Keith Laws 'Has cognitive behavioural therapy for psychosis been oversold?'

[Sean]

Thanks, bp.

 

[worldbackwards]

Also, re "the enemies of your enemies are your friends" - it's not like I'm a keen fan of those selling dodgy 'biological' treatments for CFS! I just want people to restrict the claims they make to those that are supported by good evidence, and when that is not available, to be clear about that whatever treatment they are promoting is experimental and lacking a good evidence base.

I think I'd suck at discussing CFS on twitter.

Twitter is not known for it's elegant grasp of nuance in argument!

 

[Esther12]

Twitter is not known for it's elegant grasp of nuance in argument!

I'm often so uncertain as to what I think that I usually need room to explain why the first thing I said might be wrong.

 

[Bob]

"The Mental Elf" blog has recently published a discussion of schizophrenia, including CBT as a treatment for schizophrenia, written by Keith Laws, Alex Langford, and Samei Huda.

Understanding Psychosis and Schizophrenia: a critique by Laws, Langford and Huda.
Keith Laws, Alex Langford, and Samei Huda.
The Mental Elf
27 Nov 2014.
http://www.thementalelf.net/treatme...phrenia-a-critique-by-laws-langford-and-huda/

It starts...

A new report has been published today by the British Psychological Society Division of Clinical Psychology entitled ‘Understanding psychosis and schizophrenia: why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and what can help’.

The report is being formally launched at a conference today in London.

The 180-page document has been written by a “working party mainly comprised of clinical psychologists drawn from the NHS and universities”. It has been welcomed by a number of key mental health organisations, including Mind.

This blog offers a critique of three key elements within the report, each of which has been tackled by an individual with special interest in the area:

1. CBT for psychosis: Keith Laws
2. Medication: Alex Langford
3. The psychological and biomedical models: Samei Huda

The report reviewed by our bloggers was the version available on the BPS website on 20th November 2014.

 

[Bob]

The above blog on The Mental Elf website seems to have started a public spat between some of the players...

I was alerted to it by this Tweet by Ben Goldacre... ("BPS" refers to the The British Psychological Society)...

BPS president elect is trying to silence twitter discussion of dire BPS paper
https://twitter.com/profjamiehh/status/538768180391706624…
http://www.thementalelf.net/treatment-and-prevention/medicines/antipsychotics/understanding-psychosis-and-schizophrenia-a-critique-by-laws-langford-and-huda/… Very backward.

The Tweet refers to a public spat involving (amongst others) Ben Goldacre, Keith Laws, The Mental Elf, and Jamie Hacker Hughes who is president of the The British Psychological Society (BPS)...

As per Goldacre's Tweet, the Twitter spat is played out here:
https://twitter.com/profjamiehh/status/538768180391706624

It's interesting, and very relevant to our own situation re CBT.

Brief excerpts:

Jamie Hacker Hughes (BPS President):
"This needs to continued in journal papers and conferences not on Twitter"

Goldacre responds:
"what a disgraceful attempt to silence discussion. I'm shocked"

etc...

 

[Esther12]

Thanks Bob.

I have to admit to jumping to the comments first (on the Mental Elf blog), but Kinderman's second reply, in which he seems to argue that focusing on the results from blinded trials leads to a distorted view of CBT's efficacy, is a bit odd.

He seems to attempt justify this by saying:

I don’t feel it’s appropriate to do a similar exercise with respect to drug trials (looking at potential conflicts of interest, potentially procedural issues, such as blinding there too, the adverse effects (which can often match the beneficial effects) and the long-tern consequences). But the point is that it is possible to selectively pick a certain sub-group of RCTs and then demonstrate a lower averaged effect size for that selected sub-group.

But surely for all interventions we do want to be looking at those problems, and looking for the sub-group of RCTs which have been most rigorously designed and conducted.

 

[Sean]

If at first you don't get the results you want, then just lower your standards.

Sure, why not. What could possibly go wrong.

 

[biophile]

A few more interest tweets from Laws (and one from Goldacre):

https://twitter.com/Keith_Laws/status/538833524372299776

Keith R Laws @Keith_Laws

While NICE recommends only (ineffective) CBT & it hoovers up research funds - alternatives will be very slow to develop @mollocate

https://twitter.com/bengoldacre/status/538785733239382017

ben goldacre @bengoldacre

@Mental_Elf I’m amazed and saddened by this, it’s a weak BPS paper, but resorting to “don’t discuss this on twitter” is a whole new level.

