Here I discuss topical issues in developmental psychiatry.This is the fifteenth “blog posting” in a series to be posted fortnightly on Fridays for a trial period of a year. Some of the postings are quite technical, so interested non-professional readers might want to discuss them with their GP, or a patient group such as AADD-UK, ADDISS or DANDA, or with myself.
6th August 2010
“No”
to the knife, “Yes” to Ritalin?
Obesity surgery has grown in the UK, as it has worldwide. But unless it
can be shown that it saves money which could be transferred from elsewhere
(diabetes care, for example), less than 5% of eligible patients might receive NHS operations
in the next few years.
With couple of internet searches, today I found plenty of
advertisements for self-funded surgery, including centres in India and Central
America. The demand is clearly huge.
On Wednesday this week Joan Bakewell’s Radio 4 medical ethics programme
addressed the previously little-publicised problems with obesity surgery (1). In particular, careful follow-up is needed
as banding operations may need to be repeated or redone. For patients who go
abroad, continuity of care may be less than optimal if they need to turn to the
UK NHS later.
A study published last year (in a Nature group journal) suggested
ADD / ADHD may be a significant, and treatable, cause of obesity (2). One third (78/242) of patients in an independent
Toronto weight loss clinic were found to have ADD / ADHD, and with treatment
they lost 10% of body weight. That is as good as obesity surgery.
More research is of course needed, but I find the idea that some people
with ADD / ADHD overeat makes clinical sense. Many of my patients, successfully
treated, get on with their lives more effectively, and find they “snack” less.
Because the underlying dissatisfaction and discomfort is reduced, so is the
need for “comfort eating”.
In my view this treatment effect is separate from the “appetite
suppressant” effect, which is often transient anyway, of medications such as
methylphenidate and amfetamine.
Interestingly, another large study on obesity, recently published in The
Lancet(3), showed good
results for a medication combination which included bupropion (available in the
UK only as the smoking cessation drug Zyban, but more widely used in the US for years).
Bupropion is thought by many developmental disorder specialists to be effective
in ADD / ADHD.
I am sure we will see many overweight and obese people in the UK
considering whether they might have ADD / ADHD. Surely having assessment and
possibly treatment in London is a reasonable thing to try, before flying off
for surgery in Cancun or Delhi (4)?
(4) No disrespect to Mexican or Indian surgeons intended at all. The
point is about continuity of care. It also seems possible to me that people
with severe ADD / ADHD might have a poor outcome with apparently successful surgery:
I understand this is not uncommon.
23rd July 2010
Does NHS “General” Practice support adequate assessment and treatment of mental and behavioural problems?
I have never met anyone working within the NHS who believed that more than a minority of UK general practitioners have a great interest in mental health issues. As a trained and qualified GP myself, I have much affection and regard for my non-specialist colleagues. But unfortunately because their views are often so much in line with mainstream opinion (hence those persistently high “public trust” ratings?), that can sometimes include a dismissive approach to human frailties.
A confidential survey of GP’s, published last week by the leading mental health charity Rethink, appears to have confirmed this (1). The new government wants general practitioners to decide on funding priorities for specialist services, and over three quarters are happy to do this for physical conditions, but less than a third want to be involved in mental health.
This is despite GP’s having a very negative view of existing specialist mental health services. When asked “To what extent would you feel confident in the quality of care one of your relatives would receive if they were referred to the appropriate NHS services” only 50% said they would feel confident for depression (as against 92 – 95% for physical conditions). For obsessive-compulsive disorder (OCD) the figure was 32% and for post-traumatic stress disorder it was a miserable 22%.
I don’t blame GP’s for not wanting to take on the re-funding of NHS mental health services. To do so in the current financial climate would probably mean advocating cuts to clinical services for physical conditions, which would be deeply unpopular. Privately, many of them support their better-off patients seeing independent non-NHS specialists, which in itself at least expresses a degree of discontent with the current situation.
But keeping this issue at arms length might lead patient groups to further question the ordinary good sense, even the fairness, of general practitioners. Rethink continues to highlight a previous survey as showing that “23% of people with mental illness report experiencing discriminatory treatment from GPs” (2). It could be a good time for the minority of GP’s with a special interest in mental health issues to become a majority.
The beautiful game: Americans can play (and watch) too
Writing in TheHuffington Post, an American novelist has stated that football will never catch on in the United States, because it is too boring to watch (1). “American sports fans…crave the excitement presented by the chance of a score on every play.”
