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Lancet Psychiatry: Per Fink and Sharpe recommends more intensive CBT for the severely ill

Countrygirl

Senior Member
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5,431
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UK
In this new Lancet article, our favourite duo, Sharpe and Per Fink recommend more intensive CBT for the severely ill.


http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00233-3/fulltext?elsca1=etoc&elsca2=email&elsca3=2215-0366_201507_2_7_&elsca4=Forensic and Legal Medicine|Lancet|Neuropsychiatry|Psychiatry/Addiction Medicine


The discipline of so-called medically unexplained or functional somatic symptoms is divided into a large number of terminology-defined diagnostic concepts that have been developed on the basis of expert consensus rather than through systematic research in representative samples.1 These diagnoses have been used to define inclusion criteria for clinical trials and establish which trials are selected for meta-analyses. The result is a confusing scientific literature and contradictory systematic reviews. Although a focus on symptom clusters such as gastrointestinal symptoms (irritable bowel syndrome), musculoskeletal pain (fibromyalgia), and fatigue (chronic fatigue syndrome) makes some sense because these clusters are supported by epidemiological research,2division of patients by arbitrarily defined diagnostic constructs that describe the same clinical conditions (namely medical functional somatic syndromes as opposed to psychiatric somatoform disorders) is unhelpful and could be misleading.2,3



An example is the Cochrane review on non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms,figure). The figure shows that although effect sizes were similar across the partly overlapping diagnostic groups (range 0·32–0·51), we noted a considerable difference when we grouped patients according to illness severity. The most severely ill patients gained little from group CBT (effect size 0·29 [95% CI −0·12 to 0·71]; p=0·17), whereas patients with less severe illness had substantial symptom reductions (0·72 [0·33–1·11]; p=0·0003). Although this analysis was not planned in advance and therefore should be treated with caution, its results are in line with the few systematic reviews that have attempted to cover the whole discipline of functional somatic syndromes.6 On the basis of this work, stepped-care models have been proposed in which psychological treatment delivered by specialists is reserved for patients with severe illness, whereas enhanced care alone is recommended in mild and moderate cases.6, 7 Our results suggest that the most severely ill patients might need even more intensive treatment than that delivered in our trial.

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We defined the most severely ill patients as those who reported more than 30 functional somatic symptoms during the past 2 years and who had severe impairment in daily living according to the clinician. Because these patients meet diagnostic criteria for more functional somatic syndromes than do patients with less severe illness,
 
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adreno

PR activist
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4,841
gr1.jpg


Looking at the figure, all disorders show ES lower than 0.5, which isn't even moderate. Why even bother? From this, CBT seems utterly ineffective for these disorders, far lower than ES for depression, for example.
 

A.B.

Senior Member
Messages
3,780
They should design some trials first that can distinguish between placebo and treatment effects. As far as I'm concerned, it still hasn't been proven that any of these psychological interventions is more than training people to give the "right" questionnaire answers.
 
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alex3619

Senior Member
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13,810
Location
Logan, Queensland, Australia
They should design some trials first that can distinguish between placebo and treatment effects. As far as I'm concerned, it still hasn't been proven that any of these psychological interventions is more than training people to give the "right" questionnaire answers.
Yes, I think this is one of the huge issues I have been discussing elsewhere. OBJECTIVE improvement must substantiate subjective claims that are vulnerable to extreme bias using questionnaires.

Edit: this is a comment I earlier posted to FB:

Given that outcome measures are typically subjective, and CBT might well alter how many patients fill in questionnaires, this might be a shift back toward its true effectiveness rate (which might be worse than zero) as people see through the gloss and babble. I do think CBT can help some to some degree, but its overhyped, oversold, etc. Who those some are, and to what degree, is still not being properly studied. It may even be nobody.

Psychiatry will not advance as a science until objective measures are used. Even then entire methodological systems have to be abandoned, and psychiatry evolve to modern use of the scientific method. Until then much, if not most, of psychiatry, and probably all of psychogenic medicine, will remain dubious alternative medicine that has wormed its way into medical doctrine.

