CBT for bipolar: Keith Laws challenges NICE and inadequate meta-analyses

[Bob]

NICE guidelines for psychological therapy - overstepping the evidence?
NICE claim that they provide ‘evidence based’ healthcare guidance, but Keith Laws believes this isn’t the case when it comes to psychological therapies like CBT
Keith Laws
5 February 2016
https://www.theguardian.com/science...ychological-therapy-cbt-overstepping-evidence

We routinely hear about bias and questionable research practices in the world of ‘Big Pharma’, while psychological therapies are often portrayed as pursuing a ‘purer’ path. Is it possible, however, that an organisation as renowned as the National Institute for Health and Clinical Excellence (NICE), whose recommendations apply to health practices in England and Wales but exert influence internationally, might be biased in favour of psychotherapy?

NICE was established in 1999 to provide authoritative, independent and unbiased healthcare guidance that is ‘evidence-based’. Their aims are to help practitioners deliver the best possible care; give people the most effective treatments based on the latest evidence; provide value for money; and reduce inequalities and variation in healthcare across the country. Nobody would question the aims, but how evidence-based is ‘evidence-based’?

Read on:
https://www.theguardian.com/science...ychological-therapy-cbt-overstepping-evidence

 

[Invisible Woman]

Or as I was taught as a teen (a long, long time ago) in my first into to computers - GIGO = Garbage In Garbage Out

 

[ahmo]

Remarkably not one trial in the NICE guide recorded a significant reduction of depressive symptoms in bipolar disorder. Four meta-analyses also assessed the use of CBT to reduce mania symptoms and fared no differently - all were nonsignificant and two indicated numerically worse manic symptoms following CBT. A similarly unimpressive profile was found for the other most assessed psychological intervention, psychoeducation. Yet NICE somehow conclude that psychological therapies should be used to address depression but not mania symptoms.

 

[Snowdrop]

There have been a few interesting articles from the guardian of late. None speak directly to PACE and ME but the issues they address do apply.

 

[Invisible Woman]

There have been a few interesting articles from the guardian of late. None speak directly to PACE and ME but the issues they address do apply.

Yes - we seem to be becoming part of a much larger argument re scientific & research standards, methods and transparency. This can only be a good thing I think.

 

[barbc56]

@ahmo

I was just going to post the same paragraph. Telling, isn't it!

What I want to know with no disrespect to people with bipolar, there are a few in my family. I am genuinely asking this. Is the treatment for the manic phase different for the depressive stage? You are not manic you just think you are and then you are not depressed you are just thinking you're depressed. Do the two cancel each other out and wouldn't that be confusing to the patient?

Maybe they address the whole illness? It's beyond me atm to see how this works.

Oh wait, it doesn't work so maybe my question is moot?

Thanks for the article @Bob. I have bookmarked it!

Barb

 

[Esther12]

There have been a few interesting articles from the guardian of late. None speak directly to PACE and ME but the issues they address do apply.

I was amazed something that good got in the Guardian. Have I been missing other good bits?

Would like to see a response to this. Seems like Keith Laws is getting on a roll going through different conditions and pointing out these sorts of problems. Great PACE has caught his attention.

 

[Keith Laws]

I was amazed something that good got in the Guardian. Have I been missing other good bits?

Would like to see a response to this. Seems like Keith Laws is getting on a roll going through different conditions and pointing out these sorts of problems. Great PACE has caught his attention.

Thanks. I would also very much like to see a 'response' ...
If interested, next Wednesday, we have a 'Mental Elf' live webinar debate with various experts on the NICE bipolar guide http://www.nationalelfservice.net/campfire/psychotherapies-for-bipolar-disorder/
...And I agree, it would almost certainly be worth somebody looking through the NICE evidence on ME/CFS

 

[A.B.]

So it seems there is a situation of CBT being promoted aggressively for many conditions, even when it has little if any effect. There must be some systemic error if the same mistakes are being made over and over again. Curious minds want to know what that systemic error is.

 

[luludji]

So it seems there is a situation of CBT being promoted aggressively for many conditions, even when it has little if any effect. There must be some systemic error if the same mistakes are being made over and over again. Curious minds want to know what that systemic error is.

I think the main error may be the inclusion bias.
Only people who share the beliefs with the researchers and who are not too ill will go forward with this therapies.
And will of course report benefit.
Those who are too ill or too critical will not take part in this kind of studies.
You can apply CBT to every ailment, by thus choosing the group who fits your expectations.

 

[Invisible Woman]

Curious minds want to know what that systemic error is.

Assuming cheap = effective ?

 

[chipmunk1]

Curious minds want to know what that systemic error is.

I would like to know this too.

