From Esther's first article:
I found this extract informative. He's talking about Faux Evidence-Based Behavioural Medicine, but I'd not been aware of this explicit example of a possible conflict of interest:
I could provide ample incidents for my own
career, but let me cite a recent Psychology Today blog post by Allen Frances, the former chair of the American
Psychiatric Association DSM-IV Task Force. He has become a harsh critic of the APA's DSM-5 Task Force deliberations.
The APA stands to make millions from sales of the DSM-5 manual to clinicians, policy makers, and researchers, and its members have a stake with uncounted millions of dollars over time for reimbursement for services for an expanded range of diagnoses.
According to
Frances' blog and Time magazine article reports, the APA has recruited a new public relations spokesman who previously worked at the Department of Defense and has declared Frances
"a dangerous man trying to undermine an earnest academic endeavor."
This provides a perfect example: a professional organization protesting that its efforts are "an earnest academic endeavor" and a detractor-critic is a "dangerous man." I could not have invented something better to illustrate my point.
I just hadn't (not surprising really) thought about it. I mean that DSM-5 would be a commercial product. Just goes to show how little I know - I figured it was all state-funded!
Anyway, I guess this gets to the crux of the matter with regard to the article's and future articles' purpose:
An excellent case example is provided by the Society for Behavioral Medicine's (SBM) recent declaration that psychosocial interventions to reduce pain in cancer patients are ready for systematic implementation. The announcement was presented as the conclusion of a
meta-analysis published in Journal of Clinical Oncology (JCO) on February 10, 2012 and a
closely related special issue of JCO that is edited by the senior author and has articles by him. The meta analysis is also highlighted in an April 2012 special symposium at the annual meeting of SBM in New Orleans. The special issue of
JCO as well as the meta-analysis, will be the focus of a series of blog posts.
I have not done a thorough exploration of every detail of the meta-analysis in
JCO and of the studies that were entered into it, but
when I present my critique in the next blog post, I think readers will agree that there is no further analysis necessary to undermine the credibility of the meta-analysis.
What I have found is sufficient to indicate gross deficiencies in its integration and interpretation of bad studies, the likes of which can serve to mislead cancer patients, their family members, clinicians, and policymakers.
So... is PACE and/or it's interpretation to be regarded as a (similar) 'meta-analysis' or is/are CBT and GET more specifically?
Am feeling rather dumb today (every day!) HA!!
I get this:
I am particularly concerned that false assurances about the efficacy of weak, inert, or even harmful interventions will influence
decision-making of cancer patients, their family members, and clinicians who are squeamish about using medications to control pain.
and I wonder if these thoughts can be applied to our condition:
The evidence base for medications to control pain in cancer patients is overwhelming with effect sizes that dwarf those for psychosocial interventions. The critical issues for
management of cancer pain with
medication are not the efficacy of available medications, but the poor quality of routine pain management in the community—inadequate prescribing, dosage, and administration, fueled in part by the prejudices and lack of knowledge by professionals, patients, and clinicians.
What is strikingly missing from the Society of Behavioral Medicine meta-analysis is any analysis of this problem, or of how psychosocial management should be integrated with medication or even
education about medication in the treatment of cancer pain.
Are psychosocial interventions for cancer pain complementary or alternatives to management with medication? When and under what circumstances? Psychosocial interventions have a role in facilitating effective pain management for cancer patients with medication, but what is it and what is the evidence for their effectiveness?
It would be good if it could (well it wouldn't) but we perhaps are not in a position to compare e.g. pain medication to psychological behaviour management therapies aimed at replacing them - or are we?
One of the critiques of the PACE trial for example would be a lack of adequate comparison (in my view) e.g. Standard Medical Care did not include what I have come to understand as such e.g. the prescribing for example of pain relief medication.
Whilst the NICE Guidelines have to some extent sought to address the bolded questions above I don't think they do so adequately.
Indeed I think you could reasonably argue that because specific studies have not been produced for any drugs and ME patients - they have used 'publication bias' to argue that such interventions have no merit, or to quote from the Guidelines themselves:
There is no known pharmacological treatment or cure for CFS/ME
but, that
symptoms of CFS/ME should be managed as in usual clinical practice
and, in respect of CBT/GET:
because currently these are the interventions for which there is the clearest research evidence of benefit
Publication bias? Evidence bias? Are these the only 'treatments' to have been tested and found to have been of benefit for people with our condition?
With cancer it is then perhaps more clear-cut. You have specific pain medication tested on cancer on the one hand and behavioural interventions on the other and patients who might wish to try either or who are fearful of the medications themselves or who are not being afforded clear direction and advice.
Hmmm...