Long Term Efficacy of CBT?

I get email updates from several places I consider reasonably reputable, like NEJM, that have lists of new and interesting articles. I consider those kinds of updates helpful ways of staying current. I also get other kinds of email updates that feel more like ads, or infomercials, like this one, from Psychiatric News Alert:

Study Finds Long-Term Benefits of CBT for Patients With Treatment-Resistant Depression

Patients with treatment-resistant depression who receive cognitive-behavioral therapy (CBT) in addition to antidepressants over several months may continue to benefit from the therapy years later, according to a study in Lancet Psychiatry...

“Our findings provide robust evidence for the effectiveness of CBT given as an adjunct to usual care that includes medication in reducing depressive symptoms and improving quality of life over the long term,” the study authors wrote. “As most of the CoBalT participants had severe and chronic depression, with physical or psychological comorbidity, or both, these results should offer hope for this population of difficult-to-treat patients.”


You can link to the Lancet Study, Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial, by Wiles et al,  here. It's full text.


In brief:

Background
Cognitive behavioural therapy (CBT) is an effective treatment for people whose depression has not responded to antidepressants. However, the long-term outcome is unknown. In a long-term follow-up of the CoBalT trial, we examined the clinical and cost-effectiveness of cognitive behavioural therapy as an adjunct to usual care that included medication over 3–5 years in primary care patients with treatment-resistant depression.

Methods
CoBalT was a randomised controlled trial done across 73 general practices in three UK centres. CoBalT recruited patients aged 18–75 years who had adhered to antidepressants for at least 6 weeks and had substantial depressive symptoms (Beck Depression Inventory [BDI-II] score ≥14 and met ICD-10 depression criteria). Participants were randomly assigned using a computer generated code, to receive either usual care or CBT in addition to usual care. Patients eligible for the long-term follow-up were those who had not withdrawn by the 12 month follow-up and had given their consent to being re-contacted. Those willing to participate were asked to return the postal questionnaire to the research team. One postal reminder was sent and non-responders were contacted by telephone to complete a brief questionnaire. Data were also collected from general practitioner notes. Follow-up took place at a variable interval after randomisation (3–5 years). The primary outcome was self-report of depressive symptoms assessed by BDI-II score (range 0–63), analysed by intention to treat. Cost-utility analysis compared health and social care costs with quality-adjusted life-years (QALYs)...


They took an old study, with subjects who had taken antidepressants for at least 6 weeks and had substantial depression symptoms characterized by a BDI-II score of at least 14, and followed up with a questionnaire and GP notes. Primary outcome was self-report of depressive symptoms assessed by BDI-II score. They also did a cost analysis.


Findings
Between Nov 4, 2008, and Sept 30, 2010, 469 eligible participants were randomised into the CoBalT study. Of these, 248 individuals completed a long-term follow-up questionnaire and provided data for the primary outcome (136 in the intervention group vs 112 in the usual care group). At follow-up (median 45·5 months [IQR 42·5–51·1]), the intervention group had a mean BDI-II score of 19·2 (SD 13·8) compared with a mean BDI-II score of 23·4 (SD 13·2) for the usual care group (repeated measures analysis over the 46 months: difference in means −4·7 [95% CI −6·4 to −3·0, p<0·001]). Follow-up was, on average, 40 months after therapy ended. The average annual cost of trial CBT per participant was £343 (SD 129). The incremental cost-effectiveness ratio was £5374 per QALY gain. This represented a 92% probability of being cost effective at the National Institute for Health and Care Excellence QALY threshold of £20 000.


Follow-up was a median of 45.5 months, at which point, the CBT group had a mean BDI-II of 19.2, and the control group a mean BDI-II of 23.4


Interpretation
CBT as an adjunct to usual care that includes antidepressants is clinically effective and cost effective over the long-term for individuals whose depression has not responded to pharmacotherapy. In view of this robust evidence of long-term effectiveness and the fact that the intervention represented good value-for-money, clinicians should discuss referral for CBT with all those for whom antidepressants are not effective.


