medication this is a placebo pill. This doesn't have no effect. For a
number of reasons placebo pills work. Trials have even shown that
placebo antidepressants activate different areas of the brain to achieve
their effect. In psychological therapies there are forms of treatment
which are inert in any sort of science or form of therapy. The variable
tested is the mode of the therapy, for example Cognitive Behavioural
Therapy, and the comparison is something without a science or thinking
behind it other than offering social contact.
In high quality reviews psychological therapies fair badly. A high
quality review means a review of good trials. The data is taken from the
trials and averaged using the meta-analytic technique. This combines the
effects of lots of small studies and averages them to see the effect for
a large population. There are problems with this technique, namely the
individual trials can be different in their design so might use
different measures which mean they're measuring slightly different things.
Another benefit of the meta-analytic technique is the capability to
detect publication bias. This is another problem for the meta-analytic
technique. If you take an average but leave out some data then the
average will be skewed. Publication bias is when results, often negative
results, aren't published and this can make a treatment seem better when
it's not. A clever technique called a funnel plot can be used to quickly
identify the existence of publication bias. There's more on the
Wikipedia page on how it works. Essentially small studies have larger
errors than large sample size studies. Those will fall closest to the
average. The small studies will fall randomly above and below the
average. They should be evenly distributed unless publication bias exists.
How big is this problem? Well trials of antidepressants which include
unpublished data show SSRIs aren't as effective as once thought. In fact
a placebo pill comes very close - so close that the active treatment
can't be said to be effective. The Kirsch 2007 meta-analysis is one
example but there are others.
In psychological therapies in a meta-analysis which looked directly into
publication bias there was significant publication bias. It accounts for
about one third of the average effect size in the thousand studies
reviewed in this paper published last year or the year before in the
British Journal of Psychiatry.
Many reviews of high quality trials show psychological therapies to
offer small or no benefit compared to the interventions without a mode
or prescriptive teaching. A review which uses low quality trials and a
broad definition of what's been measured is not a good application of
science. There is a mega-meta-analyisis published in 2006 which shows
CBT to be effective for many mental illnesses but used these poor
application of science. It may have also suffered from bias in other
ways. One of the authors is a major proponent of CBT. A 2009 analysis of
CBT for schizophrenia which only included high quality trails showed a
significantly smaller effect to the point where CBT was shown to be
ineffective.
This measure of effect size and the idea of clinical significance is
also important. The levels required for an effect size to be called
clinically significant in mental health is much smaller than in physical
health. So the studies which show that psychological therapies are
effective have a lower criteria of success. It's my understanding that
an effect size of 3 or 4 is considered significant in physical health
treatment whereas 1 and above is considered significant in psychiatric
research. I'm not 100% on this. It was something I gathered from a
review of job satisfaction and physical and mental health.
The power of inert psychosocial treatments and placebo pills is high. In
the non-pharmocological stuff the theory is that it's social contact
which achieves the effect as well as variance in therapist qualities
which ameliorate the effect size shown by 'super therapists'. I also
think the research process is important by which I mean that being part
of a research trial has a positive treatment benefit on measures of
subjective well being.
Of course research can come in many forms. It can be in the form of
forms and tickboxes. It can also be face to face interviews. It's the
latter I'm talking about.
What I'm talking about is using face to face research as a treatment for
subjective well being. It offers the added value of the research
information itself. Unlike therapy the researchers have no aims but to
understand the person. They are not in contact with the healthcare team
and they are not their as professionals to do anything else but try to
understand the person. It's totally non-directive. The body of work it
produces is a study into the human condition.
This is a very small thumbnail sketch of the idea. The goal in this
thought process has not been to justify a significant study into the
human condition and people's lives in modern times. It has been a result
of pondering the problem of the small effect of psychological therapies
for schizophrenia. It's been over a year's work so it's a bit of a pants
conclusion that research should be used as a therapy for schizophrenia.
It's a mad oddball idea too. That's why I like it. It's a better
solution than what NICE are currently recommending and has significant
health economics arguments because of the added value of the research
itself.
My other suggestion is much more sane but might not get much support.
It's support groups. These have an even better health economics argument
to them because they're cheaper and they're also used as the controls in
trials of psychological therapies. Hundreds of these already exist
unsupported and unaided by the NHS.
The idea wouldn't get much support because patients might feel cheated
that they were being referred to a support group instead of a
therapists. Some people might initially be dissuaded from using a
support group because it's not socially acceptable. Therapists don't
like the diea of being put out of a job by untrained people with no
professional training, even if the evidence they don't want to read
shows that many therapies are ineffective when good scientific
techniques are used.
It is bloody cheap though. And the NHS are currently not offering enough
psychotherapy for people with schizophrenia (and probably bipolar too).
Truly I am an idealist but I reveal different colours when I come up
with ideas like this. My ideal is a solution, an effective mode which
can be selected as appropriate for the individual with a high degree of
success. What I mean is a more refined 'diagnosis' of individuality with
which to tailor a series of interventions designed around the person and
who they are. This would be done scientifically and with compassion in a
society which accepted people with schizophrenia as normal individuals.
Because they are.
But neither NICE nor the NHS think at that level. They think about
research and health economics and evidence-based medicine techniques.
And that's where this mad idea fits. The research one. Not the support
groups one. The support groups one is a good idea.
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