Talking heads: some thoughts on the Lancet study of therapy for schizophrenia

There was a LOT of attention yesterday given to a study that came out in the Lancet on the effectiveness of cognitive therapy for people with Schizophrenia. The NIHR press release for the study proclaimed:

Researchers from The University of Manchester have shown cognitive therapy can be used as a safe and acceptable alternative treatment to for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs.

The study, funded by the NIHR Research for Patient Benefit Programme, aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs.

The reaction was largely very positive, with praise for the finding that ‘talking therapies’ should be offered to patients who don’t want to take medication. The release of the paper coincided with the #TimeToTalk campaign on twitter, which was a campaign encouraging people to talk to each other about their mental health problems, so there were lots of delighted tweets and posts pointing out how the study shows the therapeutic power of talking itself. The issue of medication is always a hot topic as well, with emotive takes both from those who see mental health services as too focused on compliance to medication and those who criticise ‘pill shaming’ and the implication that taking medication is some kind of cop out. In this case, lots of the tweets I saw seemed to focus on the fact that these were patients who had chosen not to use medication, and who often might then not be offered any alternative treatment.

Unfortunately, the study doesn’t really show that talking is “as effective as drugs” (as the BBC headline put it).  I won’t repeat the full list of criticisms here – the Mental Elf website, as ever, offers a balanced and informative summary of the study and of its limitations, and check out the comments as well for further points. For me, the crucial problem is in the choice of groups to compare – to make statements like “therapy is as effective as drugs” you should compare people who just get therapy to people who just get drugs, but this isn’t what happened. This isn’t a limitation of the study per se, but of the interpretation of it, and I personally think the commentary on the article – entitled “Cognitive therapy: at last an alternative to antipsychotics?” over states the findings somewhat. I do think it should be pointed out though that the authors acknowledge in the paper that this is a first step and they are planning on doing a bigger and hopefully more definitive trial.

I did find it intriguing that so many people were so quick to praise the study and to see it as ‘evidence’ that therapy should be offered instead of drugs. I think this perhaps speaks more to the perception (and reality!) that psychological therapies are harder to access, so any encouraging findings about therapies are leapt on. The side effects of anti psychotic drugs are also very damaging and the study was extra appealing because it seemed to demonstrate that therapy is a valid alternative to those drugs.  I think the eagerness to hear and report those bigger messages, about the right to have access to psychological therapy and the right to have refuse medications and receive alternatives, might be responsible for the enthusiastic reception of the study and perhaps also the anger that greeted those who critiqued it (check out the comments under the Mental Elf blog. There’s a FRENZIED CABAL against CBT I tellsya!)

One last point – one thing that sticks out for me in this debate is how ‘talking therapies’ or psychological therapies are often easily painted as ‘the good guy’ in comparison to medication, and we perhaps underestimate that they have risks and costs just like medications do. I remember a patient using CBT in a study I was on who described the huge burden and stress of going through the treatment – she described it as “a test of strength.”  This is important because we know that not everyone will get better when they use CBT, and so we’re always putting some people through this ‘test’ who actually won’t get any pay off. I think in psychological therapies it’s easy to assume that at worse someone will have had a few hours chatting to a nice therapist lady, even if it doesn’t change their mental health symptoms. I think this is a mistake. Any treatment has costs, financial and personal, and talking therapies are no different. We shouldn’t assume that just because it’s not a drug, it can’t have side effects.

Now if you’ll excuse me, I think I have a cabal to join. 😉

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2 Responses to Talking heads: some thoughts on the Lancet study of therapy for schizophrenia

  1. henrystrick says:

    Thanks for a thoughtful and sure-footed summary! Only thing I missed is that in the context of pointing out that the trial in fact did *not* compare CBT with antipsychotics, despite the headlines: although the participants were selected as refusing to take antipsychotics, more than half of those followed up *did* take antipsychotics during the trial – and those getting the antipsychotics improved more than the non-drug-takers…

    Declaring an interest: I’m of course a cabal member! 🙂

  2. Pingback: Find The Gap: Or, why researchers squabble so much. | saraheknowles

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