More and more patients and prospective patients are better and better informed. Psychiatry has not only lost its gloss, its becoming visibly more and more tarnished. Fixing this will require a shift of the basic paradigms used in psychiatric practice and research. It will require a shift from dogma to rational practice.
 
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Sidereal

Senior Member
Messages
4,856
gr1.jpg


Looking at the figure, all disorders show ES lower than 0.5, which isn't even moderate. Why even bother? From this, CBT seems utterly ineffective for these disorders, far lower than ES for depression, for example.

Not to mention that the confidence interval crosses 0 for CFS, IBS, hyperventilation and "most severely ill patients" indicating no significant effect for CBT for those conditions. It's amazing how their own data show that this treatment doesn't work yet that doesn't stop them from promoting even more of it.
 

Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
gr1.jpg


Looking at the figure, all disorders show ES lower than 0.5, which isn't even moderate. Why even bother? From this, CBT seems utterly ineffective for these disorders, far lower than ES for depression, for example.
Thanks. What amazes me is that comparison with depression. A recent meta-analysis found the effect size for depression had fallen since the 1970s from about 2.4 (miracle cure) to 1.2. But an effect size of 1.2 is still pretty-impressive. This compares with an effect size of under 0.5 for CFS in the benchmark study (PACE), even before allowing for issues of placebo effect/response bias in an unblinded trial with subjective outcomes.

You might think that with such a small effect size the proponents of CBT/GET would pause to think: 'if we can only make such a modest difference with our best shot, maybe our model is wrong?'. PACE, of course, explicityly based its therapy on a model that the illness is perpetuated by patients' flawed beliefs/behaviours.
 
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Gijs

Senior Member
Messages
690
I call it gaslighting... mental abuse! Before my illness i didn't know that scientists, docters, psychiatrists and the medical community where such stupid and simplistisch people! They need serious CBT to correct there disfunctional minds... They are the real grazy ones but the don't know it....
 

Sidereal

Senior Member
Messages
4,856
Thanks. What amazes me is that comparison with depression. A recent meta-analysis found the effect size for depression had fallen since the 1970s from about 2.4 (miracle cure) to 1.2. But an effect size of 1.2 is still pretty-impressive. So given an effect size of under 0.5 for CFS in the benchmark study (PACE), even before allowing for issues of placebo effect/response bias in an unblinded trial with subjective outcomes.

The recent P2P meta-analysis showed the same thing happening in the CFS field. The initial study by Wessely's group showed a huge and highly improbable, never-to-be-replicated effect size, as so often happens in medicine. Subsequent studies show a return to planet Earth (regression to the mean).

I suspect if PACE were repeated by other investigators who didn't have an allegiance bias to CBT, used blinded raters and non-absurd inclusion and recovery criteria, we'd see an effect size approaching 0.
 

A.B.

Senior Member
Messages
3,780
I suspect if PACE were repeated by other investigators who didn't have an allegiance bias to CBT, used blinded raters and non-absurd inclusion and recovery criteria, we'd see an effect size approaching 0.

There was a CBT and GET study done by Spanish researchers associated with a rheumatology clinic, and they found the intervention worsened physical functioning and pain scores.
Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up
 

Sidereal

Senior Member
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alex3619

Senior Member
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13,810
Location
Logan, Queensland, Australia
I suspect if PACE were repeated by other investigators who didn't have an allegiance bias to CBT, used blinded raters and non-absurd inclusion and recovery criteria, we'd see an effect size approaching 0.

You are too kind to them. I suspect we would see a modest effect size ... a modest worsening of the situation, not an improvement. Other studies using objective measures show things get worse.
 

Sidereal

Senior Member
Messages
4,856
You are too kind to them. I suspect we would see a modest effect size ... a modest worsening of the situation, not an improvement. Other studies using objective measures show things get worse.

I was allowing for use of subjective measures such as SF-36 which would probably still show some small residual effect of CBT "happy positive healing thoughts" brainwashing on questionnaire-taking behaviour. :lol: