2013 British Association for Behavioural & Cognitive Psychotherapies (BABCP) conference abstracts

[Dolphin]

2013 British Association for Behavioural & Cognitive Psychotherapies (BABCP) conference abstracts

http://www.babcpconference.com/programme/Abstract Book_2013.pdf

I don't have the time/energy/inclination to give each of CFS ones their own thread* but other people can feel free if they want. Also, if anyone wants to copy them in this thread, or elsewhere, it might be useful.
--------
Comment/Aside: If we didn't have patients, and patient organisations, raising money for research, as well as lobbying, a larger percentage of the research would likely be this sort. Personally, I think a lobbying-only approach is risky. Also, all applications are never going to be funded by grant making taxpayer-funded bodies, so to maximise number of researchers in a field, best to have money for at least some of studies that don't get funded in other ways.


*I've posted the PACE Trial one to another thread: http://forums.phoenixrising.me/inde...-to-free-txt-help-sought-to-explain-it.13888/

 

[Esther12]

Thanks D. And thanks for having a look through for us.

 

[Snow Leopard]

This is the most interesting one IMO:

Mediation effects in the PACE trial of complex treatments for chronic fatigue syndrome
Trudie Chalder, King's College London, Kim Goldsmith, King's College London; Peter White, Queen Mary's London; Michael Sharpe, Oxford University
Background: We have previously shown that both cognitive behaviour therapy (CBT) and graded exercise therapy (GET) are superior to adaptive pacing therapy (APT) and specialist medical care (SMC) in reducing fatigue and physical functioning in people with chronic fatigue syndrome (White et al 2011). The aim of this study was to investigate potential mechanisms of change underlying the efficacy of these treatmentsMethod : We examined a number of cognitive and behavioural mediators such as fearful cognitions, avoidance behaviour and walking. Mediation was assessed using Baron-Judd-Kenny, or BJK methods fitting a series of regression models.Results: Cognitive and behavioural mediating variables generally showed similar patterns, with the majority of change in the mediators occurring during the treatment phase. There was no change in the mediators between the end of treatment at 24 weeks and follow up at 52 weeks. Beliefs had the largest mediated effect on both fatigue and physical functioning for both CBT and GET. However the effect of these mediators on outcomes in GET was stronger than for CBT.Conclusion: Both CBT and GET were mediated primarily by beliefs. Both CBT and GET should target specific beliefs through behaviour change in order to change fatigue and disability.

I daresay beliefs have a big effect on questionnaire answering behaviour, that is to say the way that people answer a questionnaire is based on beliefs and optimism (or pessimism) rather than functional improvements in activity levels for example.

 

[Firestormm]

This is the most interesting one IMO:

We have previously shown that both cognitive behaviour therapy (CBT) and graded exercise therapy (GET) are superior to adaptive pacing therapy (APT) and specialist medical care (SMC) in reducing fatigue and physical functioning in people with chronic fatigue syndrome (White et al 2011).

Sorry but is that a typo? If not then I was right to burst out laughing Finally they admit the truth about PACE

 

[Bob]

Background: We have previously shown that both cognitive behaviour therapy (CBT) and graded exercise therapy (GET) are superior to adaptive pacing therapy (APT) and specialist medical care (SMC) in reducing fatigue and physical functioning in people with chronic fatigue syndrome (White et al 2011).

It does annoy me when they persistently claim that CBT and GET are superior to SMC. They don't know how effective SMC was, because it was not compared to a control group. SMC was the control, and it was more effective than the additional effect of CBT and GET.

 

[Dolphin]

Background: We have previously shown that both cognitive behaviour therapy (CBT) and graded exercise therapy (GET) are superior to adaptive pacing therapy (APT) and specialist medical care (SMC) in reducing fatigue and physical functioning in people with chronic fatigue syndrome (White et al 2011).

It does annoy me when they persistently claim that CBT and GET are superior to SMC. They don't know how effective SMC was, because it was not compared to a placebo control group. SMC was the control, and it was more effective than the additional effect of CBT and GET.

What they really should say is CBT+SMC and GET+SMC are better than SMC alone (using those two subjective outcome measures).

 

[alex3619]

I daresay beliefs have a big effect on questionnaire answering behaviour, that is to say the way that people answer a questionnaire is based on beliefs and optimism (or pessimism) rather than functional improvements in activity levels for example.

That is my take on this as well. The continued claim that functional capacity is improved is still unsubstantiated. Their endorsement of feeling improved on questionnaires is the outcome, despite objective evidence showing no improvement or a decline in functional capacity in many studies now.