(Auto)suggestion is powerful if you believe in it but the effect doesn't last.

https://en.wikipedia.org/wiki/Émile_Coué

Émile Coué de la Châtaigneraie(French: [emil kue də la ʃɑtɛɲʁɛ]; 26 February 1857 – 2 July 1926) was aFrench psychologist andp harmacistwho introduced a popular method of psychotherapy and self-improvement based on optimistic autosuggestion.[1] Considered at times to represent a second Nancy School, Coué treated many patients in groups and free of charge

Thanks to his method, which Coué once called his "trick",[8]patients of all sorts would come to visit him. The list of ailments included kidney problems, diabetes, memory loss, stammering, weakness, atrophy and all sorts of physical and mental illnesses.[citation needed]According to one of his journal entries (1916), he apparently cured a patient of auterusprolapse as well as "violent pains in the head" (migraine).[9]
C. (Cyrus) Harry Brooks (1890–1951), author of various books on Coué, claimed the success rate of his method was around 93%.[citation needed]The remaining 7% of people would include those who were too skeptical of Coué's approach and those who refused to recognize it.[citation needed]

Coué thus developed a method which relied on the principle thatany idea exclusively occupying the mind turns into reality,[citation needed]although only to the extent that the idea is within the realm of possibility. For instance, a person without hands will not be able to make them grow back. However, if a person firmly believes that his or her asthma is disappearing, then this may actually happen, as far as the body is actually able physically to overcome or control the illness. On the other hand, thinking negatively about the illness (ex."I am not feeling well") will encourage both mind and body to accept this thought. Likewise, when someone cannot remember a name, they will probably not be able to recall it as long as they hold onto this idea (i.e."I can't remember") in their mind. Coué realised that it is better to focus on and imagine the desired, positive results (i.e."I feel healthy and energetic"and"I can remember clearly").

While most American reporters of his day seemed dazzled by Coué's accomplishments and did not question the results attributed to his method,[11]), a handful of journalists and a few educators were skeptical. After Coué had left Boston, theBoston Heraldwaited six months, revisited the patients he had "cured", and found most had initially felt better but soon returned to whatever ailments they previously had.

Few of the patients would criticize Coué, saying he did seem very sincere in what he tried to do, but theHeraldreporter concluded that any benefit from Coué's method seemed to be temporary and might be explained by being caught up in the moment during one of Coué's events

 

[barbc56]

@Keith Laws

Just realized you are the author. Thanks for the article!

Barb

 

[alex3619]

Or as I was taught as a teen (a long, long time ago) in my first into to computers - GIGO = Garbage In Garbage Out

I paraphrased this a while back. BIBO. Babble in, babble out.

 

[Snowdrop]

You can apply CBT to every ailment, by thus choosing the group who fits your expectations.

And that's how we get a substantial minority of sick 16 yo's. Here is a group that is vulnerable to the idea that CBT will work.
They are a group rife with teenage angst. And CBT is not at all complicated or time consuming. A simple fix.
And before you know it--poof--it's a fad. Roll out the clinics.

 

[chipmunk1]

http://www.blackdoginstitute.org.au...psychologicaltreatmentsforbipolardisorder.cfm

Cognitive Behavioural Therapy (CBT)
Cognitive behaviour therapy for bipolar disorder would cover many, if not all, of the following elements:

• Psychoeducation
• Relapse prevention
• Medication adherence
• Stabilisation of social rhythms
• Identifying and challenging dysfunctional thoughts and beliefs
• Identification and management of stressful life events
• Identification of mood instability
• Development of skills to modify mood instability.

Studies have found both brief and longer interventions to be useful, although which phase (i.e. manic or depressive) responds best, has been debated. Increasingly, local area mental health services are recognising the importance of this intervention in preventing relapse in people with bipolar disorder and some will offer outpatient (as well as inpatient) group programs. If this were not the case in your area, referral, if the patient is willing, to an appropriately experienced clinical psychologist would be appropriate.

This sounds more like a management strategy than a treatment. Has it ever been marketed as a treatment/cure?

 

[Esther12]

Mental Elf discussion on this:

I didn't find it that interesting tbh. It was decided to not discuss the specifics much, so instead they took turns affirming how they just want what's best for patients and don't think anyone wins from extremes views over whether drugs or talking therapies are better. There was someone who was involved in the NICE guidelines on but he'd only had a day to prepare, which is a fair reason for not being able to respond to a lot of the detailed points raised, but it would have been better if they'd delayed things for a week so that he would have been able to.

Lots of similar concerns about psych trials generally to those we've mentioned in CFS CBT/GET trials here, but interesting how the discussion there (as opposed to here among patients) seemed built upon an assumption that patients will want their care and treatment (or some sort), even while they acknowledge how poor the evidence base for a lot of it is. [Unrestrained speculation ahead]: I feel like the culture of MH research has been a bit distorted by the fact that they tend to see patients as an other asking for help, rather than as people who are quite likely to prefer no treatment to treatment that has a weak evidence base. I think this is especially true for talking therapies, where so much is based on the relationship between therapist and patient: it's a bit of a personal rejection to think that your patients would rather be watching Netflix than spending time with you, and would be better off for it too.