David Tuller - Trial By Error: CBT Provides No Benefits to Advanced Cancer Patients, Study Finds

MSEsperanza

MSEsperanza

Senior Member (Voting Rights)
Trial By Error: CBT Provides No Benefits to Advanced Cancer Patients, Study Finds

By David Tuller, DrPH

Since 2008, the National Health Service (NHS) in England has been rolling out a program known as Improving Access to Psychological Therapies (IAPT). Initially focused on patients with mental health issues like depression and anxiety disorders, IAPT was then expanded to include those who are also simultaneously suffering from “long-term conditions” and so-called “medically unexplained symptoms” (MUS). IAPT has cited 50% “recovery” rates from its interventions, but these claims are not especially credible, as Liverpool consultant psychologist Michael Scott has documented on his informative blog, CBT Watch...
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The limited uptake of CBT itself should raise further questions for IAPT. The investigators did not discuss possible reasons for this phenomenon beyond noting that “our clinical experience was that physically ill people had difficulty in managing the demands of CBT.”
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http://www.virology.ws/2020/01/15/t...fits-to-advanced-cancer-patients-study-finds/
 
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Hm, I think it should be emphasized that the quoted study is only about advanced cancer and depression:

From the quoted paper's abstract:

"Although cognitive-behavioural therapy (CBT) has been shown to be effective for depression in people with cancer, it is unclear whether this is the case for people with advanced cancer and depression." (bolding mine)

Didn't read the (paywalled) study though, so don't know if the authors suggest there is evidence to generalize their findings in any way or if they start from the premise (and don't doubt) that CBT for people with depression and non-advanced cancer is OK.

However, I think it would be highly relevant if there were more research starting from “our clinical experience was that physically ill people had difficulty in managing the demands of CBT” (quoted from David's article).

So I'm a bit confused what the article essentially is about, @dave30th ?

If it is about IAPT and MUS, then the quoted study seems to me given too much weight.

If it is about evidence for efficacy of CBT for depression in severely ill patients (in general or via IAPT), then I think MUS is given too much weight.

Or perhaps more context could make your point clearer? (Which presumably the linked blog will provide, but didn't read that.)

(Edit: E.g. how robust is the evidence for efficacy of CBT for depression with and without comorbidity/ severe comorbity? Is IAPT the wrong way to provide the therapy or is it the therapy per se?)

Quoted study: Serfaty M, King M, Nazareth I, et al. Effectiveness of cognitive-behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial [published online ahead of print, 2019 Sep 30]. Br J Psychiatry. 2019;1–9. doi:10.1192/bjp.2019.207

https://www.cambridge.org/core/jour...rolled-trial/E9264C516634EC7BC3FF9E80B551A8C5
 
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James Morris-Lent said:
I guess I don't have the full picture but it strikes me as ghoulishly unfeeling to seek out people with 'advanced cancer' for the specific purpose of challenging them on their thought processes. That is what CBT is, after all.
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Doesn't it just!

It would appear that not only is it believed can CBT replace medicine, it can also replace one's faith or religion.

A snake oil cure all.
 
MSEsperanza said:
So I'm a bit confused what the article essentially is about, @dave30th ?
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Hi, I don't quite get the confusion. IAPT says it's effective for treating people with depression/anxiety as co-morbidities to long-term conditions, including advanced cancer, and MUS, as in chronic fatigue syndrome. In this study at least, IAPT has been shown to not be effective in improving depression in people with advanced cancer, raising doubts about the excessive speed with which the program is being pushed out across England and about the all the claims made for the program--including whether it can help people with ME.
 
James Morris-Lent said:
I guess I don't have the full picture but it strikes me as ghoulishly unfeeling to seek out people with 'advanced cancer' for the specific purpose of challenging them on their thought processes. That is what CBT is, after all.
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The quote about how they didn't anticipate that it would be too much to ask of very sick people is really telling of how little, if any, they understand about illness, it's completely abstract to the people who pursue this ideology, the human element simply does not exist.