 

[Simon]

Didn't they look at mediation before, and not find anything? If so, wonder how they pulled something out of the hat this time.

But the main thing about these statistical-heavy pieces is that the devil is in the detail and often authors try to make a lot out of very little. First, we know that most of the improvement came regardless of the treatment (the SMC/control element), and the subjective gains that did occur were quite modest. Given that not all of that modest gain will be meditated by beliefs, this could be a lot of fuss about nothing.

Have to say I know a bit about mediation, but nothing of Baron-Judd-Kenny methods. I do, howver, know that meditiation is very hard to demonstrate and most mediated effects are pretty unimpressive. I'm not quite sure why I'm so sceptical about these claims without seeing a full paper, but sceptical I am.

And of course, if they use the objective 6MWT as an outcome measure, there can be no mediation effect of CBT because there was no improvement gain from the therapy (relative to SMC alone). The 6MWT gain for GET was trivial so any mediation effect was tiny, but a priori you would expect any gain in walking distance from a graded exercise programme to be mediated by the exercise itself.

 

[Bob]

Conclusion: Both CBT and GET were mediated primarily by beliefs. Both CBT and GET should target specific beliefs through behaviour change in order to change fatigue and disability.

I'm not going to comment on the science behind this abstract, because we all know about the lack of science involved, and the lack of efficacy of CBT/GET in the PACE trial. This abstract is a work of fiction, and a propaganda sheet.
But the politics is interesting. This conclusion demonstrates that the authors haven't modified their approach to CFS in light of the PACE results.
They are still claiming, in essence, that CFS is not an illness, but a belief. And claiming that CFS (and associated fatigue/disability) can be treated and reversed by changing the patient's beliefs. So it's business as usual for the authors.

 

[Dolphin]

Didn't they look at mediation before, and not find anything? If so, wonder how they pulled something out of the hat this time.

Yes, here: http://forums.phoenixrising.me/inde...-to-free-txt-help-sought-to-explain-it.13888/ .

I was hoping the PACE Trial abstract would have been discussed there as people might not find it here in the future. Also, it could have been more easily compared to the existing one. But not the end of the world.

 

[biophile]

We examined a number of cognitive and behavioural mediators such as fearful cognitions, avoidance behaviour and walking. [...] Beliefs had the largest mediated effect on both fatigue and physical functioning for both CBT and GET.

The 2007 abridged protocol lists process (variables) and predictors, of response. I assume that the above abstract only deals with the former? It certainly sounds like it. So ...

Process variables

1. Step test of fitness [43].
2. Borg Scale of perceived physical exertion [44].
3. The symptom interpretation questionnaire [34].
4. Exercise and activity scale.
5. PHQ symptom sub-scale.
6. HADS scale combined score.

These are attached to the full protocol. The questions for the two bolded (belief related) questionnaires above have the following answers on a 5 point Likert scale:

- Strongly disagree
- Disagree
- Neither agree nor disagree
- Agree
- Strongly agree

A6.15 Exercise and Activity Scale
[Beliefs]
• I should avoid exercise when tired.
• Doing less helps fatigue.
• Exercise is harmful.
• I should avoid physical activity.

A6.32 Symptom Interpretation Questionnaire
[Views about your symptoms]
• I am afraid that I will make my symptoms worse if I exercise.
• My symptoms would be relieved if I were to exercise.
• Avoiding unnecessary activities is the safest thing I can do to prevent my symptoms from worsening.
• The severity of my symptoms must mean there is something serious going on in my body.
• Even though I experience symptoms, I don't think they are actually harming me.
• Physical activity makes my symptoms worse.

CBT and GET specifically targeted participants beliefs about symptoms. A small minority of participants (about 15%) responded to these therapies in terms of scores in self-reported fatigue and physical functioning.

I daresay beliefs have a big effect on questionnaire answering behaviour, that is to say the way that people answer a questionnaire is based on beliefs and optimism (or pessimism) rather than functional improvements in activity levels for example.

The continued claim that functional capacity is improved is still unsubstantiated. Their endorsement of feeling improved on questionnaires is the outcome, despite objective evidence showing no improvement or a decline in functional capacity in many studies now.

Indeed. It resonates with previous findings, demonstrating that the success of CBT/GET is not about significant improvements to other real world measures (which would make the claims more convincing), but a circular interaction between perceptions. Unimpressive for a non-blinded trial in which two groups received more optimism and encouragement than the other groups. The CBT group was even told that it was "a powerful and safe treatment".

