Thoughts/summary on going through. I ended up doing more of a summary than I planned as the audio wasn't great (not terrible either), and there's a lot of time spent on audience stuff, so I thought that lots of people might be interested in knowing what was said but find going through the video difficult. I've now added in links to a few of the papers mentioned too. I was doing less of a summary at first.
The reassuring and self-congratulatory intro is a bit irritating (I often find that the tone of these things is) and seems strangely condescending about dermatologists not having debates like this- maybe it's because they're better at limiting themselves to claims supported by good evidence? Getting to the truth about whether treatments have been oversold, especially ones as significant as CBT, isn't a fun game!
Robin Murray is the moderator. He was editor of the journal that published the PACE 'recovery' paper which abandoned the protocol defined recovery criteria and replaced it with one that was so watered down that patients could be counted as 'recovered' even if they had higher levels of reported fatigue or disability than when they started the trial. The journal also refused to publish letters which pointed out that there was a clear factual error in the justification for abandoning the original recovery criteria (an error which has still gone uncorrected), and I heard that Murray was originally planning to publish an editorial slagging off people for criticising the paper and linking this to 'ME patient harassment' stuff. This CBT for schizophrenia debate replaced a planned one on 'stigma' - ho ho ho.
McKenna: Starts off without the irritating tone London establishment debates! Mentions an RCT which seemed to have important results missing. He has a rapid response here:
http://www.bmj.com/content/317/7154/303?tab=responses It seems that they reported a significant improvement for CBT, but did not say whether there was as significant difference over the supportive listening control group. Then mentions this study
http://www.ncbi.nlm.nih.gov/pubmed/10665619 which claimed positive effect at end of treatment that was not supported by data (although there was a positive effect at 9 months). Says things got 'considerably darker' with the NICE guidelines. McKenna said that NICE said all patients 'must' have CBT, but no quote for this. We've seen with CFS though how patients often end up being pushed/manipulated into recommended treatments, but I thought that he probably went too far there. He pointed out that NICE carried out 130 meta-analyses on 31 studies, and many contained only 1 or 2 studies. For most of these, CBT was not found to be significantly effective. Says that while NICE is meant to be cool headed and objective, it's work here is a case study in selective reporting. McKenna emphasises the need to look closely at the quality of studies, and possible sources of bias. Goes on to say that it's impossible for results from CBT to be anything other than small given the data so far collected. It's hard to read some of the slides on the video, and McKenna seemed cut off by the time limit. Only 5 minutes for each of the speakers is not long.
Kingdon: Jokey comment thanking McKenna for boosting his citations so much. Puts up graph showing that lots of studies which found that CBT did not lead to a significant improvement did have CBT groups looking marginally better than control groups. Then goes on to talk about study which found no improvement immediately after treatment, but an improvement at 18 months and 5 years (Looks like this study:
http://www.feltoninstitute.org/approach/CBT.SCZ.5yearfollowup.pdf ).
My comment: It could be that CBT is more able to provide lasting value to some schizophrenia patients than befriending therapy - I've seen it argued that this is where CBT is valuable to those with depression too - don't know if there is good evidence that CBT has better results over the long term though, and this one study could be unusual. Kingdon briefly goes through some studies he's worked on, then talks about expected effect size for CBT for psychosis in relation to other medical interventions, mentioning this paper "Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses"
http://bjp.rcpsych.org/content/200/2/97 - however, given the problems with bias affecting results from CBT trials I'm not sure how strong a point that is (although there's a good chance a lot of the other effects sizes in that review are exaggerated too). Ends with a terrible bit on pharmaceutical companies selling drugs with marketing gimmicks. Goes on to suggesting it's just absurd to think that journals and peer-reviewers could be involved in over-selling a treatment: "I won't call it a conspiracy but..." [laugh from audience]. Massive appeal to authority for NICE. 'They met, they had committees, they deliberated for months...' we all know committees are never wrong. Amazing. The follow-up data seemed like a potentially worthwhile point but only looked at one trial, and this stuff is infuriating.