You do have to laugh at the delusion of highly-trained IAPT specialists. Being highly trained in BS doesn't mean anything, might as well have feng-shui masters for all that it matters. I have no idea how they actually expected this to work, or if they just thought they could continuously BS their way through failure.

Because frankly it looks like the main skill of the people involved in this whole thing is persuasion. After all this is what they do in their regular practice, try to convince very sick people that they are not, in fact, actually sick. It's the recurrent theme through the entire literature, of just how to actually persuade the patients and successfully make them swallow a BS explanation. It even seems to be the bulk of training.

And it's looking more and more like this persuasion skill allowed them to convince people to buy into funding this massive waste of public funds, though without being ready for the next step of actually doing something with it. Like a dog who catches a car, the pursuit is the thing, catching it is actually a problem because now they are faced with the reality of having sold total BS as the cure to everything.

Oversell and literally do not deliver anything. It's going to be one hell of a hangover when this party ends and the check comes.
 
Thanks for your reply, @dave30th .

My confusion might be due more to some premises of the three concepts of MUS, CBT and IAPT, all of which I have no real knowledge and have read only few of your previous articles dealing with those issues.

I'll try to explain my confusion in portions when I will have read the trial paper and Michael Scott's article.

(Edited to remove ramblings.)
 
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I think the confusion is that they are no longer treating added anxiety, depression etc. That used to be the case but now they have decided that the body expresses emotional distress, not just by anxiety and depression, but by producing physical problems like headaches, IBS and all the MUS categories.

So IAPT and the rest are being rolled out for what ordinary people would think of as physical diseases.
 
alktipping said:
am I the only one who thinks being depressed is a natural response to facing the pain and disability that comes with many illnesses . the way they phrase depression as an abnormal response should tell you something about their lack of empathy or intellect you can choose what exactly is lacking .
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Not to defend the investigators or anything, but I assume the CBT for depression in advanced cancer is different from the aberration of CBT addressing unhelpful illness beliefs that is used for "CFS" or what others would call "ME." I don't think the presumption is that the depression is an abnormal response to having cancer but that there are ways to address it that might help people cope with their situation--what I guess CBT should be used for. That doesn't seem unreasonable to me. It's different from CBT for MUS where it is expected to lead to "recovery" from CFS, IBS, etc. It's just that in this study, it didn't work.
 
MSEsperanza said:
My confusion might be due more to some premises of the three concepts of MUS, CBT and IAPT, all of which I have no real knowledge and have read only few of your previous articles dealing with those issues.
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I understand why it was hard to understand. I can see why it would be confusing unless you understand what the IAPT program is doing. I could have explained more. The program started off in 2008 to embed psychological services more closely into health care delivery, so that it was easier for GPs for example to refer patients with depression/anxiety to an associated IAPT program. Then they decided within a few years to expand the program to treat depression/anxiety specifically for people who are being treated for LTCs (cancer, diabetes, congestive heart failure) or who have MUS--CFS (per their usage), IBS, etc.

In the MUS category, it is presumed by definition that these conditions are essentially depression/anxiety disorders, so for these patients there is specialized CBT, GET, and whatever. Unlike those with LTCs who are being treated for their medical disease in addition to receiving help through IAPT, those with MUS are not necessarily offered other treatments, since these are the indicated treatments.

My concerns with IAPT is that there has been a big push to implement and then expand it to LTCs and MUS. PACE was apparently a "proof-of-concept" trial for citing in materials promoting IAPT expansion for MUS. Now it's hard to cite PACE in that way without also citing the fact that many people think it's a piece of crap. My point in the post was that claims of success for IAPT turn out not to be the case for depression in those with advanced cancer, at least according to this study. And this in a case where you'd think it might work, since research does suggest it can work for depression. So it suggests IAPT needs to think carefully about its expansion--which of course includes MUS and therefore ME in the guise of CFS--and the claims it is making for these interventions.

I hope that helps clarify!
 
