Electronic Letters to:
|
|
eLetters: Electronic letters published:
-
![[Read eLetter]](/icons/misc/sectionDOWN.gif)
Risk of harm from increased relapse of psychosis after psychological intervention
- Karl Marlowe, East London NHS Foundation Trust (30 July 2008)
-
No risk of harm after psychological intervention for psychosis
- Philippa A Garety, David G. Fowler, Daniel Freeman, Paul Bebbington, Graham Dunn, and Elizabeth Kuipers (1 August 2008)
|
|
|||
|
Karl Marlowe, Consultant Psychiatrist Tower Hamlets' Early Intervention Service (THEIS), East London NHS Foundation Trust
Send letter to journal:
karl.marlowe{at}eastlondon.nhs.uk Karl Marlowe, et al.
|
Dear Sir, The paper by Garety et al (1) was an extremely important and methodological robust examination of the impact of psychosocial interventions for schizophrenia. The editorial by Scott (2) in the same edition, suggested that there has been an over promise of CBT and the inclusion in the 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 that 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 Treatment As Usual (TAU), CBT for Psychosis and Family Intervention (FI) 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, was 35.4% and 37% for TAU, 46.8% and 54.6% for CBT; in the carer pathways this was 21.4% and 25.9% for TAU, 27.3% and 28% for CBT, 22.2% and 20.8% for FI. 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 of the effect of having a carer during psychological intervention, had not been reported before. The second table of results showed the number of relapses in the no- carer pathway was 0.79 for TAU, 1.17 for CBT; and for the carer pathway this was 0.31 for TAU, 0.63 for CBT and 0.96 for FI. The relapse rates point towards an increase in hypothesised outcome and the risk of harm or hazard (5) needs to have been discussed in greater detail, to give balance to what has already been acknowledged to be an over sold intervention. (word count =360) Reference 1 Garety P, 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 Psych 2008; 192: 412 -23. 2 Scott J. Cognitive-behavioural therapy for severe mental disorders: back to the future? Br J Psych 2008; 192: 401 -03. 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 -13. 5 Marlowe K. Early interventions for psychosis. Br J Psych 2005; 186: 262 -3. |
|||
|
|
|||
|
Philippa A Garety, Professor of Clinical Psychology Institute of Psychiatry, King's College London, David G. Fowler, Daniel Freeman, Paul Bebbington, Graham Dunn, and Elizabeth Kuipers
Send letter to journal:
p.garety{at}iop.kcl.ac.uk Philippa A Garety, et al.
|
1st August 2008 PAG/JS/010808 Editor, British Journal of Psychiatry, Royal College of Psychiatrists, 17 Belgrave Square, LONDON SW1X 8PG Dear Editor, Marlowe notes that the primary outcome of our trial was relapse and comments that it is surprising, therefore, that it was not analysed in more detail. He does not appear to understand the inferential problems raised by the lack of full or partial remission in a considerable proportion of the patients in this trial. The number with full or partial remission is itself an outcome of the trial (i.e. it is a post- randomisation measure). Those who have shown no recovery are excluded from the relapse data that Marlowe presents. In fact, twice as many people show no recovery in TAU as in CBT (18:9). The data reported by Marlowe are therefore not a causal effect of randomisation (i.e. not an intention-to- treat effect). Because of this problem, we used months in full or partial remission as our primary indicator of outcome, for which a formal intention-to-treat analysis is presented. This analysis and also a further examination of total days in hospital and number of admissions very clearly demonstrate that CBT, FI and TAU do not differ. We also reported fully on deaths and other adverse events and found no differences (the only completed suicide was in TAU). We are therefore not at all convinced by the suggestion that psychological intervention might be detrimental. Indeed, we infer on the basis of the results of this trial and of numerous meta-analyses (e.g. Pfammater et al 2006; Pilling et al 2002; Wykes et al 2008) that CBT and FI are beneficial for certain populations for a range of outcomes. With respect to the effects of having a carer on a psychological intervention, we are of course, very aware of the Hogarty et al (1997a & 1997b) study, which we also discuss. It reported mixed findings. Our point here concerned the apparently beneficial effect of having a carer on CBT, which has not been examined before, including in that study. Yours sincerely Philippa A Garety, David G Fowler, Daniel Freeman, Paul Bebbington, Graham Dunn & Elizabeth Kuipers References: Hogarty, G.E., Kornblith, S.J., Greenwald, P., et al (1997a). Three years trials of personal therapy with schizophrenics living with or independent of family. I: Description of study and effects on relapse rates. American Journal of Psychiatry, 154, 1504-1513 Hogarty, G.E., Greenwald, P., Ulrich, R.F., et al (1997b). Three years trials of personal therapy with schizophrenics living with or independent of family. II: Effects on adjustment of patients. American Journal of Psychiatry, 154, 1514-1524. Pfammatter, M., Jungham, U.M., & Brenner, H.D. (2006). Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophrenia Bulletin, 32 Suppl 1, S64-80. Pilling, S., Bebbington, P., Kuipers, E., et al. (2002). Psychological treatments in schizophrenia. I: Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32: 763-782. Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behaviour therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34: 523-537. Declaration of interest None. Trial funded by Wellcome Trust. Details for authors: Corresponding author: Philippa Garety, Professor of Clinical Psychology, Department of Psychology, PO77, Institute of Psychiatry, King’s College London, De Crespigny Park, LONDON SE5 8AF Tel: 020 7848 5046 Fax: 020 7848 5006 David Fowler, Professor of Social Psychiatry, Department of Psychology and Psychiatry, School of Medicine, University of East Anglia, Earlham Road, NORWICH NR4 7TJ Daniel Freeman, Senior Lecturer in Clinical Psychology, Department of Psychology, PO77, Institute of Psychiatry, King’s College London, De Crespigny Park, LONDON SE5 8AF Paul Bebbington, Professor of Social and Community Psychiatry, Mental Health Sciences, Charles Bell House, University College London, 67-73 Riding House Street, LONDON W1W 7EJ Graham Dunn, Professor of Biomedical Statistics, Health Medical Research Group, Community Based Medicine, University of Manchester, University Place, Oxford Road, MANCHESTER M13 9PL Elizabeth Kuipers, Professor of Clinical Psychology, Department of Psychology, PO77, Institute of Psychiatry, King’s College London, De Crespigny Park, LONDON SE5 8AF |
|||