One of his European readers responds by suggesting that high rates of ADD / ADHD might account for this drive towards instant gratification. But is it true, anyway, that people in the United States generally lack restraint, live more “in the moment”, thoughtlessly follow their impulses and desires?
If so, the US would, for example, have higher rates of alcohol and substance misuse compared with other cultures. Recent large-scale studies do not confirm this (2). The best physical indicator of alcoholism, cirrhosis of the liver, is still much more common in supposedly non-impulsive France (3). Moreover, despite a steady fall in the real price of alcohol, and relentless promotion (not least within sporting events) both overall alcohol use and misuse have declined in the US over recent decades (4).
The sport of the aspiring American businessman is golf, and US television ratings for major tournaments indicate an abundance of patience to follow such events over four days, far in excess of a ninety minute football game.
This Sunday the world cup climaxes. If the USA team had gone even further than the last sixteen (drawing against England), if they were playing against the current European champions, Spain, in the final, would football have become more of a credible spectator sport for Americans? I think so.
(2) McBride et al (2009): Further evidence of differences in substance use and dependence between Australia and the United States. Drug and Alcohol Dependence
(3) World Health Organisation (2004 figures – published 2009)
(4) Zhang et al (2008): Secular Trends in Alcohol Consumption over 50 Years: The Framingham Study. The American Journal of Medicine . This study found that “heavy” use had declined, but not alcohol dependence.
25th June 2010
Dyspraxia, or developmental coordination disorder (DCD)
Last weekend I was asked a difficult question: “do you diagnose dyspraxia?”. My answer can hardly have inspired confidence: “well, I never have, but I’m thinking of doing so in the future.”
The question came in a workshop (1) I was giving at the annual conference of DANDA (Developmental Adult Neuro-Diversity Association), an organization which supports the concept of dyspraxia in adults, alongside the much better-known conditions of autism, ADD / ADHD and dyslexia.
I think I have only seen one or two people with a main diagnosis of dyspraxia, as compared with at least a dozen with dyslexia. DANDA recognises that many people have different combinations of these developmental conditions, and the conference was, for me, a useful opportunity to catch up with some of the literature (2) on DCD (developmental coordination disorder, as some prefer to call it).
The problem, from DANDA’s point of view, is that very few specialists are prepared to diagnose dyspraxia in adults. Talking with the workshop participants, I began to see how, although many people with dyspraxia have interpersonal and organisational issues which I would usually see as either falling into the autistic spectrum on the one hand, or ADD / ADHD on the other, the “dyspraxia” concept is most meaningful for them. Perhaps this is because problems are experienced as much more within the body, and not just the mind.
Anyway, in the closing discussion I did give something of a promise that within six months I would be able to give a more definite “yes or no” answer to whether I diagnose DCD. For the moment my “official” position is “maybe...but do you think you might have anxiety, depression, ASD, ADD / ADHD...etc...as well?”
(1) “Managing anxiety and depression in neuro-developmental disorders” Workshop at DANDA annual conference, London, Saturday June 19th 2010
(2) Such as Living with Dyspraxia: A Guide for Adults with Developmental Dyspraxia (2006) by Mary Colley
11th June 2010
The reality of NHS adult ADD / ADHD services
Yesterday I attended the second annual meeting of UKAAN (UK Adult ADHD Network), which is led by academics and funded by a leading pharmaceutical company (1).
It was very interesting to hear how local NHS adult services, all English, were coping with increased referrals of patients. What seems clear is that many people are screened out, often by so-called “gateway workers”, who tell patients that they do not “meet the criteria”.
When the NICE guidelines came out, I wondered if patients with ADD / ADHD would often be found to not “meet the criteria” on the basis that their condition was “only” mild. However, it looks as though a lot of mild and moderate ADD / ADHD is simply being diagnosed as “no ADD / ADHD”.
I have already seen many people with moderate-to-severe disorders, who should fall within the NICE guidelines, but have been told that they should stop “medicalising their past failures” and just get on with their lives.
The President of UKAAN, Professor Phil Asherson, told the meeting that in many areas services are being closed. This means that people who have been on waiting lists for months may end up being told that they will not be seeing a specialist after all.
I will be suggesting to ADDISS and AADD-UK that they consider telling their members and supporters about the reality of all this in greater detail and that, for those who can afford it, paying to see an independent specialist may be the best option for at least the next 2-3 years (2).
(1) There appeared to be no promotional activity at all within the meeting itself.
(2) “2-3 years” is based on the wide perception of how long the most intense NHS spending restraint may last.