Laws: Mentions the view that 'if CBT is oversold it's in the way that many medical interventions are over-sold' says that there's something to that, so jokes that you should all just vote 'yes' for the motion. Goes on to say that actually he thinks that there are unusual things about the way in which CBT for schizophrenia is oversold. Puts up a graph showing the declining effect of CBT for schizophrenia in meta-analyses from 2001, where it was reported that 50% of patients benefit, to the last 5 meta-analyses, where only 5% of patients were benefiting. Makes the point that wasting the time of 95% of patients is a bad thing (such an under-valued point imo). Laws not so respectful of NICE's authority: goes through the list of things NICE recommends CBT to schizophrenia patients for, pointing out problems (eg: claimed to help with 'insight' and 'medication adherence' in 2002, but not in 2009 - said there was no evidence to justify inclusion in 2002, no evidence to justify changing claims in 2009), argues that there's no evidence to support NICE claim that CBT is helpful for schizophrenia patients in a number of different ways. Laws also says that it does not work for relapse, and that this was shown in [inaudible]. Slide has "It's not a panacea" quote - the familiar cheap and meaningless way to sound reasonable and cautious. Goes on to provide examples of six different negative studies being spun as positive [maybe a dig at Layard's Happiness book too?]. Quotes Kendall saying "Interestingly, psychosocial treatments - such as CBT and, more recently, art therapies... have shown more promise than drug treatments in reducing negative symptoms..." (
http://www.bmj.com/content/344/bmj.e664) - says that this is 'total nonsense'. A few other examples too, including quoting from this letter about a Kinderman and Kingdon paper:
I am a little confused by the authors’ conclusions. After clearly demonstrating no superior effect for CBT over supportive counselling on measures of symptom reduction and relapse rates, the authors conclude their paper by stating that they ‘ suggest that the optimum psychosocial management of early schizophrenia would include a combination of CBT and family intervention’. Would it be rude to suggest that the authors take into account their own findings before making such a statement?
http://bjp.rcpsych.org/content/185/5/438.1
[authors response also at that address]
Kinderman: Starts by saying that he thinks we should return to the actual motion, although I thought providing examples of people overselling CBT was pretty on-topic. Says he's the fourth white middle-class male to speak so maybe it's time to listen to some other views - puts up an anecdote he (a white middle-class male) selected. Kinderman mentions this study as showing CBT improves results to patient's brain scans -(
http://brain.oxfordjournals.org/content/early/2011/07/11/brain.awr154.long it's vs Treatment as Usual, and if that means that people are receiving no support and little social contact, it's not that great that a course of regular CBT would lead to people responding differently to angry expressions (I've only read the abstract)). Kinderman talks about NICE only saying CBT should be offered, not forced [fair point and gets applause], but imo if exaggerated claims about efficacy are being made then this does lead to treatment being imposed upon people who would not want to spend their time on it if better informed. Then he moves on to comparison with overselling of anti-psychotic medication. He paints CBT approach as underdog against entrenched interests: 'I accept that CBT is challenging the dominant orthodoxy and the financial interests of pharmaceutical companies' - thanks for accepting that. Then goes on to quote from the abstract of the recent meta-analysis Laws was involved in (
http://bjp.rcpsych.org/content/204/1/20), complaining that Laws has been more critical of CBT in blog posts than he is in peer reviewed papers (would have been better if he'd quoted examples from Laws' blog posts). Selects another anecdote from a patient's mother - she talks about her son being able to start part time work: it would be interesting to know if there was employment data from CBT for schizophrenia trials. Ends by saying that it has not been oversold, and that it is scandalous that patients do not have access to it.
Comments/questions from the audience:
1: Raises concern that promotion of CBT is leading to other psychosocial interventions (mindfulness etc) being ignored.
2: Says that he's working in an area with many psychotic patients and cannot remember any of them being referred to CBT in the last 5 years, thus undersold?
3: Patient talks about having been put on and trying lots of different drug treatments, currently found medication which has broken cycle of hospitalisations, but wants social model, not medical model. [I think that the biopsychosocial approach, as used by the British state and researchers connected to the insurance industry and DWP is massively worse than both though].
4: Clinical psychologist wants to know why McKenna/Laws think CBT is so popular with patients, and what they'd recommend instead.
Laws says largely ineffective CBT is blocking the emergence of other therapies. Goes on to say 'If I convince you that your God does not exist, then I don't have to provide you with a replacement God.' [Nervous laugh from the audience/clergy].