Note that "individuals whose depression has not responded to pharmacotherapy," were taking antidepressants for 6 weeks. The study states later that, "This definition of treatment-resistant depression was inclusive and directly relevant to primary care."

Let's look at the details. I'll start by stating that I'm not going to consider the cost effectiveness, because I don't know how. And it may be that even if the clinical effects turn out to not be impressive (spoiler!), the treatment may be worthwhile from a financial standpoint.

At the start of the current study, all patients were taking antidepressants, and were randomized to 12-18 sessions of CBT, or usual care from their GPs. I find this confusing. It seems like medication ought to be a confounder, since depression is cyclic to begin with and people respond to medications at variable rates. Also, if you consider these patients to be treatment resistant, why continue them on antidepressants?

I also find what they did with the outcome measures confusing:

The primary outcome was self-report of depressive symptoms assessed by BDI-II score (range 0–63). Secondary outcomes were response (≥50% reduction in depressive symptoms relative to baseline); remission (BDI-II score <10); quality of life (Short-Form health survey 12 [SF-12]); and measures of depression (PHQ-9) and anxiety (Generalised Anxiety Disorder assessment 7 [GAD-7])...

The primary outcome for the main trial was a binary response variable; for this follow-up, the primary outcome was specified as a continuous outcome (BDI-II score) to maximise power. The change in the specification of the primary outcome for the long-term follow-up was made at the time the request for additional funding was submitted to the funder (Nov 6, 2012).

Does this mean they changed the primary outcome? In the original CoBalT trial, "The primary outcome was response, defined as at least 50% reduction in depressive symptoms (BDI score) at 6 months compared with baseline." Did the present study start out using response, and then switch to change in BDI-II score after the fact, which we all know is a no-no? They're claiming they changed it when they requested funding for the current study, but is that before or after they had established their primary outcome measure?

Or did the current study start with change in BDI-II score as the primary outcome measure, and is that okay? In other words, if you're basing your current study on a previous study, is it valid to establish your protocol with a different outcome measure than the original study? I don't know.

Moving on. The study makes a lot of claims about secondary outcomes, and whether or not subjects were still taking antidepressants, but I'm restricting myself to thinking about the primary outcome, and the BDI-II measures are as follows:

The effect size, according to this chart, is 0.45, which is on the low side of moderate. I don't know how they did their computation, but when I used 1BoringOldman's spreadsheet (see this post), I got a Cohen's d effect size of 0.31, which is low.

I'm not sure how this constitutes "Robust evidence." I'm also not sure what's robust about a mean BDI-II of 19.2, when by their definition, a BDI-II score of more than 14 is considered "Substantial depressive symptoms."

Look. I'm not a big fan of CBT, but I'm willing to consider it as a useful treatment if you show me good data. Just don't go hyping your at-best-mediocre data like it's amazing. But of course, Psychiatric News is a product of the APA.

"Shrinks" Review-Introduction

Jeffery Lieberman's, Shrinks: The Untold Story of Psychiatry, has been in the air lately.  There was a piece in the NY Times that claimed Lieberman claims there is no evidence for the effectiveness of psychoanalysis, and in response to that, I wrote a post about some of the supposedly non-existent evidence (Analytic Evidence).

In a series of tweets in reference to my post, @1boringyoungman asked if any groups had commented on "Shrinks". For my own unconscious, narcissistic reasons (more evidence), I read this as something like, Has Dr. Lieberman commented on my post?, to which I responded, "Not to my knowledge."

In turn, @MichaelBDonner tweeted, "Hard to comment without seeming defensive. He doesn't like psychoanalysis." To which @Drjlieberman eventually replied, "Not true."

MBD: What's not true? You do like psychoanalysis?

JAL: Yes.

MBD: You like psychoanalysis. Good to know. Didn't come across to me. I stand corrected. My apologies.


