Is mental illness curable by CBT?

The report from The Centre for Economic Performance (mentioned in my last post) boldly states that mental illness is curable. To support this claim it references three papers – Layard et al (2007), Clark (2011) and Gyani et al (2011).

Layard et al (2007) calculated the expected improvement in employment rates from CBT treatment, and estimated this to be on average about one month for each person in 2 years. They emphasise that they are not claiming huge effects and go on to give estimates of the reduction in numbers of people on benefits from the introduction of IAPT, saying that the programme will easily pay for itself. I'm not sure if they'll get the opportunity to show whether the programme has met these targets.

Clark (2011) describes the national programme for IAPT including the results from the two pilot demonstration sites. He emphasises that the demonstration sites were not set up as randomised controlled trials. It is therefore not possible to exclude the possibility that improvements may have been due to natural recovery and self-fulfilling expectancy effects. 

Gyani et al (2011) analyses data from the first year of the IAPT programme. They note that people can get worse in treatment as well as better. Considerable between site variability  in overall recovery rate between 27 and 58% was found  (median 42% - approaching target of 50%). "Recovered" does not equal symptom free. Nor is it clear that any apparent benefits can be maintained over the longer term.

In reality, this literature is insufficient to substantiate the statement about the curability of mental illness as such. As I said in my last post, I’m not wanting to undermine optimism in treatment, but we do need to be realistic about the evidence. Otherwise, scientific expertise is merely being exploited for political ends. 

Of course people do recover from mental illness, but this might be a difficult, slow, costly, painful and sometimes incomplete process. Promoting CBT as a panacea is no different from pharmaceutical quackery. 

Need to be realistic about value and effectiveness of psychological therapy

David Clark's comment in the Guardian is headlined to say that psychological therapies are highly effective and save money. Steady on! As with medication, we all want a simple, quick, cheap, painless and complete cure of mental health problems. It's important to be hopeful about the outcome of treatment, but we also need to be realistic (eg. see previous blog entry How easy is it to treat depression?).

What Clark doesn't mention is the difficulty of measuring the effectiveness of psychological therapy. Expectancies affect the outcome of clinical trials and can't be controlled by double-blinding, as subjects know whether they receive the active treatment or are in the control group. There is a real issue about the adequacy of control groups (eg. see my BMJ letter).

His claim about saving money relates to the report from the Centre for Economic Performance. Lord Layard has been very influential in getting the Improving Access to Psychological Therapies (IAPT) initiative introduced into the NHS. We need evidence that IAPT has helped the economy before making such a claim.

Psychiatry is a medical speciality

I've been thinking about the motivation for the move to a remedicalised psychiatry, which I've mentioned several times previously (eg. see previous post). What psychiatrists are worried about is that their job seems to be being taken over by non-medical professionals.

I gave up my medical training for 8 years because I found it difficult to see the need for medical training in psychiatry. However confused this decision was, it does mean I am speaking from experience on this matter.

We should welcome other professionals taking on consultant roles, including being responsible clinicians under the Mental Health Act. However limited in practice this development has been so far, it is happening in other areas of medicine besides psychiatry. It offers more choice to a patient to be able to see a consultant from another profession, such as nursing or clinical psychology. Other professions should be encouraged to take on the responsibility which has traditionally been undertaken by the doctor.

Other professionals have always had a central role in managing patients in hospital. This continues to be the case with care co-ordination in the community.

None of this means that medical training is not of value for psychiatry. This is because many physical complaints have a psychogenic origin. In fact, as argued by Bill Fulford and others, psychiatry could be seen as the pre-eminent medical speciality because practice is so obviously determined by values. This may be more hidden in the rest of medicine but a focus on the person is inevitably central.

In particular , none of this justifies retreat into a biomedical psychiatry. In fact, it was the disease-centred nature of biomedicine that put me off understanding the medical nature of psychiatry when I was younger.

The editor of British Journal of Psychiatry agrees with me

The editor of the British Journal of Psychiatry, in his latest "From the editor's desk", has said he would not have contemplated becoming a psychiatrist if psychiatry had been a branch of neurology, which is relevant to a previous post. He has recently been at a conference in Belgrade "where speaker after speaker predicted the demise of our profession or its absorption into neurology or some other discipline, as the funding for mental illness and respect for psychiatrists gets progressively less". This is again relevant to another previous post. 

Like me he's disturbed by these trends. Let's hope he's right to be optimistic nonetheless.

Phil Barker on front cover of British Journal of Psychiatry

Considering his views about psychiatry, who would believe Phil Barker has his self-portrait on the front cover of the British Journal of Psychiatry, albeit under his painter's pseudonym of Phil McLoughlin? I have mentioned Phil in a previous post and contributed a chapter to his edited book Mental health ethics. He spoke at the first Critical Psychiatry Network conference I organised in Sheffield in 2001.

Not surprising that premature babies have higher psychiatric risk

The authors of an article in Archives in General Psychiatry, linking prematurity and admission to psychiatric hospital, are reported by Reuters as saying that the "increased risk may be down to small but important differences in brain development". Just finding an association does not mean that there is necessarily a causal link. The association may be related to a third factor. For example, prematurity is associated with social class, as is psychiatric admission. Social class may be more of a causal factor producing both prematurity and psychiatric admission. 

Of course the researchers know this. In their paper, they say "the association between preterm birth and psychiatric outcomes may be confounded by risk factors, including unmeasured sociodemographic and lifestyle factors (including ethnicity and socioeconomic status) ...". However, the bias to place a biomedical, rather than social, interpretation on such results is illustrated by this example. The finding of an increase in psychiatric admissions in those with premature birth should not be surprising because of the link through social deprivation.