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A recent editorial claimed that the 2014 National Institute for Health and Care Excellence (NICE) guideline on psychosis and schizophrenia, unlike its equivalent 2013 Scottish Intercollegiate Guidelines Network (SIGN) guideline, is biased towards psychosocial treatments and against drug treatments. In this paper we underline that the NICE and SIGN guidelines recommend similar interventions, but that the NICE guideline has more rigorous methodology. Our analysis suggests that the authors of the editorial appear to have succumbed to bias themselves.
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Sameer Jauhar, Consultant Psychiatrist, King's College, London.
Peter J McKenna, Research Psychiatrist, FIDMAG Germanes Hospitalàries Research Foundation and CIBERSAM, Spain.
Keith Laws, Professor, Department of Psychology, School of Life and Medical Sciences, Universit
21 April 2016
Kendall et al’s response to the charges of bias by Taylor and Perera itself seems to show evidence of bias.
In the section headed ‘CBT as a panacea’ they argue that our meta-analysis1 has been criticized for using ‘…idiosyncratic inclusion criteria and drawing conclusions unjustified by the evidence.’ We responded to these criticisms and were able to show by means of further analysis that altering the inclusion criteria did not materially affect the results. Yet Kendall et al do not cite our response – isn’t this…idiosyncratic and unjustified?
Kendall et al further state that ‘there were another four reviews of CBTp published last year and four of the five (including Jauhar et al) concluded that there were significant benefits’. This seems a perverse interpretation of what we found, which was that effect sizes for CBT at end-of-trial were small and smaller still in blind studies, becoming non-significant for positive and for negative symptoms.
Among the other meta-analyses cited, one examined CBT for negative symptoms and also found no evidence of effectiveness at end of trial or follow-up3. Another4 found an effect size of 0.16 for positive symptoms at end-of trial which lost significance when researcher allegiance was controlled for. The other two meta-analyses mentioned by Kendall and colleagues were small and selective and could genuinely be held up as examples of using idiosyncratic inclusion criteria (see http://ebmh.bmj.com/content/17/3/67/reply#ebmental_el_12207). Incidentally, as far as we can tell, none of these meta-analyses was pre-registered.
Ironically, our findings were not as unfavourable as those in the meta-analyses used by NICE in CG178, which failed to show a significant effect of CBT on positive and negative symptoms at end-of-trial and follow-up. There is also an elephant in the room here, in the shape of the 2012 Cochrane Collaboration systematic review5. This concluded there is no clear and convincing evidence that CBT was superior to other psychological interventions in schizophrenia. Why do Kendall et al not cite this high-profile publication?
Finally, Kendall et al state that NICE guidelines have played a leading role in reducing the impact of bias including from selective publishing. In this context it seems legitimate to ask what they intend to do about the POSITIVE trial, a large, well-controlled trial of CBT for positive symptoms that remains unpublished six years after analysis of major outcomes was expected to begin (see http://tinyurl.com/jzonnf3 ). Did NICE contact the authors of this study before deciding not to update their 2009 guideline? Will they be getting in touch with them when they next update it?
References
1 Jauhar S., McKenna P. J., Radua J., Fung E., Salvador R. ,Laws K. R. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry 2014; 204: 20-9.
2 McKenna P. J., Radua J., Laws K. R. ,Jauhar S. Author's reply. Br J Psychiatry 2014; 205: 160-1.
3 Velthorst E., Koeter M., van der Gaag M., Nieman D. H., Fett A. K., Smit F., et al. Adapted cognitive-behavioural therapy required for targeting negative symptoms in schizophrenia: meta-analysis and meta-regression. Psychol Med 2015; 45: 453-65.
4 Turner D. T., van der Gaag M., Karyotaki E. ,Cuijpers P. Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies. Am J Psychiatry 2014.
5 Jones C., Hacker D., Cormac I., Meaden A. ,Irving C. B. (2012) Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database Systematic Review, Issue 4: CD008712.
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Conflict of interest: None Declared
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