28th May 2010
Panorama’s bad news still buried
An article in Education Guardian this month(1) received some interesting online responses, two of which pointed out that Ritalin (methylphenidate) has been used clinically in ADD / ADHD for fifty years. There did not seem to be overwhelming agreement with The Guardian’s scourge of health misinformation Ben Goldacre, who has stated “Big Pharma is evil”(2).
There was, however, little picking up on the valid concern expressed in Are drugs the solution to the problem of ADHD among young people? that NHS specialists who diagnose and prescribe may be forced to cut corners in their assessments and monitoring(3). Just one parent with an ADD child, and a mixed experience of services, posted on this: “The best treatment involved regular visits to the psychologist (every 6 -8 weeks) with ALL the family so we could all work out what was working and what was not.”
Unlike the BBC, The Guardian is free to be opinionated. Even so, it is disappointing that all the paper’s print and online articles mentioning ADD / ADHD continue to avoid reference to Panorama’s two programmes on this topic, both of which had complaints upheld against them. The more recent one was found to be “unfair and not openminded”, resulting in a rare on-air apology (4). Given the BBC’s massive online and broadcasting influence, and Panorama’s “flagship” status, this seems to be essential context for understanding public and professional attitudes to ADD / ADHD.
I was also concerned that an academic educationalist who does not “acknowledge that ADHD is even a medical condition” because “You can't do a blood test to check whether you've got ADHD” appeared to go unchallenged. Epilepsy, bipolar disorder, migraine, schizophrenia and depression all lack definitive physical tests, and may improve with psychological treatments, but does that mean no one should ever take medication for these conditions?
As the online responses to this article showed, Guardian readers should not be stereotyped as simply following the line that mental and behavioural disorders are, in general, just “marketing” tools for pharmaceutical companies.
(2) Bad Science (2009, paperback edition) page 201. From the context, Goldacre appears to be half-joking.
(3) See “Critical Psychiatry”, 2nd April 2010, below
(4) See my postings on Panorama, 5th and 19th March, below
14th May 2010
Bright teenagers: at risk for what?
A recent study from Sweden, published in the British Journal of Psychiatry (1), appears to confirm a link between high ability and bipolar disorder. Over seven hundred thousand teenagers were followed up to see if they were admitted to psychiatric hospital in their twenties and thirties. Then their school examination grades at 16 years were compared with those of the other students who had not developed such severe mental and behavioural problems.
The adults with bipolar disorder had done better in exams as teenagers, especially in humanities subjects such as Swedish and History (but not Art). Those who had been good at Sport seemed to have a lower chance of developing bipolar disorder later.
This is an interesting study which is in keeping with the suggested link between bipolar disorder and creative ability. However, it does not mention the possibility that adult ADD / ADHD, which also can sometimes lead to hospital admission, may have been the real problem in many cases. Like much research of this kind, the diagnosis was made a long time ago (1988 – 1997), when there was even more scepticism about adult ADD / ADHD than there is now (2).
(2) For an example of how creative ability may be linked to ADD / ADHD, see my 5th February Blog piece on Vincent Van Gogh.
30th April 2010
"Nutters", "Fruitcakes" and "Loonies"
Nick Clegg has apologised for using the word “nutters” to describe the conservatives’ East European allies in the 22nd April leaders’ debate: ''I am acutely aware that the stigma of mental health causes great distress to many people and my use of language that could be considered derogatory was entirely unintentional.''
This seems a bit strange, because much of the language used in these events is pre-planned. Also, only four weeks before the debate, the mental health charity Rethink obtained an agreement from Mr Clegg, together with the other leaders, not to use “mental health slurs” during the election campaign (1).
Less than a year ago the former Labour minister, Denis MacShane, made exactly the same point about the Conservative allies, but using the more derogatory “loonies and wierdos”. This was in the House of Commons, where there appears to be a guideline against “insulting, coarse, or abusive language”, but perhaps significant is the qualification “particularly as applied to other Members [of Parliament]” (2).
Back in 2006 David Cameron talked about UKIP as being “fruitcakes, loonies and closet racists, mostly”. UKIP’s Nigel Farage demanded an apology over the racism allegation, but interestingly he said that “fruitcakes and loonies” was fine, because “we have a sense of humour”.
So Nick Clegg may have thought that his own language was an improvementon “loonies”.
(2) Some Traditions and Customs of the House: House of Commons Information Office. January 2009
16th April 2010
How mentally healthy should mental health professionals be?
