CBT doesn't really work much and science in mental health

Lynch, D, 2010, Cognitive behavioural therapy for major psychiatricdisorder: does it really work? A meta-analytical review of well-controlled trials, Psychological Medicine
http://journals.cambridge.org/download.php?file=/PSM/PSM40_01/S003329170900590Xa.pdf&code=b62ffa4b898268608a9e7b504bdd5319

Cognitive behavioural therapy - changing the way people think and behave by using talking techniques from therapists - doesn't really work according to this high quality review.The review uses a different inclusion criteria to the 'mega-analysis' which is often used to show that CBT really does work.
Butler, A. et al. 2006, The empirical status of cognitive-behavioral therapy: A review of meta-analyses, Clinical Psychology Review
http://www.sciencedirect.com/science/article/pii/S0272735805001005

So which one is true? The massive review (the 2006 one) which includes loads of papers but has a weaker inclusion criteria and, if I remember right, doesn't include a funnel plot or the smaller review of higher quality trials (the 2009 one at the top of the page)?

I'm afraid it's the one of controlled trials. At least based on the current paradigm of evidence based medicine. Blindness is so important.

The double blind randomised controlled trial gained success when it showed insulin shock or insulin coma therapy to be as effective as other treatments at the toime for...think it was schizophrenia. At the time
the insulin treatment was considered best practice around the world but the introduction of random assignment to the control or active treatment group showed that, in fact, it wasn't the best treatment.

Time and again it's the reviews that select the highest quality trials which show treatments thought to work suddenly don't. The recent noteable example is electro-convulsive therapy or ECT. This barbaric
treatment is what I hope is the last in the line of psychiatric treatments which induce seizures. The history of inducing seizures to treat mental disorder can be traced back to the work of Hippocrates who
notices paitents who had malaria seizures also had behavioural changes. The recent Bentall and Read review on ECT picked high quality trials with long term follow. This treatment of last resort was shown to be as
effective on follow up as sham ECT (where no electricity is used to shock a person into a seizure) and slightly more effective during treatment.
http://www.mindfreedom.org/kb/mental-health-abuse/electroshock/ect-review-2010-read-bentall.pdf/view
(Link to paper at the bottom of the page.)

Many, many people have died because of this treatment. Some people who've had it done are major advocates of the treatment. This presentation on TED is an example.
http://www.ted.com/talks/sherwin_nuland_on_electroshock_therapy.html

The speaker may have gotten the same benefit from sham ECT and less damage to his brain.

And so back to CBT. The controls in the trials are as effective as this new dogma of treatment for all but depression where the evidence for it's effect is small. The effect size is far below what got the Improve
Access to Psychological Therapies scheme approved.then factoring in publication bias...that demon of good
research....which is the effect of trials with negative results being hidden...well it knows off about a third of the effect size of CBT studies.
http://bjp.rcpsych.org/content/196/3/173.full

In a sense it's saddening that there's few effective cures for mental disorder. Perhaps it's all the hedonic treadmill.
http://en.wikipedia.org/wiki/Hedonic_treadmill

Or perhaps it's the operational cluster of symptoms approach doesn't provide a good way to assign treatment to diagnosis?

some notes on a conversation about mental health

This is part of a fascinating conversation last night.

As always I should probably start with a caveat on the use of language. My use of language can be complicated. I consider there is precision in the meaning of the words but I consider the concepts the most important thing. I can be guilt of using the word madness or using the word mental health problems to describe the same concept but make differentiations between mental health problems and mental illness. I probably have a split personality or something. ; ) Its just a laziness of communication.

The conversation in the pub yesterday evening started with the misquoted 1 in 4 statistic. Its actually a reasonably high quality statistic though as all statistics in social science it is a ball park figure. Its 1 in 4 in a year but its often misquote as 1 in 4 in a lifetime by most of the people who use it.

The figure comes from the work of Huxley and Goldberg from a book they published in the 1980s. They established a period prevalence of 180/1000 people with a very high expectation of a clinical mental health problem sampled (if I remember right) in a one month period and using some complicated science estimated a multiplying factor to calculate the incidence (yearly prevalence) which came to exactly 250/1000, hence 1 in 4 in a year. In their later book in the 1990s they admitted that multiplying factor may have been miscalculated and underestimated. That's good scientists for you.

