IiME letter to Mark Baker (NICE) re: CBT & GET as recommended treatments

Wracking both brain cells... I'm sure it's on s4me somewhere already. The quote might be to do with outcome thresholds rather than criteria tho'

 

Anyone have the cognitive capacity to hunt it down?

 

@Valentijn might have it in her pocket?

 

I don't remember where it is, but I think it was something Wessely said off the cuff regarding the lowered thresholds required for recovery in PACE.

 

Pretty inflammatory, would work well in an argument (or in a article)

 

Here you go @Alvin
https://twitter.com/user/status/847468025120907265

 

https://www.s4me.info/threads/prof-...tific-bbc-radio-4-14-feb-2017.991/#post-29947

 

We both got there in the end @Sly Saint ! Thank you!

 

How exactly did they report on the exclusions in PACE and were the exclusions done on objective measures or subjective ones and also could they overrule such patients previous diagnosis and did they test for or ask for proof of previous tests before excluding people.

 

Important point. Can you point me to what you think is the objective evidence here. I think one may be able to unstitch that but I need to have another look.

I agree that using Oxford can be heavily criticised on grounds of there being a serious risk of not getting a representative population and that may need to be flagged up. My push back has been against the suggestion that using Oxford is 'scientifically unsound' for a priori reasons, which I think is doubtful.

 

It isn't at all clear whether they had other conditions that had not been spotted (such as sleep apnoea), which could account for up to half of the patients screened, or whether their fatigue was not the major symptom. Their description of the Oxford criteria requires "fatigue to be the main symptom, accompanied by significant disability, in the absence of an exclusionary medical or psychiatric diagnosis..."

You need to look at figure 1 on the original 2011 report, then read through the section on Methods (page 2). You'll end up with more information, but few answers!

 

According to the original paper,

http://www.sciencedirect.com/science/article/pii/S0140673611600962

 

https://www.nice.org.uk/guidance/cg53/evidence/full-guideline-appendix-1-196524110 contains the evaluations of the evidence, and a summary of diagnostic criteria as well.

Summaries of study results are pages 54-56 (CBT), 57-59 (GET).

Data extraction from CBT/GET trials is on pages 275-317.

Validity assessments of RCTS are on pages 437-439, and controlled trials are pages 440-441.

 

Like replacing the knackered plugs in my car helps it go fine again, so lets replace the plugs on yours which is also a bit fatigued. If you then tell the other person their car is sorted and they just have to put their foot down and go ... if the real problem is the handbrake is stuck on, you will just burn the brakes out.

 

@Jonathan Edwards - Here's my notes regarding the GET evidence:

• Fulcher 1997 (1++) - 66 patients, Oxford, 2.7 years ill, 12 weeks GET v flexibility, GET 50% max heart rate
• Moss-Morris 2005 (1+) - 49 patients, Fukuda, 12 weeks CBT/GET v SMC, GET group 2.26 years ill & control group 5 years ill, P-values > 0.01
• Powell 2001 (1++) - 148 patients, Oxford, 48 months ill, 3 types of GET + 1 control
• Powell 2004 (1++) - 2 year followup - controls had crossed-over, no longer controlled?
• Wallman 2004 (1-) - 61 patients, Fukuda, unknown illness duration, GET + Pacing v controls, 6 with MDD, reduced exercise if relapse, objective outcomes compared within groups instead of with controls
• Wearden 1998 (1++) - 136 patients, Oxford, 28 months ill, fluoxetine or HR-based GET, 40 drop outs with 11 due to adverse events

There are problems other than using Oxford, but Oxford seems to be the biggest problem and the easiest to attack, especially since it could take down a lot of trials at once.

 

That is not hideously terrible, that said we have only their word they actually followed what they claim to have, their ethics in other parts of the trial undermine their trustworthiness

 

The thing is as the BPS crowd think they can just look at someone and declare them x y or z they could have been excluding left and right to narrow the entry participants down to a cohort they could claim to be Oxford for their trials but anyone who turned up with walking difficulty etc could have been excluded, or they could just say, "ah you look a bit pasty you have anemia, you are excluded" etc until they end up with a bunch of people who had a single complaint of "fatigue", which was the minimum requirement for the trial.

 

@large donner - Stretching speculation a bit far imo. I prefer to stick with what can be evidenced. That's bad enough.

 

@Alvin, yes, but, whatever the authors actually did, PACE was anyway a bust scientifically in so many ways that we've an embarrassment of riches as far as discrediting it goes, so it ought to be impossible for NICE to justify using it it in the new guidelines.

 

I agree, i do like to know details though, its always good to have many avenues to work with, you never know which one will be the Achilles heel