NICE guidance on psychological treatments for bipolar disorder: searching for the evidence. 2016, Jauhar, McKenna and Laws

Andy · Apr 14, 2018

Note: this is from 2016. It's new to me but may be familiar to others.

Summary
The recent National Institute for Health and Care Excellence guidelines for bipolar disorder offer a number of recommendations for the psychological treatment of bipolar disorder. Scrutiny of the evidence on which these guidelines are based reveals significant flaws in the methodology and conduct of the relevant meta-analyses, and calls into question the interpretation of the evidence.
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Paywalled at http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00545-3/abstract

Article in the Guardian, again from 2016.

In our paper published in Lancet Psychiatry, we re-assess the evidence used by NICE to recommend psychological therapies as an intervention for bipolar disorder. The diagnosis of bipolar disorder typically describes a cycling between periods of depression and mania (where the latter may involve grandiose ideas, increased drive and decreased sleep, which can all culminate in psychosis and exhaustion if untreated).

NICE guidance positions psychological interventions as the first line treatment for adults who are not in secondary care, and places them on an equal-footing with pharmacological treatments in the longer-term management of the disorder. In these circumstances, we might expect the underpinning evidence to be of the highest quality.

As with all NICE guidelines, the recommendations are based on reviewing trial data using meta-analysis: in this case they commissioned the National Collaborating Centre for Mental Health to do the analyses (NCCMH). The purpose of such meta-analyses is to collate data across multiple trials so we can draw more reliable conclusions about the efficacy of specific interventions.

Perusing the documentation, however, the reader will be struck by the sheer quantity of meta-analyses conducted by NCCMH - 170 meta-analyses assessing multiple psychological therapies and outcomes across just 55 trials. Consequently, each meta-analysis contains very few trials – indeed, the largest they present contains 6. More worryingly, and contrary to the purpose of meta-analysis, which is to synthesize studies, more than 50% of all meta-analyses in the NICE guide include only one trial. It would not escape the attention of someone with basic statistical knowledge that such an approach is likely to elicit false-positive findings by chance alone.
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https://www.theguardian.com/science...ychological-therapy-cbt-overstepping-evidence

pteropus · Apr 14, 2018

i am not even mildly surprised by the deliberate & elaborate deception.

Trish · Apr 14, 2018

There is something rotten in the state of psychiatry. My sympathy to the patients involved..

Hutan · Apr 14, 2018

Here's the conclusion (my bolding):

NICE undeniably go beyond the evidence in their advocacy of psychological treatments for bipolar disorder. What can be done to remedy this situation?

First, the meta-analytic trawling needs to be avoided and future analyses would benefit from registering clear and precise analyses in advance.

Second, study quality needs to be actively incorporated into the presentation of conclusions.

Third, and perhaps most importantly, the approach of NICE needs to be more critical. Seeming to set the bar too low, or lower for psychological therapies, can only raise doubts about rigour and impartiality.
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Keith R Laws is a Professor of Cognitive Neuropsychology at the School of Life and Medical Sciences, University of Hertfordshire. His research focusses on cognitive problems in Schizophrenia, Alzheimer’s disease and Obsessive Compulsive Disorder. On Twitter he is @keith_laws.
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Professor Keith Laws might be interested to hear about the NICE review of treatments for ME/CFS. He could be a compelling ally.

Esther12 · Apr 14, 2018

Hutan said: ↑

Here's the conclusion (my bolding):

Professor Keith Laws might be interested to hear about the NICE review of treatments for ME/CFS. He could be a compelling ally.
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He had joined PR. Things like that do make the loss of the forum extra annoying.

He wrote an article for the JofHP special issue: http://journals.sagepub.com/doi/full/10.1177/1359105317710246

A couple of blogs listed here: http://me-pedia.org/wiki/Keith_Laws

Hutan · Apr 14, 2018

Thanks @Esther12

Esther12 said: ↑

He wrote an article for the JofHP special issue: http://journals.sagepub.com/doi/full/10.1177/1359105317710246
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And a very nice article it is.

I do hope he joins here.

Jonathan Edwards · Apr 14, 2018

Second, study quality needs to be actively incorporated into the presentation of conclusions.

Third, and perhaps most importantly, the approach of NICE needs to be more critical. Seeming to set the bar too low, or lower for psychological therapies, can only raise doubts about rigour and impartiality.

Sounds familiar. Perhaps everyone going to the NICE stakeholder meeting should have this other T-shirt.

That should have been on their T-shirt.

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NICE guidance on psychological treatments for bipolar disorder: searching for the evidence. 2016, Jauhar, McKenna and Laws

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NICE guidance on psychological treatments for bipolar disorder: searching for the evidence. 2016, Jauhar, McKenna and Laws

Andy Committee Member

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