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England: RCT CBT for Psychosis vs. drug therapy

Discussion in 'Other Health News and Research' started by Firestormm, Nov 7, 2012.

  1. Firestormm

    Firestormm Senior Member

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    I caught this regular programme last night when listening in bed. Quite interesting, I thought. Quite disturbing perhaps as it seems to be part of a 'movement' towards challenging conventional drug therapies - which for psychosis appear to have nasty side-effects - with CBT interventions.

    I wouldn't dismiss this out of hand. The CBT being offered - listen to the patients in the interviews, and the doctors involved - is not a 'cure' for psychosis but a possible means of better being able to deal at a personal level with these episodes.

    Also includes some interesting comment about the lack of recognition for mental illness in the US by health insurance companies - though this concern is somewhat mitigated now of course:

    GO OBAMA!! :)

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  2. AFCFS

    AFCFS Senior Member

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    My understanding is that CBT really only has a fighting chance when a person is somewhat stable. It takes quite a bit of work on the patient's part and the actual ability to "test" thoughts with reality - hard to do if separated from it in a self-perpetuating psychotic state.

    I have tried it in a somewhat variant form, REBT, which I find more compelling. I think it is fine for basic anxiety-typed issues, and maybe some others, but it also requires a fair amount of insight and obsession by the patient to dig deep and crank through rather copious amounts of thought processes.

    When I hear about CBT/REBT in use today, I also get a flash of association to Karen Horney's "The Paucity of Inner Experiences" (1952). I believe it had credence then and even more so now in world that seems to want to do anything but look inside oneself for an answer.

    This lends to a bit of hyperbole, in that I think most people would really flip out if they went to a doctor today, he handed them a workbook, and told them to comeback in 15 weeks after they read it and applied it.
  3. Firestormm

    Firestormm Senior Member

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    I think it's worth listening to the broadcast. The RCT is a first from what I could understand and is in phase II. However, the usual conditions apply to psychological RCT trials in my view. Namely, that you are dealing with a) the mind and a person's ability to understand and then use what is being taught compared to a drug that presumably can have more measured effects; and b) in practice it is incredible hard to teach everyone the exact same thing and for them to then use it to the maximum effect compared to taking a pill and playing with the dose.

    There is understandable resistance in even the psychiatric profession to abandoning drug therapy and replacing it with CBT. I don't think this is what is intended by any means. Rather CBT would work alongside drug therapy. And there is the whole brickwall associated with cost. In almost any chronic long term condition, CBT and/or psychological therapy is recommended - but the NHS and Government are not funding such treatments for nearly enough people to be able to back-up any of the claims being made with 'on the ground' data.

    Personally, I would rather see everyone with e.g. my condition be offered drug therapies in the first place backed up by psychological interventions. This is more in keeping with NICE Guidelines I believe. Often though it is being presented to us as a case of 'either or' and not 'both'. If you see what I mean.

    There does come a time where 'medicine' can do no more and patients with a long term condition are/have been left to manage alone. This is where perhaps psychological interventions should be offered. But, regular reviews of medication also need to take place. Patients deserve to offered the most effective researched medications for their symptoms and not left to fester on drugs that may have gone past their 'sell-by date' or be causing side-effects that have been assumed as being part and parcel of living with the condition.

    Anyway, I thought it was an interesting development.
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  4. AFCFS

    AFCFS Senior Member

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    I agree. I think for me, I am a bit jaded at the same time. Looking across my room, I see a book shelf holding page-bent, dog-eared CBT/REBT books along with a stockpile of meds that did little to nothing for me. That being said, there is also a bit of seeking to try just about anything that holds hope. And, as suggested, it is often the case that they might work best in combo - just have not found that combo yet.
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  5. Esther12

    Esther12 Senior Member

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    I'd coincidentally seen some sceptical psychiatrists complaining about this elsewhere on-line (the programme, and the way CBT was being promoted). Not something I know much about, but I thought I'd mention the complaints that this programme gave a misleading impression.

    Generally, when results are assessed via questionnaire I think there a real danger that the efficacy of CBT will be exaggerated, as improvements in reported symptoms get confused for improvements in symptoms.
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  6. alex3619

    alex3619 Senior Member

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    First indoctrinate someone to think a certain way, then get them involved in convincing themselves - thats CBT. Then assess outcomes via a questionairre - this with a person who has been influenced to respond a certain way. Objective outcomes are very important to assess effect, and one of the problems with psychiatry in general is a lack of objective outcomes in their research. You can make people feel better with a gift certificate. Feeling better is only one outcome and possibly not a very good one in many cases.

    In order for this science to advance they need biomarkers. Many psychiatric disorders have substantive physiological changes. Bio-psychiatry and psycho-psychiatry need to come together and work on those markers. Until that happens there will always be substantive doubt about any subjectively measured outcomes.

    Bye, Alex
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  7. AFCFS

    AFCFS Senior Member

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    I think another reason psychiatrists might not like it is because it does potentially threatens their "bread and butter" of prescribing meds. It may seem intimidating to them that someone with a masters degree in psychology, counseling, or social work can, in many places, guide patients through CBT/REBT for much less coin than they charge.

    In many cases, a patient could probably get three counseling sessions AND a gift certificate for the price of a rushed session with a pdoc. Not that is better, but it may be, perhaps at least in some combination.

