The 2021 – 22 IAPT Annual Report delivered an unexpected surprise. Set against other therapy modalities, and its own past performance, the recovery rate for CBT has deteriorated significantly in the past year. Here, we showcase the data and speculate on what might lie behind this drop in performance.
Estimated reading time: 6 minutes
Table of contents
I have to confess I don’t get much joy from my yearly peer under the hood of the IAPT Annual Report. I also worry that in giving you the headlines, the result is starting to sound like a rehashed annual whinge-fest.
This year, I’m therefore delighted to be able to offer you something rather different. Not a stunning improvement in IAPT’s overall KPI data. Not much has really changed there. No, what really stands out for me this time is the very sizeable drop in the overall 2021 – 22 recovery rate for CBT, compared both to the previous year and to other bona fide therapies.
Why would this be the case? What’s happened? Many factors might be implicated, and the truth is I really don’t know. I doubt anyone else does either, assuming they’ve noticed. But speculating is fun, isn’t it, so we offer one or two options further on. Why not join us and offer your own in the comment section?
My, how you’ve grown….
IAPT has come a long way since its early days, when you could have any therapy you wanted as long as it was CBT. Now, the 2021 -22 IAPT Annual Report lists outcome and other KPI data for no less than fifteen different interventions.
Of these, I’d argue that five would broadly meet the criteria for recognition as a bona fide psychological therapy. These are Counselling for Depression (CfD), Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT) and Brief Psychodynamic Psychotherapy (BPP). I’d also included Couples Therapy for Depression, though it’s an intervention I know relatively little about.
One of the datasheets in the report (clip below) contains outcome percentages by category (recovery, reliable recovery, improvement, no reliable change and reliable deterioration) for each.
The remarkable drop in the recovery rates of CBT
From these data I’ve extracted below the recovery rates, and the number of clients on which they are based, for each of the four individual-focused psychological therapies listed above. First, take a look at the 2020 – 21 recovery rates for each. Across the four, there’s not much difference, right? IPT is a little lower than the others, but its numbers are small enough to raise issues of statistical significance.
Now, look at the recovery rates for 2021 – 22.
Whereas the recovery rates for CfD, IPT and BPP are within a whisker of each other, that of CBT has dropped by a full four and a half percentage points in a year. It is now six to seven percent below the others.
What’s behind the drop in performance?
What’s going on? All other things being equal, we would expect the outcomes of bona fide therapies to be broadly equivalent in their outcomes. That was the case in 2020 – 21, but not the following year. Factors might include:
- A change in the characteristics of the workforce delivering the interventions
- A change in the characteristics of the interventions being offered
- Insufficient sessions provided for the therapy to be optimally effective
- A preference effect, whereby clients receiving their preferred therapy achieve superior outcomes
I’d be inclined to discount the first option. It’s hard to see how the characteristics of the workforce would have changed so significantly as to impact recovery rates so dramatically in the course of one year.
I certainly wouldn’t discount option two. I’m not an industry insider, but I have the sense that within IAPT, CBT may sometimes be more of an organising term that a distinct therapeutic modality. Any significant shifts in the way those interventions are delivered may impact on outcomes.
So to option three. Are clients getting a sufficient number of sessions for therapy to show an effect? Comparing the mean number of treatment appointments for each therapy across the two years shows a modest increase in the mean for each. So not much has changed there. Unless some combination of options one and two are also at play, it’s hard to see how the number of sessions alone accounts for the reduction in the recovery rate of CBT.
Option four. Here the question is, are clients who receive CBT less likely to recover because they are not receiving their preferred treatment? We know that client preferences have a positive effect on treatment outcome, so might this be at play here?
This would be a reasonable speculation, and if we knew what clients’ therapy preferences were, we could test this. Even if that were possible, however, we have the inescapable fact that not only is CBT’s recovery rate lower than other therapies for 21 – 22, it’s also lower than its own in the previous year.
Please, if you have alternative answers to this conundrum, we’d love to hear them.
Behind the data; the people
We should always remember that behind these data are people. People in need who came seeking help. Some were helped, but using the headline indicator of recovery as a benchmark, many were not.
It seems bizarre, especially given the IAPT model of using sessional measures and being able to track progress through therapy, that the data for so many clients are failing to show demonstrable impact. But being able to track progress isn’t the same as actually doing it.
It leads me to conclude that either the model of therapy intervention isn’t sufficiently flexible to adapt to progress feedback, or worse, that no-one’s paying much attention to it. Either way, for CBT at least, and the clients receiving it, the situation looks like it’s getting worse.
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