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Patient experience of negative effects of psychological treatment: results of a national survey

  • Mike J. Crawford (a1), Lavanya Thana (a2), Lorna Farquharson (a3), Lucy Palmer (a1), Elizabeth Hancock (a1), Paul Bassett (a4), Jeremy Clarke (a1) and Glenys D. Parry (a5)...
Abstract
Background

To make informed choices, patients need information about negative as well as positive effects of treatments. There is little information about negative effects of psychological interventions.

Aims

To determine the prevalence of and risk factors for perceived negative effects of psychological treatment for common mental disorders.

Method

Cross-sectional survey of people receiving psychological treatment from 184 services in England and Wales. Respondents were asked whether they had experienced lasting bad effects from the treatment they received.

Results

Of 14 587 respondents, 763 (5.2%) reported experiencing lasting bad effects. People aged over 65 were less likely to report such effects and sexual and ethnic minorities were more likely to report them. People who were unsure what type of therapy they received were more likely to report negative effects (odds ratio (OR) = 1.51, 95% CI 1.22–1.87), and those that stated that they were given enough information about therapy before it started were less likely to report them (OR = 0.65, 95% CI 0.54–0.79).

Conclusions

One in 20 people responding to this survey reported lasting bad effects from psychological treatment. Clinicians should discuss the potential for both the positive and negative effects of therapy before it starts.

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Copyright
Corresponding author
Mike J. Crawford, College Centre for Quality Improvement, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, UK. Email: m.crawford@imperial.ac.uk
Footnotes
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See editorials, pp. 208–209 and 210–212, this issue.

The National Audit of Psychological Therapies (NAPT) is managed by the Royal College of Psychiatrists' College Centre for Quality Improvement (CCQI). It is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

Declaration of interest

G.P. was chief investigator of an NIMH-funded project that led to the development of the Supporting Safe Therapy information resource (www.supportingsafetherapy.org).

Footnotes
References
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Patient experience of negative effects of psychological treatment: results of a national survey

  • Mike J. Crawford (a1), Lavanya Thana (a2), Lorna Farquharson (a3), Lucy Palmer (a1), Elizabeth Hancock (a1), Paul Bassett (a4), Jeremy Clarke (a1) and Glenys D. Parry (a5)...
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eLetters

Enabling patients to provide fully informed consent.

Mike J Crawford, Professor of Mental Health Research, Imperial College London
Lavanya Thana, Research Associate, Imperial College London
09 May 2016

We share Yates and Mengistu surprise at how little attention has been given to negative effects of psychological treatments. Throughout medicine patients are given information about potential for negative effects of treatments so they can make informed choices about them. The principle that people should be given information about risks as well as benefits holds true in other areas of life such as choices people make about investing their money. So it really is surprising that people can be referred to and take up offers of psychological treatments without being told about the potential risks of treatment.

In the past, paternalism meant that people could be given treatments in the belief that these were in the patient’s best interests. But this approach is no longer acceptable when discussing pharmacological treatments and we believe it is no more acceptable when discussing talking treatments.

As Yates and Mengistu point out the low response rate to this national survey means that the data do not provide a definitive estimate of how often people experience harm from psychological treatments. Ongoing research by the study team and others will hopefully ensure that a clearer picture of the features, prevalence and risk factors for negative effects of psychotherapy will emerge and allow strategies to be developed that reduce them. Only then will patients be able to provide fully informed consent for the psychological treatments that may help treat their condition.

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Conflict of interest: None Declared

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‘Cognitive Behavioural Toxicity’?: Reflections from Westminster

Samuel C Yates, Psychiatry Registrar, CNWL
Mesfin Mengistu, Trust Grade Psychiatrist, CNWL
03 April 2016

At our local journal club at the Gordon Hospital, Westminster, we read with great interest Crawford et al.’s excellent paper on patient experience of negative effects of psychological treatment. All present were first struck by the novelty of the concept of considering the side-effect profiles of psychological therapies – and then, a split second later, astonished by our own astonishment. As Psychiatrists thinking about aetiology and treatment, we are fed and watered on the biopsychosocial model. We are also accustomed to sharing the potential benefits and problems associated with treatments we offer, but seemingly only in matters of medication. We are grateful to Crawford et al. for bringing this ‘blind spot’ to our attention and hope their paper will help raise awareness of the simple yet fundamental observation that psycho-social interventions may also have downsides.

As the authors have acknowledged in their limitations section, their study is not without problems. For one thing, we, like they, noted the low (19%) inclusion rate of participants relative to the original sample identified. There may well be significant differences between the characteristics of the 19% who did take part and the 81% who did not, creating considerable potential for bias. Secondly, with a view to excluding potential confounding, we would have liked to know a good deal more about the clinical details of the participants – their diagnoses and, in particular, what other treatments they may have been receiving.

In additional to these methodological observations, we were left with a sense that the practical applicability of the study’s findings is significantly limited by the lack of what the authors term ‘qualitative data about negative effects’. When trying to imagine ourselves drawing on the paper as part of evidence-based practice, we strongly suspected that patients would not find the following information overly user-friendly: ‘And, in terms of potential side-effects, there is a 5.23% chance that you will have ‘lasting bad effects from the treatment’’. We would be keen to know more about what the authors’ ‘ongoing analysis of in-depth interviews’ has revealed in this regard.

Finally – more at the level of intrigue than critique – we were interested by two findings which appear to point in rather different directions. The first is the strikingly low rate (5.23%) of reported side-effects of therapy, with roughly 87% of respondents reporting no negative effects. Taking into account the earlier point about giving as much consideration to potential side-effects of psychological (and social!) interventions as biological ones, and considering that the efficacy of psychological therapy is, at least for some conditions, broadly similar to that of medication, the side-effect rates identified seem almost too good to be true. We wonder if this may reflect a corollary in patients of our own hitherto lack of awareness of the potential downsides of psychological treatment. On the other hand, our eyes were caught by Table 3 of the paper which seems to indicate that receiving a large number of sessions of psychological treatment is associated with an increased rate of side-effects. Of course, it may be that the higher number of sessions is due to increased severity and complexity of cases, where we would expect negative experiences (perhaps interpreted as side-effects) to be higher. However, we cannot rule out the possibility of the eponymous phenomenon of ‘cognitive behavioural toxicity’ which should clearly be a focus for further consideration and research.

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Conflict of interest: None Declared

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