Nobody is arguing that you can completely characterize responses to a psychological/psychiatric therapy. However there seems to be a total acceptance of vague waffle. The IAPT uses their own standardized recovery procedure, using methods at least briefly mentioned here:
http://www.ncbi.nlm.nih.gov/pubmed/23872702
So they
already standardize it, just do so without any objective validity...
I have some doubts about "recovery" and "moving to recovery". Some of the published papers use terms like "recovery" and "reliably recovered". Reliable how? I am looking into this.
Thanks for highlighting that paper (
Enhancing recovery rates: Lessons from year one of IAPT - full text) Very appropriate title, in my view, just the emphasis is on enhancing 'rates' rather than enhancing recovery.
Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration
Marvellous. Actually, this study has both good and bad things, and in some ways defines recovery more robustly than the PACE trial, even though it still doesn't define recovery that the man or woman in the street - or even most GPs in their surgery would recognise ie a restoration of good health.
The bad
See above. Plus: This study reports recovery for any patient for who was flagged as 'completing' the course and had attended
at least 2 sessions (not unreasonable since the first session is meant to be assessment). The problem with this approach is that if someone deteriorates and gives up on the course after 2 sessions, their final session score is kept - whereas their actual outcome score might be way lower due deterioration at home and out of sight. If someone being treated for anxiety/depression gets worse, they may not go back because they don't think the course helps, or perhaps even because the worsening anxiety/depression itself makes them less likely to attend. Perhaps this explains why only 6.5% of patients 'reliable deteriorated'.
The better
1. Note they give results for both reliable improvement AND reliable deterioration, defined as the same change in the opposite direction. This PACE failed to do, and refused an FOI to release this important information. Apparently it will be published one day, but it is already 2.5 years late.
2. Patients can't recover by taking just one small step
Previous reports of outcomes in IAPT services have used the “recovery” index. An individual is judged to have recovered if s/he is a case at pre-treatment and has dropped below the clinical/non-clinical cut-off for depression and anxiety at post-treatment. This measure does not take into account whether the observed change is greater than the measurement error of the scales. As a consequence, a patient who starts treatment just above the clinical threshold and finishes treatment just below it will be classified as “recovered” even if the improvement is not statistically reliable.
How very true: PACE take note again.
So here's the details, which actually look pretty reasonable to me. They measured anxiety and depression, using the following scales, and used something called Cronbach's-alpha (statisticians name with flair) as an error measure that improvement must exceed:
Questionnaires (do skip)
Depression was assessed with the 9-item Patient Health Questionnaire Depression Scale (PHQ-9:
1) which ranges from 0 to 27 (high is bad) with a recommended cut-off of 10 or above for distinguishing between clinical and non-clinical populations.
Anxiety was assessed with the 7-item Patient Health Questionnaire Generalized Anxiety Disorder Scale (GAD-7), which ranges from 0 to 21 (high is bad).
What counts as recovery:
Depression, PHQ-9, range from 0-27, "Recovered" <= 9
plus patients must improve by at least 6 points
Anxiety, GAD-7, range from 0-21, "Recovered" <= 8
plus patients must improve by at least 6 points
Note these are pretty big steps to count as improved, not one or two points on the scales.
Patients must also be above the 'recovery' threshold on both anxiety and depression.
[for PACE geeks only]
I wonder how the PACE recovery rate of 22% for GET and CBT would change if they excluded those who simply stepped across the recovery threshold with mimal change?
Actually, 13% of patients were the 'healthy' side of the (fatigue or function) recovery thresholds before the PACE trial started so we know there were plenty of people loitering near the recovery line.