Murray speculates that CBT is used to cover the fact that psychiatrists are often poor at talking to patients, and that maybe one reason for diminishing effect size is that earlier positive studies had social impact, encouraging changes to TAU which integrated aspects of what made CBT effective. If CBT was really helping 50% of patients, and that benefit was now a part of TAU, wouldn't we have noticed massive improvements in outcomes for patients? Seems like a story designed to let everyone feel good about themselves.
5: Fergus Kane says that there are many different types of CBT for psychosis. Says that it should really be getting better over the 30 years of practice. Says it's not honest to say CBT is not effective if control is befriending, as befriending works, placebos work, etc.
[A bit OT, but befriending therapy sounds less good a control than I'd realised, as to prevent it overlapping with CBT they've added in restrictions that could lead to patients feeling liking things important to them were being avoided :
2.2.2. BF
This approach has been previously described and is
based on the principles of social support (Milne, 1999).
The approach depended on a high quality interpersonal
relationship which focused on neutral i.e. non-psychotic
issues. BF as delivered was non-confrontational and
non-collusive and conversation was always directed
away from symptoms to everyday activities such as
hobbies, the weather, holidays and sports. No home-
work was given and no techniques used except those of
keeping the conversation going, personal disclosure and
maintaining an interest in the patient's current opinions
and activities.
They do need to prevent BF becoming CBT, and a lot depends upon how that sort of restriction works in practice, but it does seem like a rather artificial restriction to conversation for those receiving BF]
Kinderman says that CBT is not squeezing out other psychosocial approaches, but is the vanguard against the biomedical model. Important to give people choice rather than only drugs. Says that we need to give people what we think is best, scepticism painted as abandoning them. Disagrees with Murray that positive affect of CBT is just from talking to patients.
6: Complains that Laws/McKenna metanalysis is biased, and says that Murray has just written an editorial in which he uses it as an example of why he no longer trusts meta-analyses (couldn't find this). Claims blinding makes results less reliable, as patients try to hide improvements from assessors so that they do not know if they were in the treatment group of not.
McKenna suggests that this could be used as an argument in support of insulin comas for psychosis as much as CBT [or any other dodgy treatment].
7: German lady says something (sorry having trouble with the accent) about support groups becoming better (adopting CBT approaches) and this being a reason behind declining effect size. Then goes on to talk about the need to use outcome measures which are important to patients. Then talks about the desire to change patient's relationships with voices, and says that it's discriminatory to think that voices should be got rid of. IMO: Good to get as much data as possible and important to involve patients in designing/selecting outcome measures, but also it's likely that different outcomes will be important to different patients, and that's why ideally they should be provided with reliable data for a range of outcomes so that they can make up their own mind - some patients are likely to be uninterested in receiving CBT to just change their relationship with their ongoing hallucinations.
8: Trainee says that he struggles to understand mechanism by which CBT can reduce symptoms rather than reduce distress at symptoms.
Kinderman says it's not really the place for a seminar on this, but that it is thought that one mechanism by which symptoms occur is that patients misinterpret internal voices as external, and that by CBT exploring the meaning of these voices you can help people understand and make sense of these voices. Claims that by relating them to experiences that have happened in their lives it can make more appropriate and helpful sense of the experiences that they're having. Says that this is not rocket science and is quite straight forward, but does take sitting down and listening to people. Says that when people are paranoid, that's people making sense of the world around them, and they're interpreting other's actions in a malign way, normally because of things that have happened to them in the past, and that reality-testing these ideas helps them feel better.
Is there evidence to allow therapists to say how current auditory hallucinations relate to patient's past experiences? Or evidence that they're able to do so in any sort of reliable manner? I'm uncomfortable with the idea of encouraging beliefs because those in authority think they are 'appropriate and useful' if there is not also good evidence indicating that they are likely to be true (maybe I'm paranoid about this?!)
McKenna replies by asking how Kinderman would make sense of John Nash's (From A Beautiful Mind film) hallucinations, Kinderman says something about a seminar and Murray moves things on.
9: Asks what the two sides think about the idea of using both CBT and medication.
Kindon says that's what is generally done. Kinderman says that he has some concerns about the long-term impacts of medication, and that his older bother suffers from psychotic episodes and he see positive and negative affects of medication.