After this exchange, I decided I wanted to read the book. But I didn't want to buy it, because I didn't feel like contributing to Lieberman's income. I tried the NY Public Library, but there were like 30 holds ahead of me (also my card has apparently expired and I have to go to a branch to renew it, which I'm too lazy to do because I don't know where I put the card, since I usually just use their app to check out books).

So I bought it. The $14.99 Kindle version, as opposed to the $21.17 hardcover version.

My plan was to read it in its entirety and then write a review, but I'm finding it hard to get through. It's engaging enough as a read, I'll give it that. But the tone is quite disparaging. I'm trying to keep an open mind while I read it. Maybe he has some valid points to make. Research in psychoanalysis is notoriously complicated and controversial, since it's innately a non-manualized treatment, and it goes on for such a long time, and it's so dependent on the particular dyad, and much of the research doesn't correspond with the kind of controlled studies we're used to seeing for drugs or short-term, manualized treatments. So maybe I can learn something.

But the tone is kind of like, "This is what those silly, misguided shrinks think, but of course, we know better, wink, wink." The thing is, thus far, and I'm about a quarter of the way through, he hasn't explained what's wrong with what those silly, misguided shrinks think, or why we know better. He just states it as fact.

But along with prescient insights, Freud's theories were also full of missteps, oversights, and outright howlers. We shake our heads now at his conviction that young boys want to marry their mothers and kill their fathers, while a girl's natural sexual development drives her to want a penis of her own. As Justice Louis Brandeis so aptly declared, "Sunlight is the best disinfectant," and it seems likely that many of Freud's less credible conjectures would have been scrubbed away by the punctilious process of scientific inquiry if they had been treated as testable hypotheses rather than papal edicts.

The next paragraph goes on to describe the way Freud would megalomaniacally discredit anyone who didn't agree with him, which is true, to the best of my knowledge, but doesn't it sidestep the question of why oedipal theory constitutes a misstep, oversight, or howler? Are readers just supposed to accept that this is so, without an explanation of what's wrong with it? Papal edict, indeed.

The only "evidence" Dr. Lieberman has supplied for why analysis is no good is in descriptions of incidents like Wilhelm Reich's Orgone Accumulator. Somehow, this ridiculous idea of Reich's discredits all of psychoanalysis.

Another problem. The book describes the history of psychoanalysis. I'm not a historian. In fact, I'm kind of the opposite of a historian. If it didn't happen in 1492 or 1776, I don't know anything about it. So I'm willing to assume that this history is accurate. But Lieberman treats the history as though that's all there is to know about analysis. It's analogous to saying, "I've studied the history of Bellevue Hospital, so I know everything there is to know about the care of psychiatric inpatients."

Sure, it's fun to read about what a jerk Freud was, and who he kicked out of his circle when, but that doesn't tell you anything about the practice of psychoanalysis.

Lieberman makes a point of describing the way he cured a patient of his conversion disorder with an Amytal interview. Nice work, Dr. L, but do you think that means you conducted an analysis with the patient? Or do you think that means analysis is useless, since conversion disorders were what Freud initially treated, and they may respond to medication? And does that, in turn, imply that you think today's analysands all sought out psychoanalysis as a treatment for their conversion disorders? Or that conversion disorders are all that can be or should be or are treated by an analysis?

To me it seems like the book is intended to escort the lay reader into the sacred halls of neuropsychiatry and biomarkers, to convince the unwary reader that any psychiatric treatment that doesn't involve medication, or lasts longer than 30 sessions, is bogus. And that the true psychiatry, the kind that Lieberman practices, is scientifically valid and effective. Just like the rest of medicine. That's his agenda, I get it, but I think he's misleading.

And speaking of misleading. I saw the following image in the April 17th edition of Psychiatric News:

There's Dr. Lieberman in his white coat, like all psychiatrists wear, getting ready to lead a discussion on May 18th at the APA meeting, on psychiatry's past, present, and future. And there's his book, Shrinks: The Untold Story of Psychiatry, by Jeffrey A. Lieberman, MD.