People drawn to the “helping professions” are often seen as having problems of their own. Whether this is really true, in a clinical sense, for just a few individuals or more widely is difficult to know.When I first had experience of psychiatry as a student in the mid-1980’s this was a fairly common subject of discussion.
It seems to have gone more underground now, presumably as a result of thewidening of the “worried well” concept in official NHS thinking. Psychiatrists, psychologists, nurses and others may be less willing to risk being seen as self-obsessed whingers, when they work in services focused on “severe and enduring illness”.
Will ADD / ADHD prove to be any easier for us to be more open about? With 2 million adults in the UK having the severe or moderate condition, and another 8 million with less clearly defined milder problems, the numbers are similar to common disorders such as depression and obesity.
For someone like myself, now working independently, it is relatively easy to acknowledge mild ADD, which has probably been a causative factor for depression in the past. I have not had major symptoms for nearly two decades, and believe that I have developed mental resilience. However, given that most of my current practice comes from the growth in adult ADD / ADHD, a semi-experimental trial of a non-stimulant remains a possibility.
But for those still working in the NHS, a more cautious approach might be wise, especially at a time when spending cuts and political rhetoric create uncertainty. Managers keen to prove themselves as more than pen-pushing bureaucrats can respond to “stop moaning” calls from the top (1) in unpredictable ways.
Unlike the BBC’s Panorama (1), The British Medical Journal (BMJ) gives space to a wide range of views on mental health and behavioural disorders. An article on adult ADD / ADHD last week is an example of how polarized debates can become. One side repeated, as fact, Panorama's “unfair and not open-minded” opinion on the poor long-term outcome for medication in ADD / ADHD (2).
The BMJ published my own comment online (3), pointing out the need to test and monitor new nurse-led adult ADD / ADHD diagnosis and treatment (4). Of course, the Department of Health is quite right to look for the most cost-effective ways of delivering services, and nurses bring their own distinct and valuable skills to a wide range of clinical settings. But I have already had two conversations with specialist NHS nurses working with children and teenagers, who were concerned at being pushed into taking on too much responsibility too soon.
“Critical Psychiatry” is generally skeptical about all “medicalisation” of problem emotions and behavior. So it seems a bit odd to me that the authors of this piece attacking adult ADD / ADHD suggest that “more established diagnoses…depression, anxiety, and modern conceptions of bipolar and bipolar spectrum disorder” be kept in preference.
This does, though, raise a further question about clinical specialists. Why should adults with “non-established” ADD / ADHD have less direct access to NHS psychiatrists and clinical psychologists, than people with “established” conditions? Surely it is more logical that they have more?
The BBC’s recent bad news, about Panorama’s flawed ADD / ADHD programmes (1), seems to have been buried by the general pre-election media coverage. I have been assured that the BBC Trust’s delayed decision (itself still a subject of the complaints process) was not deliberate “news management” timing; but myself and ADDISS did find it interesting last year that the initial recognition of a problem with the 2007 programme was made public in early August (2), a traditionally quiet time when press releases often don’t get followed up.
Therefore it may take some months to discover the changes, if any, to the way mental health and behavioural disorder issues are now dealt with by the BBC.
For me, the problem with the 2007 programme (3) was not just the one-sided presentation of research on medication. It was the avoidance of any exploration of why Craig, the teenager whose ADHD and perhaps other problems caused him to end up in Court, was not receiving any input from local NHS services. No local professionals or managers were questioned (they were in the 2000 programme), and the interview with NICE’s Dr Tim Kendall was extremely limited.
By making the overall issue about medication, rather than local services, the 2007 programme in effect promoted the Department of Health’s policy that specialist mental health services are focused on “severe and enduring” problems, and can therefore exclude moderate and mild ones. This policy has now been in place for nearly two decades and has undoubtedly removed billions of pounds from the DOH’s “frontline services” balance sheet. However, many ADD / ADHD specialists believe that failure to intervene earlier, in these less severe disorders, results in substantial financial costs later in terms of underemployment, prison places, and adult mental health problems. Dr Kendall might have been asked some difficult questions on NICE's narrow money-orientated evaluation process, but that didn't happen.
Perhaps Panorama has unbroadcasted material which would throw light on all this. A fuller review of the reasons for the “unfair and not open-minded” programme might also include emails and other communications from and to the Department of Health (4).