Depression in advanced cancer, or any cancer, I wonder how much is due to having to put on a brave front. CBT which tries to change the patient's cognitions does not seem very appropriate.

We all know how bad it is with ME and it must be worse with terminal disease. You can't tell people close to you how bad things are because you do not want to upset them. It is difficult to fins a balance.

My friend had a very aggressive cancer and every treatment seemed to work but then it came back. Eventually she decided against any more things with a very low chance of success but high possibility o her feeling terrible. I was the only one she could talk to about it as I understood just how tired of it all her body was.

So I think cancer patients need a safe place to express their fears and emotions rather than CBT for depression.
 
alktipping said:
am I the only one who thinks being depressed is a natural response to facing the pain and disability that comes with many illnesses . the way they phrase depression as an abnormal response should tell you something about their lack of empathy or intellect you can choose what exactly is lacking .
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I think this is a terminology problem, not that the bpsers have got it right, they see depression everywhere. Major depression with apathy, lack of emotion, all that suite of horrible symptoms is not a natural response to pain and disabilty. Most people get angry, upset, grieving, frightened, anxious but that is not depression.

I a guilty of it myself, saying I am depressed when I just feel down.
 
Good point @Mithriel and it’s telling that they had to give extra training beforehand. Would have thought this client group deserve fully trained counsellors who can adapt to provide a suitable approach rather than CBT. I suspect what they got was better than my sausage machine experience of IAPT low intensity CBT but I still can’t imagine how that would be anywhere near as good as person centred counselling like I get from my counsellor that I pay for myself.
 
dave30th said:
And this in a case where you'd think it might work, since research does suggest it can work for depression.
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Does it? This isn’t something I know very much about. I’ve always guessed that CBT is mostly bull***t and that any real benefits for people with mental health problems are probably due to being given sensible advice about lifestyle management (not applicable to ME/CFS-type CBT) and spending time with a human being who appears to care.

Is there any robust evidence that CBT per se can be effective as a treatment for depression? Have there been adequately controlled trials?

With regard to the advanced cancer CBT study, it was notable how many patients didn’t complete the course. My suspicion is that, because of their prognosis, people with advanced cancer have a much lower bull***t threshold and are likely to be more difficult to manipulate into answering questions about their mood/symptoms differently (which is one thing we know that CBT can be effective at persuading people to do).

When I was being given CBT for ME/CFS 20 years ago, it took about 30 seconds to realise that it was going to a complete waste of time. If I had had a terminal prognosis I would almost certainly have stopped it after one session – I would rather have spent the time talking to a sat-nav than a pre-programmed CBT therapist. But because my condition wasn’t imminently life-threatening I felt much more pressure to go along with it. I was concerned that if I refused the treatment, or said what I really thought about it, I would be labelled as negative and awkward, which might have had a negative impact on the way I was treated thereafter. But if I’d known that I wasn’t going to be around for much longer, and nobody was telling me that CBT was going to affect my prognosis, I guess wouldn’t have felt the same pressure and I might have been more honest.

Having said that, I wasn’t being given CBT for clinical depression or anxiety, and I can imagine that my feelings about CBT may have been different if I had been suffering from either of those conditions and the therapy was aimed at helping with those problems rather than reversing a non-mental illness.
 
Mithriel said:
Depression in advanced cancer, or any cancer, I wonder how much is due to having to put on a brave front. CBT which tries to change the patient's cognitions does not seem very appropriate.
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I also wonder how many depressions (there are more than one kind of depression) are caused by biological illness (cancer or other causing brain inflammation / toxicity / etc), not psychological factors?

In this context, CBT for 'treating' depression is useless at best, and potentially harmful (patient's depression doesn't get better, therefore they're doing CBT 'wrong' or not trying hard enough or innately a loser or...).

If CBT is learning to live with depression, that's a different approach and expectation.

I recently learned there are 27 different causes of psychosis, but only 1 of those is treatable with anti-psychotic medications.

I wonder how many different causes of a depression are purely psychological, where CBT to treat it would be appropriate?
 
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