That's funny, because the book cover on Amazon, and the one on my Kindle, looks like this:

Same title, same author, but look! Who's Ogi Ogas? I googled him, and it turns out he's not a Dr. Seuss character. He's a computational neuroscientist, science book author, and game show contestant. Dr. Ogas won half a million dollars in 2006 on Who Wants to be a Millionaire.

He co-authored, A Billion Wicked Thoughts: What the World's Largest Experiment Reveals about Human Desire, which was published in 2011. One description stated:

The researchers wrote a computer program to capture sexual queries in publicly listed catalogs of Web searches. They later categorized the searches and did some number crunching. They estimate that their research reflects the online behavior of 100 million people.

Does any of this disqualify Ogi Ogas as a co-author or whatever he was of Shrinks? No, of course not. But why did JL chose him? Surely there must have been someone better suited.

And finally, the hubris. Lieberman offers a comment about the misguided patient who sought out Wilhelm Reich's care:

You use the word, "confidently", you throw in a couple of science-y sounding brain structures, you mention medication by its class, and CBT, the acceptable therapy, and what do you get? Optimistic, normal, symptoms controlled.

That was easy!

And this pretty much says it all:

I really hope the book starts to redeem itself at some point, and I'm not just out $14.99.

An MOC Step?

Email today from the APA:

Dear Colleague:

The APA Board of Trustees is aware of members’ significant concerns over the “Part IV: Improvement in Medical Practice” portion of the American Board of Psychiatry and Neurology (ABPN) Maintenance of Certification (MOC) Program. Therefore, yesterday, the APA Board voted unanimously in support of the following motion:

MOTION:

• The American Psychiatric Association (APA) Board of Trustees, acting on the recommendation of the Assembly Executive Committee, and representing over 36,000 psychiatrists, supports the elimination of Part IV of Maintenance of Certification (MOC).
• Therefore, the Board of Trustees recommends to the American Board of Psychiatry and Neurology (ABPN) that they lobby and advocate the American Board of Medical Specialties (ABMS) to eliminate Part IV of the MOC,
• that the APA reaffirm its commitment to lifelong learning and quality improvement and support for the highest scientific and ethical standards of medical practice, and
• that the APA will establish a joint Board and Assembly Work Group with the charge to evaluate the broad issue of maintenance of certification for psychiatry and its relationship to maintenance of state licensure and other accrediting bodies. The goal of the work group is to return timely reports to the Board and Assembly including recommendations, if appropriate, for any positions the APA should take regarding any and all parts of MOC.

APA CEO and Medical Director Saul Levin, MD, MPA, and I have sent a letter to the ABPN, which is clear about the confusing and cumbersome nature of the program and the substantial concern which our membership and the Board of Trustees has regarding the evidence base of Part IV of MOC. At the same time, the Board further reaffirmed the APA’s “commitment to lifelong learning and quality improvement and support for the highest scientific and ethical standards of medical practice.” I look forward to being able to share the Board-Assembly Work Group’s findings in the near future.

We highly value our collaborative relationship with the ABPN and will work with them, other groups and, of course, our members to resolve the widespread concern about these issues.

Sincerely,

Paul Summergrad, MD
President

American Psychiatric Association

To remind people, Step IV consists of the Performance In Practice (PIP) modules, the 5 peer reviews, and the 5 patient reviews, which I wrote and complained about in one of my earliest posts, Alphabet Soup, back in November of 2012. Currently, we are no longer required to do both the peer and patient reviews (and I consider these last to be a boundary violation), but rather, one or the other, or a couple of other possibilities which I was going to cut and paste from the ABPN page, but for some reason the chart won't load on my computer. I think two of them are a 360 degree review and 5 resident reviews.