    Of course some clinics/treatment centers may be set up this way in the first place, but I have also seen pdocs grimace at the thought of having to read psychologists' notes, as if if there observations seem inconsequential or so beneath them. There is some unneeded rivalry and disdain in the field that probably helps no one. But then, again, insurance companies like the idea of cheap treatment options, so motives, money, and politics often smear the reality of efficacy.
  8. Firestormm

    Firestormm Senior Member

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    Hi Ester,

    Yes the programme did mention the concerns expressed by some psychiatrists but they did so along the lines of them being 'old school' I seem to recall.

    I guessed in my comment above that this was a controversial area for other reasons one of which is the olde 'it's all based on questionnaires' meme. Perfectly valid of course. The programme though was biased, however the RCT is proceeding.

    The two patients featured (they didn't feature any patients who might have lent some balance i.e. any who didn't feel CBT had helped) claim to have gained from CBT and significantly so - and that's important, right? Though for the life of me I can't recall if both of them had surrendered their medications as a result - I think they had.

    The programme was also a little alarming I felt, in that instead of ending with a warning to 'consult your doctor before coming off any medications' it said something like 'reduce your dose gradually'. Hence my expressed concern initially - not well explained I grant.

    Really though, I would rather people listened to the broadcast (I presume you have), because like it or not there is a growing 'trend' to see 'talking therapies' and 'self-care' replacing or at least having similar priority as drug therapy.

    What appears to be holding this growing 'movement' back is funding, and not will or a belief that these things are effective. Indeed at a local level, we are told that funds are being made available for this kind of management therapy from central sources whereas funding for conventional treatment is being restricted.

    There is a significant upfront cost burden here - drugs are cheaper generally than talking therapy - but does this reverse if patients can better learn to self-manage? Do patients return to needing a 'top-up' of talking therapy leading to greater and on-going cost? Are drugs for long term conditions really being replaced? Does CBT keep patients out of hospital? Etc. etc. etc.

    And, if I am on benefits or claiming sickness insurance (or something) would my being on little or no ongoing drug treatments, but having had an initial dose of talking therapy and subsequently practising self-management, have any effect on my claims? What I mean to say is - is the 'world' ready to believe?

    Sorry. Might not be making any sense this morning. Back later :)
  9. Esther12

    Esther12 Senior Member

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    AAAArghghg! Just deleted a long reply.

    Oh well, it was pretty rambling. Short version: I've not listened: I was just posting because I'd coincidentally seen other people being critical of the programme, and know how the BBC can spin things in a way that sounds very convincing and reasonable, so thought I'd mention that others were unhappy with the way the programme was done.

    I think it's really important to be as honest as possible with patients, but other than that I have no idea what would be best in this area.
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  10. Firestormm

    Firestormm Senior Member

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    Gone on Esther! 'Treat' yourself and have a listen :)

    I hate it when I do that (the deleting). What a waste of energy and effort :cry:
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  11. AFCFS

    AFCFS Senior Member

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    You know, CBT could turn that frustration to a happy face.:)
    I have listened: Is it just me or does BBC sound like NPR or vice versa (perhaps they are the same)? In any event, 29 minutes of flat, monotone, voices makes me want to to take an anti-psychotic. And there is unnecessary repetition that seems to it drag it on...and on.

    - But then, maybe CBT would also allow me to even view this from a different perspective.
  12. Esther12

    Esther12 Senior Member

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    I've not listened to the programme but did allow myself the pleasure of reading the paper which led on to this (open access): http://www.mentalhealthexcellence.o...ns/Morrison et al. (2011) CT with no meds.pdf

    It doesn't look great to me, but it was only an exploratory trial and this is not an area I know well enough to really comment. Schizophrenia seems like such a difficult topic. I'm just really glad not to have to deal with those sorts of problems myself.

    As treats go, I'd rate this as less fun than Disney world.

    Yeah - it's that sort of thing. But the BBC has a lot more money, is less good, and is a pretty dominant player in British media.
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  13. Firestormm

    Firestormm Senior Member

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    I 'liked' your comment above Esther except the bit about the BBC. Don't know what you're talking about there I am afraid :)
  14. Esther12

    Esther12 Senior Member

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    Maybe I only get the best bits of NPR! I've just turned my partner against the BBC - and they were someone who always loved cosy radio 4. The BBC is okay-ish, but it's more trusted and respected as an institution than it should be, and it's willing to look after it's own in order to maintain that trust and respect imo.

    Was just looking at this, which looked at CBT in addition to medication (improving adherence to treatment is one of the way's CBT is thought to help):

    http://www.ncbi.nlm.nih.gov/pubmed/19476688


    Controversial area, but to me it looks like CBT is over-hyped in a wide range of areas. For anxiety, it seems like a sensible approach, and has better evidence for efficacy there too... but the spin that surrounds it in other areas makes me feel somewhat sceptical about all claims of efficacy. I'm also much more aware of the dangers that occur when CBT places medical staff in positions of authority over the minds of others than I was previously.

    I think that we're going to look back at the way CBT came to dominate MH, and regret it.
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  15. Firestormm

    Firestormm Senior Member

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    Very interesting study from Glasgow there Esther. Thanks.

    Lol. What's NPR?! Sorry. I haven't a clue (Radio 4 LOVE IT!!) :)
  16. Esther12

    Esther12 Senior Member

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    Sorry - NPR: America's broadcaster with the ethos the BBC is meant to have, but much less money. Does some good in depth news shows, and things like 'This American Life' which is a series of amusing mini-documentary things.
  17. Firestormm

    Firestormm Senior Member

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    Ahhhhhhhh..... okey dokey. Thanks :D

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