(3) The BBC Trust ordered the programme to be removed from the BBC website. Today, weeks later, I was still able to view it at http://www.bbc.co.uk/accessibility/win/hearing/alt/panorama/sub_3.shtml . It has also been placed on YouTube as “A Panorama report on the life of a young child hooked on medication prescribed for his so called ADHD condition. “
(4) I remain open to a range of explanations for the problems with the programmes; and I am not suggesting that Panorama deliberately colluded with the Department of Health, to be misleading.
5th March 2010
The flagship investigators need further investigation – but perhaps help and support as well
The BBC Trust has ruled that Panorama, in its 2007 program questioning ADHD medication, was "not fair and open minded"(1). It has ordered an "on air" apology: Panorama’s first in years (2). The headline message is that the Trust has handed out a strong reprimand.
But the Trust also says that viewers were not deliberately misled: the program makers could have "misunderstood the underlying material". I think that families and patients affected by ADD / ADHD will find this contradictory: how can a lack of fairness and open-mindedness arise solely from a misunderstanding?
It appears even less credible when the experience of the journalist involved is taken into account: on the Panorama website Shelley Jofre is presented as a specialist in this area who has made many programs, "instrumental in forcing an overhaul of how drugs are prescribed". In a “meet the team” video the risks "when you take on a major multinational drug company" are said to be just part of the job. The 2007 complaint pointed out that the ADHD program was a follow-up to one made in 2000, about which Panorama had, years ago, accepted a previous complaint was valid (and the “flagship” Panorama rarely concedes error). No mention is made of all this in the BBC Trust’s written reasons for its finding of a possible misunderstanding: the impression given is of a single rogue episode.
Many people who have sought diagnosis and treatment for their children with ADD / ADHD have been angry about these programs, feeling that they were portrayed not only as gullible dupes of the pharmaceutical companies, but also, by implication, as bad parents. I doubt that they will be happy with the BBC Trust’s decision to close the matter by having a quiet word with the BBC’s deputy director-general.
However, I have a degree of sympathy with the Trust’s implied view that the underlying issues are difficult to understand. As a non-academic adult psychiatrist I still find that the MTA (3) study of pre-teen children with ADHD, which generated dozens of published papers, does not reveal its meaning easily. I think I understand that the follow-up study was always likely to be difficult to interpret, given that the patients in the treatment groups were no longer encouraged to stick to their randomly assigned treatments (medication, behavioural, and “treatment as usual”). But even after the BBC Trust’s investigation I am still unclear why Professor Pelham, the psychologist who was co-author of the study, and whose views on the poor longer-term outcome of medication were ruled to have been given undue emphasis, appeared so confidently to disagree with his psychiatrist co-authors, when I understand that he had not done so in print.
Therefore I think Panorama should make available the video of its full interview with Professor Pelham, as well as other material, because it may still have relevance for how we interpret the MTA study and the follow-up. We might even see whether Panorama had the potential to make a good and genuinely interesting program, rather than the flawed one, which is regarded by many people as simply biased. If parent and patient groups want now to see a deeper enquiry or review, of all Panorama’s mental health related output, I would support that.
But I think it should be kept in mind that poor journalism and editing might be due to other causes than ordinary bias. I was unable to find any research directly bearing on precisely this context, but a comprehensive study of war reporters (4) has shown that substance misuse, depression and post-traumatic stress disorder (all problems that might even be linked to ADD / ADHD) are more common than in “ordinary domestic” journalists. Shelley Jofre’s “taking on the pharmaceutical Goliath” video might not exactly indicate the “macho values” which draw people to conflict zones, but she does talk about the “sleepless nights” that her work brings.
(2) I was unable to find mention of a previous Panorama apology on the BBC website. Incidentally, I could find no mention either of the BBC Trust’s findings on the Panorama website, which continues to state that the 2007 program “reveals that new research shows giving children drugs for ADHD works no better than doing nothing in the long-term.”.
(3) Multimodal Treatment Study of Children with ADHD: background explained in the BBC Trust report
“Autism is a serious, lifelong and disabling condition” (1) according to the chief executive of the National Autistic Society (NAS), which continues its excellent work in raising awareness about developmental disorders. But I wonder sometimes if this all-or-nothing headline message might discourage people from seeking treatment, when they see themselves as having milder problems.
The idea that autism is a spectrum not just of how it presents, but also of how severe it is, shading into normality in both respects, has been around for a while now. I have recommended Simon Baron-Cohen’s book The Essential Difference to several patients, because I thought it might be helpful to see how one leading researcher into autism views this issue.