So now, the APA has FINALLY jumped on the bandwagon, when they see that there are other certifying boards (like the National Board of Physicians and Surgeons, see my post, Another Board) out there that don't require crazy PIP modules that have no evidence to support their utility. The PIP modules are a money-maker for the APA, or at least they have been, so I assume the motivation for getting rid of them as a requirement comes from the fact that the APA is losing membership and money, and may lose more if its members recall that the APA did absolutely nothing to prevent the institution of these requirements, to begin with. Only now are they establishing a Board and Assembly Work Group.

I guess I'll take what I can get from the APA, and maybe this is better than nothing. But they've done poorly by their constituency with regard to MOC in the past, and I don't see any reason to assume they'll do any better in the future, unless supporting their constituency happens to coincide with their own interests, whoever "they" are.

APA-thetic

I'm becoming increasingly, shall we say, disenchanted with the APA. Even more than I was when I terminated my membership a couple years ago.

The latest escapade contributing to my disenchantment is the Milliman American Psychiatric Association Report, Economic Impact of Integrated Medical-Behavioral Healthcare, Implications for Psychiatry. For some reason, I can't get an independent link to come up for this-it just generates a pdf in my downloads file, but there are links to it, and its summary HERE.

This is a 39 page document prepared for the APA by Milliman, Inc., a firm that provides "actuarial and related products and services". It reads like a piece of PR, wonder why. Phrases like,

The field of psychiatry is poised to become a major participant as IMBH evolves. Psychiatry has a direct role in the value proposition of integrated/collaborative care and stands to benefit from the savings generated by effective integration programs.

are what make me think so.

They estimate that somewhere between $26.3 and $48.3 billion can be saved annually through use of integrated medical/behavioral healthcare systems, like collaborative care.

First, they proceed to demonstrate how they came up with those figures. I'll attempt not to be too detailed, but they claim that, "Medical costs for treating those patients with chronic medical and comorbid mental health/substance use disorder (MH/SUD) conditions can be 2-3 times as high as (for) those beneficiaries who don‘t have the comorbid MH/SUD conditions. The additional healthcare costs incurred by people with behavioral comorbidities are estimated to be $293 billion in 2012 across commercially-insured, Medicaid, and Medicare beneficiaries in the United States.

Significantly,

"Most of the increased cost for those with comorbid MH/SUD conditions is attributed to medical services (more than behavioral), creating a large opportunity for savings on the medical side through integration of behavioral and medical service."

My question is, "How? "

Some of the figures are interesting. I should mention that I basically believe their figures, just not their conclusions, but who knows. They looked at 3 types of insurance, Commercial, Medicare, and Medicaid, and divided these into populations, and then researched how much was spent on each population. Commercial and Medicare were divided into 4 populations: No MH/SUD; non SPMI (severe and persistent mental illness) MH; SPMI; and SUD. Medicaid was divided into No MH/SUD and MH/SUD.

Here's a screenshot of Per Member Per Month Costs per Population for the Commercially insured:

You can see that a lot more is spent on medical care for those with Mental Health and Substance Use problems ($750, average), than for those without ($280).  What I've highlighted is incidental but interesting. $23 per person per month is spent on those with a Non-SPMI MH diagnosis for behavioral treatment, vs. $74 for behavioral meds. In the SPMI population, it's $128 vs. $175.

That's 3 times as much for meds than for other behavioral care in the Non-SPMI MH group. Tell me, what kind of therapy does $23 a month buy? And this is commercial insurance we're talking about, not medicare or medicaid.

In fact, medicare spends $579/month, and medicaid spends $309/month on medical care for Non-MH/SUD, vs. the $280 for commercial insurance. And medicaid spends $286/month on non-pharmacologic behavioral care for those with MH/SUD diagnoses, vs. an average of $75/month spent by commercial insurance. Maybe this is because those with medicare and medicaid tend to be sicker than those with commercial insurance.

Here's another chart with my highlights:

Why are behavioral facility costs roughly the same for those with a Non-SPMI MH diagnosis, and those without? And why are professional behavioral costs for No MH/SUD ($3690) actually greater than costs for SPMI ($3457)? Are there patients who are receiving behavioral treatment without a behavioral diagnosis? And if so, how are providers coding and being reimbursed?