We have previously shown that both cognitive behaviour therapy (CBT) and graded exercise therapy (GET) are superior to adaptive pacing therapy (APT) and specialist medical care (SMC) in reducing fatigue and physical functioning in people with chronic fatigue syndrome (White et al 2011).

Sorry but is that a typo? If not then I was right to burst out laughing. Finally they admit the truth about PACE.

Hehe. The sentence would still be questionable even if they said disability instead of functioning, because, when compared to SMC, CBT on average was not found to meet the definition of clinically useful difference.

 

[biophile]

Didn't they look at mediation before, and not find anything? If so, wonder how they pulled something out of the hat this time.

If these are the same findings, it sounds like something was found but was not particularly convincing:

http://www.trialsjournal.com/content/12/S1/A144

How do treatments for chronic fatigue syndrome work? Exploration of instrumental variable methods for mediation analysis in PACE – a randomised controlled trial of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care. [Oral presentation]. Kimberley Goldsmith, Trudie Chalder, Peter White, Michael Sharpe and Andrew Pickles. Trials 2011, 12(Suppl 1):A144 (Published: 13 December 2011) doi:10.1186/1745-6215-12-S1-A144

Objectives
Background

Chronic fatigue syndrome (CFS) is characterised by chronic disabling fatigue. The PACE trial compared four treatments for CFS and found that for therapies added to specialist medical care (SMC), cognitive behaviour therapy (CBT) and graded exercise therapy (GET) were more effective than adaptive pacing therapy (APT) and SMC alone in improving physical function and fatigue. What are the mechanisms of these treatments? CBT and GET may affect outcomes through thought processes and behaviours (mediators). Traditional Baron, Judd and Kenny (BJK) methods for estimating mediation effects can be subject to bias; instrumental variable methods (IV) can address this problem. The aims were:

To explore potential IVs for causal analysis of mediation in PACE.

To compare IV estimates to those obtained using BJK methods, which are unbiased only under restrictive assumptions such as no unmeasured confounding.

Methods

Two treatment arms were compared at a time. BJK methods were applied using three ordinary least squares (OLS) regression models. IV methods were applied by compiling a list of baseline variables that could act as IVs in interaction terms with treatment arm and then assessing these using OLS with the mid-treatment measurement of the putative mediator as the outcome. Instrument strength was assessed using the R2 change between models with main effects only and with the interaction term. Two-stages least squares regression (2SLS) was used to estimate effects in the presence of IVs. Collective instrument strength was assessed using an F test and partial R2.

Results

The IVs were weak, with a maximum R2 change of 0.03. The five strongest IVs were therefore used in the 2SLS in each case. There was modest mediation of CBT and GET effects (approximately 20% of the total effect). The IV-derived estimators were somewhat different in magnitude than the BJK estimators and were less precise. There is scope for modelling a common effect of mediators on outcomes across trial arms.

Conclusions

There was evidence for modest mediation of CBT and GET effects. Potential IVs for the study of PACE treatment mechanisms can be found, however, these were weak. Combining trial arms may allow for more efficient analysis using IVs.

 

[Firestormm]

Sorry but is that a typo? If not then I was right to burst out laughing Finally they admit the truth about PACE

OK. Well as I have finally received two 'likes' this morning. I can stop thinking that a) my sense of humour is unique; and b) that I had misread the damned line. Damned strange the things I worry about!

 

[Bob]

OK. Well as I have finally received two 'likes' this morning. I can stop thinking that a) my sense of humour is unique; and b) that I had misread the damned line. Damned strange the things I worry about!

I re-read that line many times, and couldn't see anything wrong with it. I've finally caught up! Well spotted Mr Firestormm!

 

[Bob]

Conclusion: Both CBT and GET were mediated primarily by beliefs. Both CBT and GET should target specific beliefs through behaviour change in order to change fatigue and disability.

The 2007 abridged protocol lists process (variables) and predictors, of response. I assume that the above abstract only deals with the former? It certainly sounds like it. So ...