https://twitter.com/Keith_Laws/status/539075924747386882

Keith R Laws @Keith_Laws

So now we know *one* reason CBTp survives - neither NICE nor some advocates have any interest in RCT quality

https://twitter.com/Keith_Laws/status/539074801667964928

Keith R Laws @Keith_Laws

But having said that - it is precisely how NICE have operated on CBTp - no attention to study quality

https://twitter.com/Keith_Laws/status/538966486711549952

Keith R Laws @Keith_Laws

. @Rooingaround @profjamiehh @peterkinderman @PsychiatrySHO @SameiHuda @Mental_Elf Try to publish paper critical of CBTp-set aside 3-4 years

https://twitter.com/Keith_Laws/status/539070852894302208

Keith R Laws @Keith_Laws

That's clarified things - Peter Kinderman expresses his view about blind vs nonblind RCTs assessing CBT for psychosis http://t.co/yU7Y2XsToO

https://twitter.com/Keith_Laws/status/539074259302506496

Keith R Laws @Keith_Laws

A plea to put the clinician bias back into effect sizes by Peter Kinderman- bit stunned really http://t.co/yU7Y2XsToO

Keith Laws has a website with data from his meta-analysis: http://www.cbtinschizophrenia.com ... What surprised me is that most of the many CBTp studies were blinded, and how there has been discussion elsewhere over the importance of blinding in such trials. When it comes to CBT for CFS, almost none of the trials were blinded, and the relevance of blinding is ignored.

 

[Esther12]

I read the blog now and thought I'd post my thoughts here as I don't really know what I'm talking about, and thought it could be better to discuss things here than interrupt things over there.

Laws' section was a concise summary of things already discussed in this thread. I'm not sure if this is right, but I sometimes get the impression that Laws avoids talking about the benefits of medication because he doesn't want to be the anti-CBT pro-meds guy. It seems strange that he focuses on criticising the claim that "people gain around as much benefit from CBT as they do from taking psychiatric medication" but does not talk about what benefit people gain from medication.

I've not read Understanding Psychosis, so it's probably a bit silly be judging a critique of it, but I wasn't so keen on Alex Langford's section, eg:

A note on ‘terminology’

I was also interested in the constant use of inverted commas around ‘antipsychotic’, and indeed the sporadic use of ‘psychosis’ itself in the same state. Clearly the authors, and those who they feel they represent, choose to see the terms not as ‘real’ but as ‘constructed’ or ‘disputed’. I’m fine with that – but I wonder if it will serve the interests of the majority of people for whom this report is meant. For those who have come to form their narrative of suffering and healing using these terms, which is plenty, I can see the inverted commas being quite devaluing. Again, I’m happy to be challenged.

That just seems like the sort of cheap, hiding-behind-patients argument I see some of the pro-CBT people using. Another claim is challenged with the statement that this "completely fails to match my experience of clinical reality." Maybe the assertion in Understanding Psychosis was founded on nothing more than the authors clinical experience, but I didn't feel like this was a criticism that had much punch.

This bit made me think 'what's wrong with undermining how medications are commonly thought to work':

However, despite the scattered strong points, the space dedicated to medication reads very much as a step-by-step critique of it. For example, more than half of the free text in the ‘how medication can be helpful’ segment is spent undermining how medications are commonly thought to work – with highly scientifically controversial statements.

The ‘key point’ that there is ‘little evidence that [medications correct] an underlying abnormality’ is bizarrely unfounded. An excellent summary by Kapur & Howes (referenced earlier in the report itself) and further imaging studies by Howes and others provide solid evidence for elevated presynaptic dopamine levels being a key abnormality in psychosis, and there is copious evidence that inhibiting the action of this excess dopamine using antipsychotics leads to clinical improvement in psychosis.

I'm not well informed here, but was instinctively sceptical of the claim that there was good evidence that medication worked by correcting a specific underlying abnormality and VaughanBell challenged this in the comments. I thought VaughanBell's criticism of the next section, and of the general tone and intent of the blog, was pretty weak though.

I also felt out of my depth with the Samei Huda section, but this bit on Bental reminded me a lot of the things which disturb me about the patient materials so far released from FINE:

The UPS report would have been stronger if it acknowledged it’s weaknesses, but this goes against its absolutist view that all psychosis phenomenon can be understood. It states Bentall’s view that once psychosis can be understood then there is no reason to posit an underlying illness. Hence any weaknesses in understanding are skated over, and phenomena not easily explained in this way are minimised.

Also, another thing about Peter Kinderman's comment bugged me:

First, one important conclusion would be that it’s important that we support individual choice. There is plenty of evidence that there are a number of beneficial therapies that the NHS should provide. There is plenty of evidence that many can be beneficial. There’s also evidence that our own personal preferences are both valid and important. And there simply isn’t overwhelming evidence to reject one approach and support another. So, point #1 – support individual choice.

The thing, patient choice really requires accurate information about efficacy.

Having the NHS pay for homeopathy, and medical staff to give patients results from non-blinded trials before asking them if they want it, is not empowering patients to have their preferences and values guide decisions about their own health care, it's allowing quacks to manipulate and mislead those with health problems.

To me, it seems like the NHS tries to do too much, and that we'd be better off with it focussing on what it does well with any resources for quality of life issues beyond this going directly to those that we want to help, so that they can be genuinely empowered to improve their own lives.