Let's move on to the heart of the document. How can this data help us to provide better and more cost-efficient care in an integrated care model? The answer is something called, Value Opportunity, which is, "The potential for savings if we could manage all of a patient‘s comorbid conditions more effectively."

For example:

The value opportunity for chronic kidney disease is, "$2,251 PMPM ($6,901 - $4,650) additional healthcare spending for those treated for substance abuse and $1,582 PMPM ($6,232 - $4,650) additional costs for those treated for Non-SPMI conditions."

So all we have to do is cure patients of their Mental Health and Substance Use Disorders, and that will put them into the No MH/SUD population, so then their medical costs won't be as high. Right?

The bottom line:

Across all populations (commercial plus Medicare plus Medicaid), we estimate a total annual value opportunity of $293 billion through integration of behavioral and medical services in the U.S.

Well gee, Mr. and Mrs. Milliman, that's a lot of money! Will integrated care really be able to produce this result?

Yes, my boy.

For example:

"The Pathways study focused on the outcomes of a program utilizing specialized nurses to deliver a twelve-month depression treatment program for patients with diabetes. This program was administered through a randomized controlled trial that compared the systematic depression treatment program with care as usual. Total outpatient costs were approximately equal during the 12-month intervention period for both the intervention group and the usual care group, but during the 12-month period following the intervention, median outpatient costs for the intervention group were $50 PMPM lower than costs for the usual care group. Over the entire two year period, including the intervention period, total healthcare costs (including inpatient and outpatient health services) were $46 PMPM lower for the intervention group than for the usual care group. This represents savings of about 5% of total healthcare costs for the intervention group over a 2 year period."

Hold on, there! Where does the $50 PMPM come from? Is it savings in medical care for diabetes?

According to the abstract (check the link to the study, above):

Conclusion: The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.

In fact, most of the abstract doesn't jive with the description above. Maybe they did a follow-up study that I didn't find.

The Milliman document also cites the Multifaceted Diabetes and Depression Program (MDDP) study.

"Although not statistically significant, medical cost savings of approximately $39 per member per month (PMPM) were observed during the eighteen months following the implementation of the MDDP program." (emphasis mine)

They also cite the IMPACT Study, and state that, "Total healthcare costs were tracked for a 4-year period following the intervention, and costs for the intervention group were an average of $70 PMPM lower than costs for those receiving usual care. This represents savings of about 10% of total healthcare costs for the intervention group over a 4 year period. Patients in the collaborative care management program had lower costs in every category that was observed, and the results of a bootstrap analysis indicated that patients in the collaborative care program were 87% more likely to have lower total healthcare costs than those receiving usual care."

I don't like the "total healthcare costs" phrase. Where was the money saved? In "every category that was observed"? What is this "bootstrap analysis"?

IMPACT studied interventions for depression in the elderly, in primary care settings. It found that depression improved over 12 months. That was the stated purpose of the study. Outcome measures assessed depression, depression treatments, satisfaction with care, functional impairment, and quality of life. The study was not designed to test healthcare spending.

They offer a couple more fumpfed examples, but here's the OMG kicker:

The American Medical Association estimates that there are 41,784 psychiatrists practicing patient care as of 2012. The Bureau of Labor Statistics estimates average annual earnings of $174,170 per practicing psychiatrist as of May 2011. This translates to $7.3 billion in psychiatrist wages annually. Comparing this estimate to the projected savings estimate of $26-48 billion means that the potential financial impact of IMBH programs can be up to 3.5 to 6.6 times annual psychiatrist earnings. Stated another way, a 10% gain sharing arrangement for psychiatrists (where they are credited with a certain percentage of actual achieved healthcare cost savings through a contractual arrangement) of savings from integration has the potential to increase annual earnings estimates for psychiatry overall by about 50%. In this example, that leaves the other 90% of savings through collaborative care to be shared with others in the collaborative care teams, to be used to lower healthcare premiums, and to be reinvested in community based care.

