doctors just governmentally approved torturers. And the fact that less and less treatment of any medical condition is available on the NHS is just going to make life suck worse than it already does for vast numbers of people. I'm convinced this whole thing isn't just institutional sadism but is a deliberate population reduction policy.

Rant over!
 
Patients referred to IAPT may have legal grounds to bring claims against the NHS if misdiagnosed. There is a concern that IAPT therapists focused on depression and anxiety complaints may miss deterioration in patients with underlying physical complaints, or wrongly interpret worsening of physical symptoms, as signs of anxiety or stress.
Click to expand...

If CBT helps some MUS patients minimise psychological distress, anxiety and depression (often co-morbid complaints to chronic health conditions), this does not mean patients no longer suffer MUS.
Click to expand...

we observe that recovery is operationally defined by IAPT in a way that will not resemble how most MUS patients understand recovery – for instance, recovery from chronic back pain should mean much reduced or non-existent back pain, rather than less depression or anxiety
Click to expand...
 
Andy said:
I don't disagree with anything you write but the people delivering IAPT treatment for "MUS" would be able to use the "best evidence available" defence. The ones who made up the "evidence" will, most likely, never have to defend themselves.
Click to expand...

I think they may well be stepping on the edge of thin ice here. One could argue that PACE demonstrated that CBT (directive for ME) doesn't really work. It is now on open record (thanks to forums like this one) that patients haven't found it helpful, have sometimes found it harmful and had feedback deliberately ignored.

Sooner or later they are going to go fall through that thin ice. While they are dragging their heels, more evidence and arguments are being produced and publicly discussed. They no longer have the luxury of deniability. The longer this farce goes on for the heavier the penalties will be.
 
Last edited:
Andy said:
I don't disagree with anything you write but the people delivering IAPT treatment for "MUS" would be able to use the "best evidence available" defence. The ones who made up the "evidence" will, most likely, never have to defend themselves.
Click to expand...

At this point things being what they are in the world, it may be possible to argue for a precedent on the grounds that justifying a defence on best evidence given the facts would encourage future abuses of the same kind. Or so I'm going to think until reality kicks in.
 
Invisible Woman said:
I think they may well be stepping on the edge of thin ice here. One could argue that PACE demonstrated that CBT (directive for ME) doesn't really work. It is now on open record (thanks to forums like this one) that patients haven't found it helpful, have sometimes found it harmful and had feedback deliberately ignored.

Sooner or later they are going to go fall through that thin ice. While they are dragging their heels, more evidence and arguments are being produced and publicly discussed. They no longer have the luxury of deniability. The longer this farce goes on for the heavier the penalties will be.
Click to expand...

It would depend on expert witnesses if it got to that stage. The argument was that person x should have known based on evidence y that someone could be harmed.

The expert witness for person x would argue that the information wasn't reliable, well distributed or accepted. They would use things like the NICE guidelines and NHS websites to justify it as being the current accepted practise.
 
Important point:
Some leading UK clinicians characterise MUS as a major cost problem to the NHS and a challenge to GPs [8], with reference to studies that suggest MUS account for up to 45% of GP consultations [70]. If correct (we think not), IAPT would collapse under the weight of MUS patients – a reductio ad absurdum. The fact GPs need to refer large swathes of patients to IAPT indicates a failing in contemporary medicine – how to accommodate the needs of patients with medically unexplained complaints.
Click to expand...
The rationale behind the programme is self-defeating, proportionally to its success. Being unsuccessful is actually the only reason it does not crumble under its own weight, with most patients referred being filtered out. If the programme were successful it would be unable to meet its own demand, especially given the peeks we have seen behind the scenes, of massive turnovers and staff that actually meets the selection criteria for their own services.

In the end, those patients referred to IAPT are not helped by their GP and even less so by the programme. So the exact same outcome, but are actually dropped twice. One says not my problem, the other also says not my problem. Billions later, you now have doubled all your problems, at great cost and with no benefits. Just BPS things.
 
ukxmrv said:
It would depend on expert witnesses if it got to that stage. The argument was that person x should have known based on evidence y that someone could be harmed.

The expert witness for person x would argue that the information wasn't reliable, well distributed or accepted. They would use things like the NICE guidelines and NHS websites to justify it as being the current accepted practise.
Click to expand...

Both sides can call on expert witnesses though. The longer this goes on the more evidence will be stacked against them.

I'm not saying we'd win a case today or even tomorrow, but the day will come.
 
ukxmrv said:
The expert witness for person x would argue that the information wasn't reliable, well distributed or accepted. They would use things like the NICE guidelines and NHS websites to justify it as being the current accepted practise.
Click to expand...

Well, they will find a report, as part of the documentation of the next ME NICE guidelines, from this expert witness making it absolutely clear that the weight of evidence for CBT and GET is that they do not work. I won't mind having to justify that in a court of law under cross examination. I have got to rather enjoy being cross-examined in medical cases!
 
Jonathan Edwards said:
Well, they will find a report, as part of the documentation of the next ME NICE guidelines, from this expert witness making it absolutely clear that the weight of evidence for CBT and GET is that they do not work.
Click to expand...
it would be great if you could slip in there that web-based CBT doesn't really do much for symptom improvement in IBS as well but now is being pushed to be offered to everyone who presents with IBS.
 
it is rather perverse that people in serious need of psychological counselling are being turned away in droves due to lack of funding but empire builders are draining funds for something that benefits no one but themselves . is there no individual accountability for the overpaid and obviously inept boards who sign off on this fraud.
 
cbt watch
IAPT’s Mistreatment Of Those With Medically Unexplained Symptoms (MUS)
in our paper published today in BMC Psychology, Keith Geraghty and I write of Improving Access to Psychological Therapies (IAPT) malpractice with MUS clients , see link https://doi.org/10.1186/s40359-020-0380-2

A series of seven core problems and failings are identified, including:

  1. an unproven treatment rationale
  2. a weak and contested evidence-base
  3. biases in treatment promotion
  4. exaggeration of recovery claims
  5. under-reporting of drop-out rates
  6. a significant risk of misdiagnosis
  7. inappropriate treatment.
We concluded that:
There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients’ physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

Dr Mike Scott
Click to expand...
http://www.cbtwatch.com/iapts-mistreatment-of-those-with-medically-unexplained-symptoms-mus/
 
You must log in or register to reply here.
Back
Top Bottom