Wider measures of IAPT outcomes needed

Oliver James has posted references on his website, which he mentioned in his talk given at the Limbus Critical Psychotherapy conference on 'Challenging the Cognitive Behavioural Therapies: The Overselling of CBT's Evidence Base'. The essential point he was making is that CBT outcomes over the long-term may not be as good as they appear in clinical trials over the short-term.

I've mentioned before the overstatement about the effectiveness of the Improving Access to Psychological Therapies (IAPT) programme (eg. How do we know that IAPT outcomes are not just due to expectancy effects? and Need to be realistic about value and effectiveness of psychological therapy). As pointed out by Hepgul et at (2015), even if recovery rates for IAPT are 50%, this means "approximately half of patients are not meeting standard definitions of recovery at the end of their treatments". As they go on to say, "Furthermore, it is likely that a substantial proportion of those who do recover may go on to relapse in due course".

One of James' references is Weston et al (2004). This article does not argue that brief, focal treatment cannot produce apparent powerful results over the short-term but recognises that relapse rates are high. Rates can be as high as 85% over 10-15 years (Mueller et al, 1999). The reality is that many psychiatric disorders are characterised by multiple periods of remission and relapse or symptom exacerbation over many years. Some people do seek further treatment after a course of IAPT or other psychological therapy. Weston et al (2004) found that roughly half of the patients in the active condition of clinical trials of empirical supported therapy for depression, panic and generalised anxiety had sought further treatment by 2 years post-treatment. Of those treated for depression, only third of those who improved remained so after two years. The figure for panic was slightly better at roughly half. Controlled data over the longer term is rare but one such study, the NIMH Treatment of Collaborative Depression Research program (Shea et al, 1992), found that 78-88% of those who entered treatment completely relapsed or sought further treatment by 18 months and that this was a no better an outcome than the controls. Uncontrolled data does suggest that the effects of psychotherapy are longer lasting at 6 months post-randomisation, at least for depression, although effects significantly decrease with longer follow-up periods (Karyotaki et al, 2016).

Clinical improvement is not the same as social recovery and there may be residual symptoms even for those classed as recovered with IAPT. In essence, we don't know how many of the so-called recoveries in the IAPT programme are due to the placebo effect or spontaneous improvement. People tend to get better anyway over the shorter term whether they go for IAPT or not. Saying that IAPT is a 'marvellous treatment', and misleading people about how effective it is, has to stop. This is no different from misleading people about how effective medication is (see previous post). I'm not saying that short-term therapy can't be helpful, but we do need to be honest about the limits of therapy. It may be tempting to overstate the case to obtain political funding for services but it's not scientific.

Critical psychiatry is part of medicine

I mentioned on my personal blog (see post) that I am going back to Cambridge University in the autumn to do a PhD in Psychology on "The foundations of critical psychiatry". I'm glad I did a psychology degree when I was younger, otherwise I wouldn't have been able to do this. I have been accepted by the Psychology department, whereas Psychiatry and Clinical Medicine wouldn't have been interested.

It's a pity that mainstream psychiatry sees critical psychiatry as too threatening. I suppose it's understandable when it's questioning the biomedical faith that mental illness is due to brain disease (see previous post). But psychiatry and medicine should be patient-centred (see another previous post).

These differences shouldn't divorce psychiatry from medicine, although some critical practitioners have suggested that mental health services should be non-medical (eg. see previous post). I don't agree with them, as critical psychiatry is part of medicine (see another previous post). Psychiatry should be broad and open enough to welcome my PhD.

Overemphasis on disease entities in psychosis

I have mentioned in a previous post that Jim van Os wants to abandon the term 'schizophrenia'. In a follow up article, Guloksuz and he essentially argue for a unitary model of psychosis.

However, in a way, this is missing the point. They acknowledge the "lack of diagnostic markers in psychiatry" but seem to express surprise that this "impedes an objective classification". They seem to think it was a good idea that RDoC (eg. see previous post) was set up to create a so-called objective classification, whereas what they need to do is recognise that classification is inevitable subjective, at least to some extent (eg. see my article).

They still think that there is a likelihood of "distinct diseases" in the broad psychosis spectrum disorder. This is where they are wrong and they need to give up the wish to discover such entities (eg. see previous post), whether it's schizophrenia or a more unitary psychosis.

Giving up the disease model of mental disorder

I mentioned in my Lancet Psychiatry letter that doctors, because of their medical training, have difficulty in giving up the disease model of mental disorder. Yet this is what the Division of Clinical Psychology (DCP) would encourage them to do (see position statement). This is not a controversial argument. It fits with the WHO QualityRights initiative (see recent Lancet Psychiatry article). As the article says, "A movement to profoundly transform the way mental health care is delivered and to change attitudes towards people with psychosocial, intellectual, and cognitive disabilities is gaining momentum globally".

DCP does not totally dismiss the value of psychiatric classification if only because "these systems provide seemingly ‘tangible’ entities for use in administrative, benefits, and insurance systems". But it does argue for "an approach that is multi-factorial, contextualises distress and behaviour, and acknowledges the complexity of the interactions involved in all human experience". Read how balanced the perspective is. It is relevant to the teaching of doctors as well as clinical psychologists and others working in the mental health field.