By David Tuller, DrPH
Since 2008, the National Health Service (NHS) in England has been rolling out a program known as Improving Access to Psychological Therapies (IAPT). Initially focused on patients with mental health issues like depression and anxiety disorders, IAPT was then expanded to include those who are also simultaneously suffering from “long-term conditions” and so-called “medically unexplained symptoms” (MUS). IAPT has cited 50% “recovery” rates from its interventions, but these claims are not especially credible, as Liverpool consultant psychologist Michael Scott has documented on his informative blog, CBT Watch.
Meanwhile, MUS experts who promote IAPT—some of them close academic colleagues of the lead PACE investigators–have regularly exaggerated the estimated costs of these ailments to the NHS. Specifically, they have misquoted a seminal study in their field of expertise and claimed that MUS patients accounted for 10 % of total NHS costs (in England). The actual figure from the study was that people of working-age with MUS accounted for 10 % of costs for that age group, not total NHS costs. The mistake more than tripled the apparent economic impact of MUS. Last year, two major journals—the British Journal of General Practice and BMJ Open–corrected papers they had published after I alerted them to these errors.
There is plenty of evidence that the IAPT’s hopes and claims exceed its current grasp. A study published last September by the Journal of British Psychiatry, for example, has found that interventions provided by IAPT therapists proved no more effective with a core patient group than treatment-as-usual. The study is called “Effectiveness of cognitive–behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial.”
(I came across this trial while reading Scott’s recent article, Ensuring IAPT Makes a Real World Difference, in the journal Mental Health in Family Medicine. Other references in Scott’s article reinforce concerns about IAPT.)
Most of the investigators were from University College London. In contextualizing their findings, they noted that “the benefits of CBT for people with advanced cancer had been previously unclear because of underpowered trials, poor diagnosis and measurement of depression, lack of detail about interventions and concerns about generalizability.”
Their own conclusion was pretty stark. Here’s what they wrote:
Delivery of CBT through the Improving Access to Psychological Therapies (IAPT) programme has been advocated for long-term conditions such as cancer. Although it is feasible to deliver CBT through IAPT proficiently to people with advanced cancer, this is not clinically effective…[O]ur results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness.
The study included 230 participants with advanced cancer and depression; they were randomly allocated to receive CBT or treatment-as-usual and assessed at multiple time points up to 24 months. The main outcome measure was a well-known instrument called the Beck Depression Inventory-II, which has been used previously with patients with advanced cancer. The analysis found no statistically significant effect on depression and on several secondary outcome measures.
Those randomized to receive CBT did not access the intervention to the degree available. They each received an average of 4.7 sessions of CBT out of the 12 sessions possible. More than a third—36%–had no CBT sessions at all. Nevertheless, the investigators determined that the outcome would have been similar even if participants had accessed all the sessions. “The per-session effect of CBT was too small to scale up to a clinically significant change even if the full 12 sessions were delivered,” they wrote.
The limited uptake of CBT itself should raise further questions for IAPT. The investigators did not discuss possible reasons for this phenomenon beyond noting that “our clinical experience was that physically ill people had difficulty in managing the demands of CBT.”
The investigators made efforts to create fertile trial conditions for demonstrating the possible effectiveness of the CBT intervention. The study used only IAPT therapists already skilled in delivering so-called “high-intensity” CBT. Moreover, the investigators developed specialized materials and a training module to ensure that the intervention matched the needs of these advanced cancer patients. According to the study,
A treatment manual informed by previous work…was developed for the trial by members of the research team. CBT therapists attended a 1-day course on how to use the manual and adapt their standard CBT work for people with advanced cancer. This included adapting techniques within the constraints of physical illness, working with realistic negative thoughts, dealing with fears about death and dying, and including carers in sessions where appropriate.
Despite these favorable conditions, the trial produced null results—which in turn raise serious questions about the current NHS strategy for IAPT. Seems like UK health officials might have some rethinking to do.