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Andrew Amos, Associate lecturer, James Cook University
17 June 2019
Aceituno’s systematic review of economic evaluations of early intervention in psychosis (EIP)1 is an example of the use of spin to misrepresent advantages of EIP, a topic reviewed elsewhere2. Although it refers to standard protocols for systematic reviews, it doesn’t critically analyse the collected articles, leading to wildly optimistic conclusions.
I provide several examples, noting my earlier review which critically analysed the papers extant at the time.3 Aceituno reports a cost-effectiveness study based on CBT to prevent transition to psychosis as a positive study, without reference to the fact that the current consensus is that it is not possible to prevent transition to psychosis.4 If a treatment is not effective, it cannot be cost-effective.
The first paragraph of Aceituno’s discussion concludes: “Investing in EIP could, as the best-case scenario, save money, and is at least a more cost-effective alternative than treatment as usual.” As it reviewed cost-effectiveness articles, the article did not provide evidence on whether EIP saves money. Indeed, the review excluded one study explicitly for its cost-minimisation approach, the relevant type of study for assessing whether an intervention can save money.
While Aceituno notes significant methodological limitations in this literature, it doesn’t analyse the fact that 11 of 14 studies demonstrated “Selective reporting (reporting bias)”, according to the Cochrane Risk of bias tool. Alongside the comment: “…more rigorous trials have failed to demonstrate clinical or functional differences with standard care…” this lack of critical interest in evidence of systematic misreporting suggests that Aceituno et al have not actually scrutinised the literature, but only followed protocol.
In addition to ignoring evidence of systematic bias, the failure to identify limitations of specific articles should convince readers of the value of this review. For example, using service records, Tsiachristas identified all patients with psychosis in several regions of England, then compared treatment costs of patients managed in EIP units with those of patients in non-EIP units.5 As there was no matching on duration of illness or treatment, essentially this study compared the costs of treating patients in the first few years of treatment (EIP) to costs of treating patients with established, chronic illness. Given Aceituno doesn’t mention this extreme confound, it seems fair to wonder what level of methodological compromise would have been enough to conclude that the literature cannot be relied upon.
References
1. Aceituno D, Vera N, Prina M, McCrone P. Cost-effectiveness of early intervention in psychosis: systematic review. Br J Psych 2019; online before print
2. Amos A. A review of spin and bias use in the Early Intervention in Psychosis literature. Prim Care Companion CNS Disord 2014; 16(1): 10.4088/PCC.13r01586
3. Amos A. Assessing the cost of early intervention in psychosis: A systematic review. Aus NZ J Psych 2012; 46(8):719-734.
4. Fusar-Poli P, McGorry PD, Kane JM. Improving outcomes of first-episode psychosis: an overview. World Psychiatry 2017; 16:251-265.
5. Tsiachristas A, Thomas T, Leal J, Lennox BR. Economic impact of early intervention in psychosis services: results from a longitudinal retrospective controlled study in England. BMJ Open 2016; 6:e012611.doi:10.1136/bmjopen-2016-012611 ... More
Conflict of interest: None declared
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