Thursday, June 28, 2007

Comments on “Increasing the Availability of Evidence-Based Psychological Therapies in Scotland”

Entry for 28 June 2007:

National Health Service Education for Scotland (NES) is a governmental body whose board is appointed by the Health Minister of the Scottish Executive. Alex McMahon, Head of Mental Health Delivery and Service for NES recently issues a document entitled, “Increasing the Availability of Evidence-Based Psychological Therapies in Scotland”. This document lays out what is referred to as a “‘Phase 1’ Plan”. Here is a summary of this plan:

A. The Proposed Plan. The plan focuses largely on drastically increasing the training of CBT therapists in Scotland.

This is justified to begin with by referencing the Scottish Executive Health Department (SEHD) report 'Delivering for Mental Health' (2006; ), and in particular,

"Commitment 4 - We will increase the availability of evidence-based psychological therapies for all age groups in a range of settings and through a range of providers."

There are two parts to the plan:

1. A scoping exercise, which is in progress, which involves consulting a wide range of people, health boards, mental health professions, users etc..

2. A plan for training 50 more Cognitive Behavior Therapy (CBT) practitioners, more CBT supervisors etc.

The focus on CBT is justified as follows:

"The rational for focussing on CBT in the first instance is based on its recognised effectiveness across a wide range of settings, its applicability across all tiers of service provision, and its record for generating effective, low intensity approaches to 'mild-moderate' problems which provide realistic alternatives to anti-depressant prescribing. "

Toward the end of the report, reference is made to including other approaches to therapy at some later date, and possibly for later stages of a stepped care model.

B. Beginning of a Response:

Here is a start at crafting a response to proposed plan; I would welcome additional suggestions and input!

The proposed plan appears to be flawed in several ways, but the overwhelming emphasis on CBT is puzzling and a cause for concern. What is needed is a clear, reasoned set of arguments, and a plan to disseminating those arguments.

1. The SEHD mandate emphasizes a variety of practitioners, but the current plan focuses exclusively and narrowly on CBT. This is not in keeping with the Scottish Executive’s position as reflected in Commitment 4.

2. The proposed scoping exercise fails to include a review of the scientific evidence, relying instead on the assertion that that CBT is effective. This is not a tenable scientific position, and in fact is at variance with the NICE Guidelines for treatment of depression and anxiety, which emphasize the need for a variety of psychological and psychopharmacological treatments.

3. The plan fails to acknowledge the available scientific evidence, which suggests that a variety of therapies are effective for common psychological problems such as depression and anxiety. These therapies include psychodynamic, person-centred/experiential, and family therapy. For example, a large recent naturalistic study by Stiles et al. (2006), of patients seen on primary care settings in the UK, found equivalent outcomes. (This study has since been replicated with an even larger sample and tighter methods.) In general, major reviews and meta-analyses of the research evidence going back more than 25 years indicates that the major therapeutic approaches are roughly equivalent in their effectiveness for common psychological problems. This means that it is unscientific to focus on only one therapeutic approach.

4. The plan points to the need for low-intensity (i.e., nonintrusive, inexpensive) treatments for depression and anxiety, but fails to mention the existence of the most widely available, effective, low intensity treatment, namely, psychological counselling (e.g., King et al., 2000). If the SEHD wishes to rapidly deploy a significant number of low-intensity psychological therapists for treating, for example, mild to moderate depression, they need look no farther than the existing pool of trained, experienced counsellors in Scotland!

King, M., Sibbald, B., Ward, E., Bower, P., Lloyd, M., Gabbay, M., & Byford, S. (2000). Randomised controlled trial of non-directive counselling, cognitive-behavior therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care [Monograph]. Health Technology Assessment, 4 (19), 1-84.
Stiles, W.B., Barkham, M., Twigg, E.., Mellor-Clark, J., Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health Service settings. Psychological Medicine, 36, 555–566.

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