© 2008 The Royal College of Psychiatrists
Correspondence |
Risk of harm after psychological intervention
Tower Hamlets' Early Intervention Service, East London NHS Foundation Trust, London, UK. Email: karl.marlowe{at}eastlondon.nhs.uk
Edited by Kiriakos Xenitidis and Colin Campbell
The paper by Garety et al1 was an extremely important and methodologically robust examination of the impact of psychosocial interventions for schizophrenia. The editorial by Scott2 in the same issue suggested that there has been an overpromise of CBT and the inclusion in the National Institute for Health and Clinical Excellence (NICE)3 guideline might have been oversold as there was a lack of evidence of efficacy in schizophrenia. There are several points which need to be added to those discussed in the paper and in the editorial.
The hypothesis used to calculate power was based on the primary outcome of relapse from a non-affective psychosis (ICD–10 category F20–29, and not F2 as reported in the paper), using TAU, CBT for psychosis and family intervention as comparison interventions. It is therefore important to focus on this outcome and it is surprising that this was not analysed in greater detail.
The published relapse rates after full remission and from full/partial remission in the no-carer pathway were 35.4% and 37% respectively for TAU and 46.8% and 54.6% respectively for CBT; in the carer pathways they were 21.4% and 25.9% for TAU, 27.3% and 28% for CBT, 22.2% and 20.8% for family intervention. It would have been important to analysis the pathways separately as the no-carer pathway shows a trend for an increase in relapse rates. This was indeed the statistical evaluation in the seminal personal therapy/family therapy 3-year study by Hogarty et al,4 where offering therapeutic intervention in a no-carer pathway led to significantly increased rates of psychotic relapse. The discussion in the published paper was thus incorrect in the assertion that the effect of having a carer during psychological intervention had not been reported before.
The second table of results showed the mean number of relapses in the no-carer pathway: 0.79 for TAU and 1.17 for CBT; for the carer pathway this was 0.31 for TAU, 0.63 for CBT and 0.96 for family intervention. The relapse rates point towards an increase in hypothesised outcome and the risk of harm or hazard5 needs to have been discussed in greater detail, to give balance to what has already been acknowledged to be an oversold intervention.
REFERENCES
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1
- Garety PA, Fowler DG, Freeman D, Bebbington P, Dunn G, Kuipers E.
Cognitive–behavioural therapy and family intervention for relapse
prevention and symptom reduction in psychosis: randomised controlled trial.
Br J Psychiatry 2008;
192: 412
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[Abstract/Free Full Text] 2 - Scott J. Cognitive–behavioural therapy for severe mental
disorders: back to the future? Br J Psychiatry 2008; 192: 401
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[Abstract/Free Full Text] 3 - National Institute for Health and Clinical Excellence. Schizophrenia: Core interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. NICE, 2003 . 4
- Hogarty GE, Kornblith SJ, Greenwald D, DiBarry AL, Cooley S, Ulrich
RF, Carter M, Flesher S. Three years trials of personal therapy with
schizophrenics living with or independent of family. I: Description of study
and effects on relapse rates. Am J Psychiatry 1997; 154: 1504
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[Abstract/Free Full Text] 5 - Marlowe KH. Early interventions for psychosis. Br J
Psychiatry 2005; 186: 262
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[Free Full Text]
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