Haritonov Sergey Führung für CBT
This is the first in a new series of Mental Elf blogs produced in partnership with the British Journal of Psychiatry. Each month we will select a new paper from click at this page BJPsych to be blogged by a young psychiatrist with research experience.
And now, over to Joe Hayes for the first blog! There are signs that we are failing people with depression. Haritonov Sergey Führung für CBT recent study click in BJPsych found that only 1 in 5 people Psoriasis in Haarkur depression in high-income countries, and 1 in 27 people in low- and middle-income countries, received adequate treatment Thornicroft et al.
Moreover, it is this story that seems to capture the public imagination. The other powerful narrative has been that antidepressants are no more effective than placebo and that pharmaceutical companies cannot be trusted because they have hidden this from us.
We are repeatedly Psoriasis psychosomatische Erkrankungen that the increasing placebo effect is the reason for drug companies withdrawal from psychiatric drug development.
Professor Irving Kirsch and colleagues played an important part in developing this narrative with their highly cited meta-analysis Kirsch et al. The overall effect of new-generation antidepressant medications is below recommended criteria for clinical significance.
We also find that efficacy reaches clinical significance only in trials involving the most extremely Haritonov Sergey Führung für CBT patients, and that this pattern is due to a decrease in the response to placebo rather than an increase in the response to medication.
This finding has now been refuted by a number of study level and individual-participant level meta-analyses Melander et al. Further, the study by Kirsch et al. Despite the conflicting evidence, the idea that baseline severity impacts on antidepressant treatment effectiveness was taken up wholeheartedly by NICE and other agencies.
Interestingly, whilst this was going on, albeit more quietly, similar findings were being reported concerning psychotherapy: CBT might only be effective when depression is most severe and may be little better than placebo Driessen et al. This phenomena was described in a Mental Elf blog from last year. This new meta-analysis published in the BJPsych Furukawa et al, seeks to address Haritonov Sergey Führung für CBT issue of initial severity effects by identifying all randomised controlled trials of CBT versus pill-placebo and accessing and meta-analysing individual-participant data IPD-MA.
Traditionally meta-analysis involves combining and analysing quantitative evidence from a number of studies to produce a pooled effect estimate. In this design the researcher obtains raw patient level data from each study identified as relevant.
This approach has particular strengths: Studies were eligible if they were randomised controlled trials RCTs of adults with major depressive disorder MDD who received an intervention of face-to-face individual or group CBT, with a control Haritonov Sergey Führung für CBT of individuals receiving pill-placebo.
The search for eligible RCTs was comprehensive Sophora für Psoriasis kaufen used a number of databases, but did not search grey literature or approach researchers in the field to identify potentially unpublished studies. Authors were then contacted, and individual-level participant data was requested. Whilst these exclusions are logical, we must be aware that this analysis is therefore likely to exclude a large number of trials of CBT for depression.
Both these scales are widely used in depression research, but a number of issues have been raised with them, especially in delineating clinical significance from statistical significance Fava et al.
Additionally in this meta-analysis, included RCTs used different versions of these scales, with different item questions and numbers of items. To do this raw scores at baseline and endpoint were divided by study-specific standard deviations. The authors then investigated whether the standardised baseline score modified the effect of the symptom change score i.
Multiple imputation was used to manage missing data. There is no discussion of why, or to what extent, data were missing, which is a limitation of the paper. Whilst this may be the most appropriate approach, it is likely that data are missing not at here i.
This is the biggest achievement of this study; that data from all identified RCTs was provided to the authors to be reanalysed. Haritonov Sergey Führung für CBT reporting was single-blind assessors were not aware of treatment allocationBDI reporting was not blind because it is a self-report measure.
The authors report that almost RCTs were excluded because they did not learn more here a comparison with pill-placebo. All sensitivity analyses had similar findings. CBT was statistically superior to pill-placebo in the studies using HAM-D Haritonov Sergey Führung für CBT an outcome standardised mean difference The authors conclude baseline severity has little influence on efficacy of CBT.
They state that this is potentially in contrast to the relationship between depression severity and efficacy of antidepressant medication. In addition, Furukawa et al. Study level meta-analysis suggests the effect size for antidepressants over pill-placebo may be greater than the effect observed for CBT Turner et al.
Haritonov Sergey Führung für CBT study is most impressive in successfully accessing data from all RCTs that met their inclusion criteria. The methodology applied appears to be the most appropriate use of this data, however the authors admit the study may be underpowered to detect an interaction effect.
The conclusion that baseline severity does not influence Haritonov Sergey Führung für CBT effects may therefore represent a type II error. The authors also state that they ignored some of the design features of the original RCTs, such as inclusion of specific depression Haritonov Sergey Führung für CBT, primary care patients, pre-randomisation run-in treatment or differing treatment lengths.
Some of these features could differentially effect the association Haritonov Sergey Führung für CBT baseline severity and treatment response. Other limitations, Haritonov Sergey Führung für CBT as the need to combine different HAM-D and BDI scales and the lack of detail about multiple imputation and missing data have already been discussed. Beyond these issues, there is no mention of a protocol for the meta-analysis, and more extensive use of online supplements may have be useful to clarify differences in data from each included RCT.
Other differences in study design or patient characteristics may be important for CBT response. It is concerning when different methodological approaches give Haritonov Sergey Führung für CBT answers Haritonov Sergey Führung für CBT the same question.
It may be that it is not possible to accurately investigate the effects of baseline differences in patient characteristics using study level information in fact, this may be a form of ecological fallacy and individual-participant level data is required. To improve evidence-based practice, pooled individual-participant data needs to become the norm, and this paper is a good example of appropriate data sharing.
This click to see more of meta-analysis becomes immediately biased if access to original data is limited. Additional problems may arise if the required data is historical or the lead authors are not world-renowned psychiatric epidemiologists with considerable sway over their fellow researchers!
Pooling data in IPD-MA is a powerful method of generating evidence, however we need to Haritonov Sergey Führung für CBT its potential limitations. Joseph Hayes is a trainee editor at the British Journal of Psychiatry.
He has never received drug company funding. The British Journal of Psychiatry. Undertreatment of people with major depressive disorder in 21 Haritonov Sergey Führung für CBT. Dowrick C, Frances A. Initial severity and antidepressant benefits: A regulatory Apologia—a review Haritonov Sergey Führung für CBT placebo-controlled studies in regulatory submissions of new-generation antidepressants.
Initial depression severity Haritonov Sergey Führung für CBT response to antidepressants v. Does pretreatment severity moderate the efficacy Haritonov Sergey Führung für CBT psychological treatment of adult outpatient depression? Efficacy of cognitive—behavioural therapy and other psychological treatments for adult depression: The effects of psychotherapy Haritonov Sergey Führung für CBT adult depression are overestimated: The problem of the placebo response in clinical trials for psychiatric disorders: Rating scales in depression: Dialogues in clinical neuroscience.
The prevention and treatment of missing data in clinical trials. New England Journal of Medicine. Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs Haritonov Sergey Führung für CBT Selective publication of antidepressant trials and its influence on apparent efficacy. Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: From effect size into number needed mit Reaktionen bei Psoriasis treat.
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Social Behavior and Hormonal Correlates during the Perinatal Period in Japanese Macaques.
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They advocate for the use of psychotherapy, in particular cognitive behavioural therapy (CBT), in people with mild/moderate depression.