Process variables

​

1. Step test of fitness [43].​

2. Borg Scale of perceived physical exertion [44].​

3. The symptom interpretation questionnaire [34].​

4. Exercise and activity scale.​

5. PHQ symptom sub-scale.​

6. HADS scale combined score.​

​

These are attached to the full protocol. The questions for the two bolded (belief related) questionnaires above have the following answers on a 5 point Likert scale:

- Strongly disagree
- Disagree
- Neither agree nor disagree
- Agree
- Strongly agree

A6.15 Exercise and Activity Scale

[Beliefs]​

• I should avoid exercise when tired.​

• Doing less helps fatigue.​

• Exercise is harmful.​

• I should avoid physical activity.​

​

A6.32 Symptom Interpretation Questionnaire

[Views about your symptoms]​

• I am afraid that I will make my symptoms worse if I exercise.​

• My symptoms would be relieved if I were to exercise.​

• Avoiding unnecessary activities is the safest thing I can do to prevent my symptoms from worsening.​

• The severity of my symptoms must mean there is something serious going on in my body.​

• Even though I experience symptoms, I don't think they are actually harming me.​

• Physical activity makes my symptoms worse.​

​

Thanks for highlighting all of that, biophile. The questions are illuminating.

I'm not really in the mood for further PACE studies, hence my venting earlier in the thread.
But just another short comment about the abstract (edit: actually perhaps it's turned into a shortish rant)...

In the PACE trial CBT was found to be ineffective in all objective outcome measures, including disability.
So any changes in behaviour and beliefs, after CBT, failed to reduce disability and other objective outcomes.
Any change in beliefs made no difference to disability or the actual lives of the patients.
For 15% of participants there was a change in self-reported outcomes. These patients believed that they had improved, when they had not.
So what did CBT change? It changed beliefs of a minority of patients.
But it is not surprising that some patients changed their beliefs (despite their continued disability) because CBT is precisely designed to change beliefs.

So, where it says "CBT and GET were mediated primarily by beliefs", the paper is saying that the changes in beliefs (that CBT brought about for a minority of participants) were mediated through beliefs?
In other words, CBT is designed to change beliefs, and in 15% of patients, it does.
Wow, what a surprise.
I hope the media have been alerted to this shocking revelation!

But despite the brainwashing, CBT was demonstrated to being ineffective at changing the lives and disability of the patients, as per all of the objective outcome measures.

There's no winning with propaganda papers like these.
Just one example:
"I am afraid that I will make my symptoms worse if I exercise."
I assume that they interpret this as a 'belief' but, if it is a 'belief', it is based on a rational interpretation of medical facts, because post-exertional malaise is a defining feature of the illness.
If CBT was designed to change such a belief, then (not only is CBT ineffective) it is anti-science, and dangerous.
Also, the therapists were trained to reduce the participants' levels of exercise if symptoms increased dramatically. Why? Because the patients' symptoms flared up in reaction to exertion, and by reducing activity levels, the symptoms had a chance to stabilise. So, were the therapists also "afraid that they will make the symptoms worse if the patient exercises?" Were the therapists complicit in this imaginary illness? Were the therapists' false beliefs mediated through CBT, and did their false beliefs change over time?



Rant over. Thanku for listening.

 

[Dolphin]

Thanks for highlighting all of that, biophile. The questions are illuminating.

I'm not really in the mood for further PACE studies, hence my venting earlier in the thread.
But just another short comment about the abstract (edit: actually perhaps it's turned into a shortish rant)...

In the PACE trial CBT was found to be ineffective in all objective outcome measures, including disability.
So any changes in behaviour and beliefs, after CBT, failed to reduce disability and other objective outcomes.
Any change in beliefs made no difference to disability or the actual lives of the patients.
For 15% of participants there was a change in self-reported outcomes. These patients believed that they had improved, when they had not.
So what did CBT change? It changed beliefs of a minority of patients.
But it is not surprising that some patients changed their beliefs (despite their continued disability) because CBT is precisely designed to change beliefs.

So, where it says "CBT and GET were mediated primarily by beliefs", the paper is saying that the changes in beliefs (that CBT brought about for a minority of participants) were mediated through beliefs?
In other words, CBT is designed to change beliefs, and in 15% of patients, it does.
Wow, what a surprise.
I hope the media have been alerted to this shocking revelation!

But despite the brainwashing, CBT was demonstrated to being ineffective at changing the lives and disability of the patients, as per all of the objective outcome measures.

There's no winning with propaganda papers like these.
Just one example:
"I am afraid that I will make my symptoms worse if I exercise."
I assume that they interpret this as a 'belief' but, if it is a 'belief', it is based on a rational interpretation of medical facts, because post-exertional malaise is a defining feature of the illness.
If CBT was designed to change such a belief, then (not only is CBT ineffective) it is anti-science, and dangerous.
Also, the therapists were trained to reduce the participants' levels of exercise if symptoms increased dramatically. Why? Because the patients' symptoms flared up in reaction to exertion, and by reducing activity levels, the symptoms had a chance to stabilise. So, were the therapists also "afraid that they will make the symptoms worse if the patient exercises?" Were the therapists complicit in this imaginary illness? Were the therapists' false beliefs mediated through CBT, and did their false beliefs change over time?



