How should we evaluate research on counselling and the treatment of depression? A case study on..., 2017, Barkham et al

Andy · Jan 22, 2019

Abstract
Background

Health guidelines are developed to improve patient care by ensuring the most recent and ‘best available evidence’ is used to guide treatment recommendations. The National Institute for Health and Care Excellence's (NICE's ) guideline development methodology acknowledges that evidence needed to answer one question (treatment efficacy) may be different from evidence needed to answer another (cost‐effectiveness, treatment acceptability to patients). This review uses counselling in the treatment of depression as a case study, and interrogates the constructs of ‘best’ evidence and ‘best’ guideline methodologies.

Method
The review comprises six sections: (i) implications of diverse definitions of counselling in research; (ii) research findings from meta‐analyses and randomised controlled trials (RCTs); (iii) limitations to trials‐based evidence; (iv) findings from large routine outcome datasets; (v) the inclusion of qualitative research that emphasises service‐user voices; and (vi) conclusions and recommendations.

Results
Research from meta‐analyses and RCTs contained in the draft 2018 NICE Guideline is limited but positive in relation to the effectiveness of counselling in the treatment for depression. The weight of evidence suggests little, if any, advantage to cognitive behaviour therapy (CBT) over counselling once risk of bias and researcher allegiance are taken into account. A growing body of evidence from large NHS data sets also evidences that, for depression, counselling is as effective as CBT and cost‐effective when delivered in NHS settings.

Conclusion
Specifications in NICE's updated guideline procedures allow for data other than RCTs and meta‐analyses to be included. Accordingly, there is a need to include large standardised collected data sets from routine practice as well as the voice of patients via high‐quality qualitative research.
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Open access at https://onlinelibrary.wiley.com/doi/full/10.1002/capr.12141

Posting this as it has been highlighted in the comments of Spoonseeker's latest blog that the concept expressed in this review is to be used to 'lower the bar' that NICE uses to assess treatments by, and therefore "to use the IAPT MUS data set in the NICE Guidelines review as evidence for the effectiveness of CBT and GET for ME/CFS patients"
Link to comments section of the Spoonseeker blog, quote is from the comment by Couch Turnip, https://spoonseeker.com/2019/01/21/coming-down-the-line/comment-page-1/#comments
Our thread on the blog here, https://s4me.info/threads/spoonseeker-coming-down-the-line.7775/

I've no idea if that argument is 'right' or not but thought it was worth adding to the general discussion.

Peter Trewhitt · Jan 22, 2019

Not with it to read everything properly, but a first thought is that this weakening of evidence considered as relevant is potentially both bad and good.

Shifting away from insisting on rigorous experimental design may be a way of keeping bad research such as PACE in the mix, but it also may allow in such as patient surveys demonstrating the harm resulting from GET or PACE type CBT.

Sly Saint · Mar 23, 2020

from CBT Watch

18th March 2020 Leave a comment

a study by Barkham and Stone https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1899-0 of over 33,000 IAPT cases has revealed high intensity counselling as being the most cost effective, requiring on average just 6 sessions compared to the 9 sessions for high intensity CBT, to achieve the same result. But the NICE Guidance recommends CBT as the first line treatment not only for depression http://www.nice.org.uk/guidance/cg90 but also the common anxiety disorders. In the 2 years since the published study, IAPT appears not to have considered that there is likely something wrong with its’ data set when it provokes a conclusion at variance with the NICE Guidance. However it is IAPT that has muscle at the coal face, not NICE. The juggernaut of IAPT carries on, paying lip service to NICE Guidelines to placate NHS England and local Clinical Commissioning Groups.

The Barkham and Stone study also suggests that whatever of the 4 trajectories clients take in IAPT: 1. high intensity counselling (9%) 2. high intensity cbt (18%) 3. low intensity cbt followed by high intensity counselling (20%) 4. low intensity cut followed by high intensity cut (53%) there is no difference in outcome, all improve by 6 points on the PHQ9 each starting off at a score of 15. This would suggest that there are no meaningful distinctions between the categories and that the stepped care approach bears no fruit. Yet IAPT continues with stepped care. IAPT fails on quality control, it can provide no meaningful data with regard to treatment integrity i.e a guarantee that an evidence based protocol has been followed for a reliably identified disorder. Nor can it provide any evidence that the observed changes of score would not have happened with the passage of time and attention (an active placebo).

Regrettably IAPT, markets itself superbly with Ontario in Canada being the latest to be conned by the IAPT model, when will people wake up and smell the coffee.

Dr Mike Scott
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@ScottTriGuy

ScottTriGuy · Mar 23, 2020

Sly Saint said: ↑

from CBT Watch

@ScottTriGuy
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Thanks -- I left a comment and am trying to track him down, but his name is pretty common.

ScottTriGuy · Mar 23, 2020

Sly Saint said: ↑

from CBT Watch

@ScottTriGuy
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ah, he's the creator of CBT Watch, I though he was an Ontario doctor.

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