It is likely that there are many people who are functioning, perhaps working, but not really doing very well, who probably have mild autistic spectrum disorders. Traditionally, psychiatry has assumed that “perfectionism” or “rigidity” are fixed and untreatable personality traits. This has been challenged by many studies now, and this week a report from researchers in Lyon, France (2) adds to the evidence that medications can improve the core features of autism.
Treatments (or “interventions”) in severe or moderate developmental disorders do not usually cure in the sense of moving the features of the condition into the spectrum of “normality”. A change from severe to moderate, or moderate to mild, would be considered a good response. But by starting off with a mild disorder, and moving towards normal functioning, whatever that is, you might have good reason to think that you had been cured of your disability.
In a letter, written in English and currently on display in London, Van Gogh describes procrastination and hyperfocusing:
"My dear Russell…for ever so long I have been wanting to write to you – but then the work has so taken me up. We have harvest time here at present and I am always in the fields…when I sit down to write I am so abstracted by recollections of what I have seen that I leave the letter. For instance at the present occasion I was writing to you and going to say something about Arles as it is…instead of continuing the letter I began to draw on the very paper the head of a…little girl I saw this afternoon whilst I was painting a view of the river with a greenish yellow sky."
There is also a suggestion of the regret and self-blame which many adults with ADD / ADHD experience:
"I enclose the slip of scribbling, that you may judge of my abstractions and forgive my not writing before as such."
Van Gogh calls his subjective inability to control and focus attention his "abstractions", and he refers to this again towards the end of the letter:
"I must hurry off this letter for I feel some more abstractions coming on and if I did not quickly fill up my paper I would again set to drawing and you would not have your letter."
Biographies of Van Gogh do not provide much detail of his earliest childhood years, but in his late teens and twenties he certainly showed a restlessness and impulsivity in work and relationships which would be compatible with ADD / ADHD. A more difficult question is whether treatment, in perhaps enabling him to combine his artistic talents with just a little commercial success in his lifetime, would have dulled his creativity. I don’t think so, because that is not what ADD / ADHD treatment appears to do, when used properly.
The letter to John Peter Russell, written in April 1888, can be seen in Room 6 of the Royal Academy in London until 18 April 2010. It is a good idea to book in advance for the exhibition, called The Real Van Gogh: The Artist and His Letters.
22nd January 2010
The pursuit of Happiness
Exactly five years ago, at 10 Downing Street a group of politicians and academics came together to discuss how to improve the well-being of the British people.
Professor (Lord) Richard Layard had written a paper for the meeting: in it he noted how NHS funding in mental health had been reduced for less severe but still disabling conditions, and that many of the two million people who were receiving medication from non-specialists, in consultations of just ten minutes (still standard in general practice today), were keen to try psychotherapy.
Previously, in his 2004 book Happiness Professor Layard had suggested that UK income tax should increase to the levels of other West European countries, because higher taxes increase happiness, by discouraging people from working too hard. The French, at least, seem to have disagreed by voting for Nicolas “work harder and earn more” Sarkozy as their President in 2007.
Following the Downing Street seminar, new funding over 2009 – 2011 means that more people will be able to receive NHS cognitive behavioural therapy (CBT). But at least two questions remain. Firstly, the referring GP’s consultation will still probably be only ten minutes, so will the newly-trained CBT therapists adequately assess the patient’s diagnosis? As Professor Layard himself noted “…it is estimated that GPs misdiagnose mental illness at the first GP visit on a third of occasions”.
Second, is CBT really as evidence-based as claimed?(1) Parts of the Layard group’s glossy The Depression Report: A New Deal for Depression and Anxiety Disorders sound rather similar to the “sales talk from drug companies”(2) which the Professor noted in his seminar paper. CBT is “new...forward-looking” rather than “backward-looking”, “short” as opposed to “endless”. There are “Hundreds of clinical trials” mentioned, without making it clear that this includes therapies other than CBT; or that only recently have psychotherapy trials begun to be registered in advance, so we cannot be sure how many negative trials up to 2006 remain unpublished.
In private, many clinical psychologists agree that CBT has been hyped. I must get round to asking them what they think about higher taxes as therapy.
(1) As I said in my talk at the April 2009 ADDISS conference, I would generally encourage anyone who is offered CBT on the NHS, to try it. I will look at why people with developmental conditions might do less well, or even be harmed, by “standard” CBT in a future posting.
(2) In fact, I doubt that any 2005/6 pharmaceutical marketing material would have been so “hard sell”.
The documents referred to can be found on the LondonSchool of Economics website.