Rant over. Thanku for listening.

This is probably an example of where it's important that people like patients write letters to the editor and the like: other psychologists are unlikely to make such points as many psychological studies* rely on non-objective measures of one sort or another (either patient rated or rated by a clinician).

We need to be the little boys and girls pointing out that the emperor is wearing no clothes.

* i.e. including studies they have done before, might do in the future or at least refer to in their own work.

 

[alex3619]

[Satire} I don't know what all the fuss is about. The PACE trial was highly effective at changing disease attributions and beliefs about CFS. It convinced huge numbers of doctors that potentially highly biased subjective evidence is more important than physical and objective evidence, that contradictory information can be ignored, and that logical fallacies are OK in medicine. I would say that is a big win for CBT, a big win for psychogenic medicine, and a big win for those who benefit from these.

 

[Simon]

Interesting to compare this new abstract, which sounds more impressive, with the original Clinical Trials conference abstract from 2011 which was more detailed:

[Method: Mediation was assessed using Baron-Judd-Kenny, or BJK methods]

Beliefs had the largest mediated effect on both fatigue and physical functioning for both CBT and GET. However the effect of these mediators on outcomes in GET was stronger than for CBT.

Conclusion: Both CBT and GET were mediated primarily by beliefs. Both CBT and GET should target specific beliefs through behaviour change in order to change fatigue and disability.

The finding is that CBT/GET was mediated primarily by beliefs, with no mention of the size of the effect, or methodological problems

Background Traditional Baron, Judd and Kenny (BJK) methods for estimating mediation effects can be subject to bias; instrumental variable methods (IV) can address this problem...

To compare IV estimates to those obtained using BJK methods, which are unbiased only under restrictive assumptions such as no unmeasured confounding.

Results
The IVs were weak, with a maximum R2 change of 0.03. The five strongest IVs were therefore used in the 2SLS in each case. There was modest mediation of CBT and GET effects (approximately 20% of the total effect). The IV-derived estimators were somewhat different in magnitude than the BJK estimators and were less precise. There is scope for modelling a common effect of mediators on outcomes across trial arms.

Conclusions
There was evidence for modest mediation of CBT and GET effects. Potential IVs for the study of PACE treatment mechanisms can be found, however, these were weak. Combining trial arms may allow for more efficient analysis using IVs.

Note that this conference abstract never went on to become a full paper, suggesting that the findings were not worthy of publication, or the authors didn't like their own findings.

Key points:

• Meditaion effects were in fact only 20% of total effect (and total effect wasn't huge), suggesting this is indeed a lot of fuss about nothing. Note the effect size not mentioned in the new absract
• The study aims to use IV to measure mediation instead of Baron Judd Kenny method (BJK) which is likely to be biased - the new abstract only mentions BJK, the biased method, with no mention of the IV approach in the earlier work.
• A maximum IV effect on R-squared of 0.03 is tiny, it means that including the IV mediator improves the model by 3% for the strongest IV - impressive in no ones' book

 

[Bob]

Simon, thanks for showing the comparison.

I'm about to get political again, but comparing the two abstracts is a case of witnessing the process of poor scientific results being converted into good propaganda.

 

[biophile]

There are also two more abstracts that are both more recent than the 2011 original but older than the last:

http://kivik.no/ISCB/wordpress/wp-content/uploads/2012/08/iscb33_2012_abstractbook_web.pdf

Results

The IVs were weak, with small R2 changes. The IV-derived estimators were different in magnitude and less precise than the BJK estimators. The relative precision of different IV estimators varied 10-18%. There is scope for modelling a common effect of mediators on outcomes across trial arms.

Conclusions

Potential IVs for the study of PACE treatment mechanisms can be found, however, these were weak. Combining trial arms may allow for more efficient IV analysis.

http://www.da.ugent.be/cvs/pages/en/final_program.pdf

Results:

Tests of instrument strength indicated these were weak (ie. poor predictors of the mediator). The IV estimators were different in magnitude and less precise than the BJK estimators. The relative precision of different IV estimators varied 10-18%. There is scope for modelling a common effect of the mediators across different treatments.

Conclusions:

Interaction term IVs in PACE were found to be weak. Combining trial arms may allow for more efficient analysis.