We have a commitment to support choice for all evidence-based therapies and as such welcome the recommendations in the draft guideline for the three main modalities practised in the UK, namely cognitive behavioural therapy (CBT), psychodynamic psychotherapy, and what is termed in the guideline as ‘counselling’.
Our response presents arguments for ‘counselling’ to be given equal weighting to CBT and psychodynamic psychotherapy. It also highlights that the existing analysis continues to privilege randomised controlled trials (RCT) evidence and fails to consider evidence arising from the IAPT dataset, a routine outcomes dataset, which shows how those with depression fare in response to NHS primary care treatment.
The aim of the NICE guideline is to improve treatment of depression in NHS primary care. The IAPT database provides the key (and only) evidence of how actual NHS patients with depression have responded to the treatment recommendations of the 2009 NICE depression guideline, or how NICE recommendations work in clinical reality. To ignore this data is extraordinary.
We retain the view that the arguments made to ignore this critical source of data on NHS primary care mental health treatment are not convincing. This is troubling since evidence from the IAPT dataset is that counselling is as effective as CBT as an intervention for depression. Existing evidence from IAPT annual reports demonstrates that patient recovery rates have been virtually equivalent between CBT and counselling.
It is our view that IAPT data needs to be considered alongside evidence from trials to form a more complete and accurate assessment of the comparative effectiveness of psychological therapies. This is a fight we will continue to take to NICE beyond the close of this consultation exercise.
In this second response we retain significant concerns about the lack of consideration of the service user voice in the revised guideline. We believe this significantly undercuts confidence in the recommendations, as well as being contrary to both NHS and NICE policies around prioritising user experience.
We highlighted concerns in our last response that the section on the patient user experience in the 2009 guideline had not been updated; which meant that by release this section will be over a decade old. While there was some inclusion of service user voices in the process of the guideline development, it still fails to take into account the considerable growing literature on how those with depression experience treatment for depression.
In our original consultation response, we raised concerns about the fact that the economic analysis is based on the assumption that all psychological therapies are delivered by practitioners on the same pay scale as a band 7 clinical psychologist. However, many counsellors and psychotherapists delivering psychological therapies at step 3 within IAPT services, and more broadly within the NHS, are working at band 6. This makes them considerably more cost effective than this analysis suggests. Currently, the results are potentially misleading and that the cost effectiveness of counselling as an intervention for depression in adults is not appropriately represented.
We argue that the hourly costs of counselling are systematically lower than those for other psychological interventions, meaning that the relative cost effectiveness of counselling is underestimated.
Dr Andrew Reeves, Chair of BACP says:
“Our responsibility, to both our members and the public, means that we campaign for a range of treatments to be available through the NHS for those with depression.
"This commitment reflects the considerable evidence of broad equivalence between therapies for depression and also the evidence that it is important to give clients choice about treatment options because doing so improves treatment outcomes.
"Through our two responses we have scrutinised in detail not only the evidence but also the methods used to develop the recommendations, which will have a significant impact on shaping service delivery.
"Recommendations from previous guidelines have impacted negatively on the counselling workforce as result of counselling being recommended as a second-tier treatment.
"We hope that by giving stakeholders the chance to comment further, NICE use this opportunity to act on our concerns, to give counselling the recognition it clearly deserves, and provide the public with wider access to a proven treatment for depression.”