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Invited commentary on … NICE v. SIGN on psychosis and schizophrenia

Published online by Cambridge University Press:  02 January 2018

Mark Taylor*
Affiliation:
Intensive Home Treatment Team, Royal Edinburgh Hospital, Edinburgh, UK, and University of Queensland, Brisbane, Australia
Udayanga Perera
Affiliation:
Department of Psychiatry, District General Hospital, Monaragala, Sri Lanka
*
Mark Taylor, Royal Edinburgh Hospital, Edinburgh EH10 5HF, UK. Email: marktaylor2@nhs.net
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Summary

How contemporaneous guidelines interpret similar data is interesting but not relevant here. Conflicts of interest are important and various. Two clinically important recommendations in the National Institute for Health and Care Excellence (NICE) guideline CG178 deserve re-visiting.

Type
Analysis
Copyright
Copyright © Royal College of Psychiatrists, 2016 

How contemporaneous guidelines interpret similar data is interesting but not relevant here. Switching the discussion from an analysis of the National Institute for Health and Care Excellence (NICE) guideline CG178 1 to a comparison of CG178 with the Scottish Intercollegiate Guidelines Network guidance 131 2 (SIGN 131) is simply an obfuscatory diversion. Our original editorial Reference Taylor and Perera3 only mentions SIGN 131 twice – once in conjunction with the British Association for Psychopharmacology schizophrenia guideline – and we did not ‘claim’, as Kendall et al Reference Kendall, Whittington, Kuipers, Johnson, Birchwood and Marshall4 wrongly state, that SIGN 131 ‘was unbiased’. Furthermore, SIGN 131 was not an ‘update’ or ‘largely based’ on the 2009 NICE guideline CG82, 5 as also stated twice, beyond noting that NICE did kindly furnish SIGN 131 with their meta-data to 2007, on which CG82 was derived. The SIGN 131 multidisciplinary group then conducted their own systematic reviews and interpretation programme of any subsequent relevant literature. SIGN commenced in 1993 and lent its methodology to NICE when they began in 1999, so it is unclear which is ‘more rigorous’.

Conflicts of interest and bias

Impugning the opposition is another classic debating trick. Kendall et al suggest that we have ‘succumbed to bias’ without further explanation. Examining the basis or validity for the recommendations in CG178 does not mean the questioner is biased. To question is to be scientific, and our editorial merely states that CG178 is ‘open to a critique of bias’. Conflicts of interest are important in any discussion of bias, and can be varied. Reference Maj6,Reference Dragioti, Dimoliatis and Evangelou7 Potential conflicts of interest here might include: training fees, grant applications and publication royalties for the recommended interventions; researcher or guideline allegiance; receiving money from NICE to promote NICE; and putting forward research questions that mirror the authors' own career interests. NICE itself Reference Dragioti, Dimoliatis and Evangelou7 and others 8 have expressed concern regarding the governance of NICE guideline groups.

Recommendations re-visited

Two clinically important CG178 recommendations deserve re-visiting. First, authorities Reference Coghill9 regard at-risk mental states (ARMS) – for which CG178 has a whole new chapter – as an unreliable category with little predictive validity. Kendall et al state that CG178 recommended to ‘offer CBT for people with ARMS’ based on a meta-analysis they themselves conducted, without commenting on the ARMS construct validity, fidelity of the intervention or resource implications.

Second, advocating cognitive behavioural therapy for psychosis (CBTp) as sole therapy (i.e. no medication of any sort) during the first month of first-episode psychosis arguably lacks clinical face validity and could potentially be dangerous given the high suicide rate in this population. Reference Van Os and Murray10 Extrapolating recommendations from ’sparse’ data is also ill-advised. Moreover, the practical issues of what happens when CBTp is refused or not available locally are simply not addressed by CG178.

In a serious disorder such as schizophrenia, all effective treatments are welcome. CBTp may well have a small benefit (effect size 0.2) in psychosis, Reference Hor and Taylor11 although recently there have been concerns regarding the reproducibility of psychology studies. Reference Turner, van der Gaag, Karyotaki and Cuijpers12

Our original editorial used tendentious language with the aim of provoking rational debate – a pillar of scientific progress. It seems we have partially succeeded in that aim.

Footnotes

See pp. 316–319, this issue.

Declaration of interest

M.T. was co-chair of SIGN 131, and has received hospitality or fees from Lundbeck, Janssen, Roche, and Otsuka in the past 3 years.

References

1 National Collaborating Centre for Mental Health. Psychosis and Schizophrenia in Adults: The NICE Guideline on Treatment and Management (Updated Edition) (Clinical Guideline CG178). National Institute for Health and Care Excellence, 2014.Google Scholar
2 Scottish Intercollegiate Guidelines Network. Management of Schizophrenia (SIGN 131). SIGN, 2013.Google Scholar
3 Taylor, M, Perera, U. NICE CG178 Psychosis and Schizophrenia in Adults: Treatment and Management – an evidence-based guideline? Br J Psychiatry 2015; 206: 357–9.Google Scholar
4 Kendall, T, Whittington, CJ, Kuipers, E, Johnson, S, Birchwood, MJ, Marshall, M, et al. NICE v. SIGN on psychosis and schizophrenia: same roots, similar guidelines, different interpretations. Br J Psychiatry 2016; 208: 316–9.Google Scholar
5 National Institute for Clinical Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care (Clinical Guideline CG82). NICE, 2009.Google Scholar
6 Maj, M. Non-financial conflicts of interests in psychiatric research and practice. Br J Psychiatry 2008; 193: 91–2.CrossRefGoogle ScholarPubMed
7 Dragioti, E, Dimoliatis, I, Evangelou, E. Disclosure of researcher allegiance in meta-analysis and randomised controlled trials of psychotherapy: a systematic appraisal. BMJ Open 2015; 5: e007206.CrossRefGoogle ScholarPubMed
8 NICE Triennial Review Team. Report of the Triennial Review of the National Institute for Health and Care Excellence: 63–5. Department of Health, 2015.Google Scholar
9 Coghill, D. Are NICE guidelines losing their impartiality (letter)? Br J Psychiatry 2015; 207: 271.CrossRefGoogle Scholar
10 Van Os, J, Murray, RM. Can we identify and treat ‘schizophrenia light’ to prevent true psychotic illness? BMJ 2013; 346: f304.Google Scholar
11 Hor, K, Taylor, M. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol 2010; 24 (4 suppl): 8190.CrossRefGoogle ScholarPubMed
12 Turner, DT, van der Gaag, M, Karyotaki, E, Cuijpers, P. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry 2014; 171: 523–38.Google Scholar
13 Open Science Collaboration. Estimating the reproducibility of psychological science. Science 2015; 349: 6251.Google Scholar
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