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

Keith Geraghty,Michael J Scott

doi:10.1186/s40359-020-0380-2

Abstract

BackgroundImproving 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 textA 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, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.ConclusionsThere 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 psycho-behavioural 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.

Highlights

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
If we look at National Health Service (NHS) clinical data, in one study of adult Myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS) patients treated with Cognitive behavioural therapy (CBT) in specialist units, Collin et al found that while approximately 1/ 3rd of Myaglic encephalomyelitis or chronic fatigue syndrome (ME/CFS) patients report some benefits from CBT, only 5.7% of patients counted themselves as no longer having ME/CFS after treatment [54]
Conditions that fall under the medically unexplained symptoms (MUS) label, such as ME/CFS or IBS, are not exclusively medically unexplained

Summary

Main text

Difficulties defining MUS Medically unexplained symptoms refer to persistent bodily complaints for which adequate examination (including investigation) does not reveal sufficiently explanatory structural or other specified pathology [2, 8]. A problematic treatment model IAPT literature often refers to a cognitive behavioural (CB) model of medically unexplained symptoms [2, 5]. This ‘CB model of MUS’ is set out in a paper by Deary et al, that discusses research around aetiology of MUS and the use of CBT as treatment modality [13]. Grouping patients with unexplained symptoms into a broad category (MUS) carries a high risk of misdiagnosis This concern is observed in a review of 418 CFS patient referrals to a specialist chronic fatigue clinic, where 37% of referrals were rejected as inappropriate, and of these, 61% had a likely alternative diagnosis [62]. We further speculate that if the rationale behind CBT is disclosed to MUS patients, many will reject treatment or withdraw from treatment – we see high dropout rates in early IAPT provider data [23]

Conclusions

Background

Findings

Discussion