Laws says recent Lancet study is the only one to look at CBT for unmedicated patients and found lots of serious adverse events.
10: Asks whose decision it is that it's misattributed thinking?
Kinderman says that no-one person is deciding, but that it's the conclusion of a lot of research into hallucinations. Says that if there is no external voice, but the patient thinks there is, then if we disregard supernatural explanations it is by definition a misattribution (I thought that the questioner was asking 'who decides that a patient's belief that an auditory hallucination is a result of problem with their brain rather than life experience is a misattribution' but could well have missed her meaning).
McKenna says that of the two theories of hallucination i) misattribution of internal thoughts ii) over-activity in the speech area of the brain, there's no good evidence for either. Kinderman disagrees, Murray moves things on.
11: Mentions other talking therapies, including encouraging patients to talk to an empty chair or puppets. Mentioned that he got good results for a small RCT using avatars.
12: Ed Sykes from the Science Media Centre (he's an observer offering advice at the ME/CFS collaborative - because the SMC have been so great for ensuring accurate reporting in this area!): He's been listening to both sides and feels like Laws/McKenna have successfully argued that CBT has been oversold in paper's abstracts, while Kinderman/Kingdon has successfully argued that NICE recommended treatment is under-provided. Wants to know if Laws/McKenna think treatment is of some value.
Conclusions:
McKenna: Live by meta-analysis, die by meta-analysis.
Kingdon: Says he was going to criticise the Laws methodology for not focussing on target symptoms, as CBT targets specific symptoms, but he won't do that (he just did). Could challenge them on heterogeneity. Instead says he will challenge Law's maths.. but it turns out Laws was right (that there were more authors for the Morrison RCT study than there were patients left in either arm at the end: 19 vs 18 & 18). Goes on to say that if people have suffered trauma, surely we should be listening to them. Then quotes patient testimony. Asks people to vote against motion and "help make sure that everybody who will benefit from these interventions does so".
While voting goes on Murray says that this is a debate with high stakes, so he's pleased that it has been good humoured.
My impression: I didn't really like the format and felt that I've learnt more from the discussions taking place on-line.
I'd have liked to see more back and forth, particularly on:
Is there decent evidence that CBT does better in long-term follow up than it does in the short term?
Is there decent evidence that CBT leads to improvements in employment rates?
Did Kinderman have specific quotes of Laws doing negative spin on his blog? If so, can Laws defend them.
I'd have also liked more discussion about the extent to which therapists can accurately identify how patient's life experiences lead on to specific hallucinations. Is this just myth building/supposedly noble lies? (Maybe I'm less well informed on this stuff than they expected the audience to be).
Do both sides agree that the evidence indicates it's around 5-15% of patients who will benefit from CBT? If so, is this being made clear to patients offered CBT? There was a weird lack of discussion over the specifics here imo.
Also, I think that maybe Laws and McKenna wanted to avoid criticising CBT while talking positively of meds, and as some of the overselling involved comparing CBT efficacy to meds that meant we didn't get into the details as much as I'd have liked. The time limits would have made this difficult, given the likely spin around meds and the problems with side-effects, but without this I felt like a lot of the examples of overselling were difficult to judge the importance of. NICE was the most important one covered but they only had examples of NICE listing ways in which CBT was helpful when there was not good evidence that this was the case, not NICE claiming that (for example) 50% of patients would benefit from CBT. Also, arguing that NICE should not recommend CBT could be presented as being 'anti-choice', especially while other areas of social support are being cut - not that this sort of pragmatic concern means that CBT is not being oversold.
I thought Kinderman and Kingdon did a good job of turning it into a debate about whether patients should have the choice of doing CBT. I wonder if Laws and McKenna should have pointed to some of the overselling which has gone on in the media as well as in academic papers as media reports might be expected to have more of an impact on patients - but then, a lot of researchers seem happy to turn a blind eye to over-selling of all sorts of research in the media so maybe no-one would have cared.
I've got some more confused and uncertain thoughts on all this that I think I'm going to let stew for a bit, or else see if anyone else's comments prompt some clarity.
Alex Langford @PsychiatrySHO 
Keith R Laws @Keith_Laws 
