Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified

Abstract

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, underreporting 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 psychobehavioural 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.

What psychological interventions are effective for the management of persistent physical symptoms (PPS)? A systematic review and meta‐analysis

“…Patients with PPS report more social isolation, psychological distress, more functional and occupational impairment, poorer quality of life and overall impaired health status in comparison to general practice patients not meeting the criteria for PPS (Creed et al, 2012 ; Dirkzwager & Verhaak, 2007 ; Woo, 2010 ). Depression and anxiety are common in patients with PPS (Burton et al, 2011 ) and are indicators of improvement in recovery (Geraghty & Scott, 2020 ). Accordingly, developing better management strategies for patients with PPS is a health care priority.…”

Examining the psychology of practitioners, institutions and structures:

“…In respect of humility, it is also pertinent that MUS research indicates that some patients value practitioners admitting that they do not know, rather than pretending otherwise (Kornelsen et al, 2016;Sharma et al, 2020). Finally, humility holds that non-medically trained practitioners should be cognisant of their training limitations (Geraghty & Scott, 2020) and should encourage the patient to consult with medical professionals in cases of doubt, rather than ascribing all manner of somatic symptoms to psychosocial causes.…”

“…In terms of future research directions, there is a need to explore the experiences of people labelled with MUS in psy settings; in particular, the high drop-out rates amongst people labelled with MUS referred to IAPT (Geraghty & Scott, 2020) are of interest.…”

“…Accordingly, the UK National Health Service (NHS) mental health initiative, Improving Access to Psychological Therapies (IAPT) has in recent years rolled out its provision to include MUS, whilst medical doctors are encouraged to refer people labelled with MUS to IAPT or other psychological services, which may limit biomedical 2 Although I am aware that the term 'patient' can be considered disempowering, I am not convinced that alternatives (clients, service-users) are preferable and I use the term patient with an awareness of debates in this regard. Hunt •8 investigations (Geraghty & Scott, 2020). Whilst cognitive behavioural therapy (CBT) remains a 'treatment' of choice for many MUS, psy practitioners of differing orientations within and outside the NHS tend to draw upon equally psychologizing and arguably moralizing BPS-inspired or broadly BPS-compatible narratives to conceptualize MUS (Luca, 2011;Maizels & Adamson, 2017;Penman, 2021).…”

A randomized controlled trial protocol for persistent physical symptoms associated with indoor environment or chronic fatigue: Effectiveness of video-based functional case conceptualization and web-program for improving quality of life

“…However, the effect sizes have remained rather moderate and the information on factors explaining the variability of individuals´ responses to treatment is scarce (Kleinstauber et al, 2011;van Dessel et al, 2014). It has also been suggested that the rationale behind the psychosocial treatments remains unclear for the patients and thus results in unwanted effects such as withdrawal from the treatment (Geraghty and Scott, 2020). To respond to these challenges some studies have suggested that tailoring treatments according to personalized profiles might improve the effectiveness (Rosmalen et al, 2020;Senger et al, 2021a,b).…”