The figure is also backed up by the Adult Psychiatric Morbidity Survey using British Housepanels Survey data (if I remember right) uses a 2 week sampling period to establish a 1 in 6 figure at any one time. That sampling period is around half that used in the Huxley and Goldberg 180 in 1000 figure and 1 in 6 is approximately 167 in 1000. Using the same multiplying factor the 1 in 6 figure comes in slightly lower than 1 in 4 a year which is expected with the shorter sampling period. They're both in the same ball park. There's also no evidence I've ever found for a 1 in 4 in a lifetime measure of people with mental health problems.

Both those high quality examples produce a 1 in 4 figure but its important to know what that means and that's what's often contented by mental health scientists and statisticians when discussing 1 in 4. Does it mean mental illness (psychiatric illness), mental health problems (a broader definition) or experience of mental distress (as is used by one of the major UK charities in a lot of its marketing)?

Lets get rid of the last one first. In any sense of real use of language 1 in 4 is not to do with people who experience mental distress. Everyone in their lifetime experiences mental distress, or 99.95% do because there are always exceptions and different experiences of life. That may even be true for the incidence as well.

The second two options are where the debate gets interesting though takes something of a tangent. The idea of psychiatric mental illness is a concept based dogmatically on the strict fitting of symptoms to the cluster of systems defined in the accepted diagnostic criteria (usually DSM). High scores on the screening tool used in the APMS do not mean the same as a clinical interview or a diagnosis given by a psychiatrist, though it would indicate a high probability that the individual may be suffer from mental illness. "mental health problems" are often misconstrued as a euphimisation of mental illness whereas those who are precise with the language consider them to be lesser conditions or conditions based around distress specifically rather than the spectrum of psychiatric illness.

The conversation last night moved onto the point about homosexuality. After it was demedicalised first in America there was a debate about a diagnosis about homosexuality that was to remain in. I can't remember the name of the diagnosis but it covered the period of adjustment and the associated distress where a person goes from considering themselves hetereosexual (or 'normal') to accepting the homosexual feelings and desires. This diagnosis was not kept in DSM-III and future revisions. If I remember right the diagnosis was not included because the distress was thought to be a normal part of the process and therefore not to be medicalised.

(need to find the reference for this)

The conversation also moved onto grief as another example where 'normal' distress is not considered part of the mental health system. An often underused diagnosis in primary care is the adjustment disorder which relates to a life stressor creating symptoms defined as mental illness, however it carefully excludes anything related to grief. Bereavement and its consequences though they may be distressful and may induce social or psychological dsyfunction seems not to be part of the mental health systems compassion. (This has to be balanced by the fact that practice and academia are two very different worlds and it is likely that a GP may consider a referral for psychological therapies even if they suspect symptoms may be caused by a death and may consider medication).

Another digression moved into alternate mental health systems, specifically religion, and their consideration of grief. First of all this particular "alternate mental health systems" is a concept that needs further explaining is a separate post but for the moment its necessary to accept that the psychiatric system is not the only system that has ever controlled and helped people with emotional, behavioural or other forms of expressions of unusualness or distress. The example of a system of grief management was taken from the Islamic system (though in fact this may be a cultural system rather than specific to the religion). It is culturally accepted and it is even encouraged to wail and cry and 'freak out' and externalise as much as possible after a death. These behaviours are possibly considered "a bit much" in repressed societies but in other societies the holding in of grief and showing a bit of stuff upper lip is conisdered a poor way to deal with the aftermath of death. In the same system though there is a time limit on this grief. After one month the mourning period is over and it becomes time to get on with things.

Its surprising that there's nothing on grief in DSM-IV-TR. In fact there is. On page 756 of the 1323 page manual there's a short paragraph on the section about depressive disorders. It sets 2 months as the length of time before a diagnosis of major depressive disorder can be given and an individual offered short-term psychotherapy to deal with unresolved grief issues and pharmacotherapy. It also mentions that normal grief 'symptoms' usually happen within 2-3 weeks and resolve spontaneously over 6-8 weeks. That's it.

So the psychiatric system is clearly different from what most people would expect based on the ideal of a formalised system of human compassion. Its careful to select which forms of distress are normal and which aren't. It carefully attempts to tread that line between what is thought to be normal and what it considers an illness and abnormal, even though 1 in 4 people in a year are likely to receive a psychiatric diagnosis. The diagnostic criteria seems to leave certain types of distress out, specifically grief, lumping it in haphazardly into a paragraph in the length section on depressive disorders. And it used to 'treat' normal ways of being such as homosexuality.

Its a bloody interesting thing eh?!