APA, I'm so over you.

It's All in the Spin

Another email from the APA today, oh joy:

CBT More Efficacious Than Other Psychological Interventions for Positive Symptoms of Psychosis.

This was based on the article: Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies, published February 14th on AJP in Advance.

CBT was compared with supportive counseling, social skills training, psycho-education, cognitive remediation and befriending in 48 trials.

Results  Cognitive-behavioral therapy (CBT) was significantly more efficacious than other interventions pooled in reducing positive symptoms (g=0.16). This finding was robust in all sensitivity analyses for risk of bias but lost significance in sensitivity analyses for researcher allegiance, which suffered from low power. Social skills training was significantly more efficacious in reducing negative symptoms (g=0.27). This finding was robust in sensitivity analyses for risk of bias and researcher allegiance. Significant findings for CBT, social skills training, and cognitive remediation for overall symptoms were not robust after sensitivity analyses. CBT was significantly more efficacious when compared directly with befriending for overall symptoms (g=0.42) and supportive counseling for positive symptoms (g=0.23).

The APA seems rather pleased with itself about this result. The email even linked to a news article, CBT Addresses Most-Debilitating Symptoms in Chronic Schizophrenia.

A new cognitive-behavior therapeutic strategy [Recovery Oriented Cognitive Therapy (CT-R)] is helping patients overcome major obstacles to their recovery, especially the negative symptoms...that are considered to be the most intransigent and disabling for patients with schizophrenia. The strategy has been implemented throughout the Philadelphia public mental health system and in Georgia

You'd think they'd at least cross check their own links. CT-R is especially helpful with negative symptoms, but the meta-analysis demonstrated that social skills training was significantly more efficacious than CBT in reducing negative symptoms.

The email caught my eye because I had just finished reading this month's Carlat Report, in which there was an article entitled, "CBT for Schizophrenia: Is Talk Cheap?", which, in turn, references, "Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias," published in the British Journal of Psychiatry.

THIS study looked at 50 trials of CBT for schizophrenia, and found that when raters were blinded to the type of treatment provided, effect size of CBT relative to placebo dropped from 0.62 in unblinded studies, to 0.15 in blinded studies, for overall symptoms. For positive symptoms, the drop was from 0.57 to 0.08. 
Pooled effect sizes were 0.33 for overall symptoms, 0.25 for positive symptoms, and 0.13 for negative symptoms. 
Not sure why they didn't describe the difference between unblinded and blinded studies for negative symptoms. Maybe because the pooled effect size was so low to begin with.

It's kind of like what I wrote about the APA excitement about the meeting in May. Pick some highlight, maybe Alan Alda, talk about how great the meeting will be, and ignore all the annoying little facts that might put a damper on things. 

Why Does this Bother Me?

I got an email today about the annual meeting of the APA, which is in NYC this year. I suppose I could attend, even though I terminated my membership in the APA a while ago. This was in the email:

APA 2014: Changing the Practice and Perception of Psychiatry

APA President Jeffrey Lieberman, M.D., is using the Psychiatric News Alert as a forum to reach APA members and other readers. This column was written by Dr. Lieberman and Philip Muskin, M.D., chair of the APA Scientific Program Committee. Please send your comments to pnupdate@psych.org.

Annually, thousands of mental health professionals descend on a major American city to participate in a three-ring circus of pedagogic activities that comprise the annual meeting of the American Psychiatric Association. This event is an academic smorgasbord of all information relevant to psychiatric medicine and mental health care. It provides one-stop shopping for clinicians who wish to avail themselves of the latest scientific developments and all the education needed to practice their craft. The annual meeting is the highlight of the year for U.S. psychiatry.

APA’s 167th Annual Meeting will take place May 3 to 7 in New York City and will be the epicenter for those who wish to learn of emerging knowledge and connect to leaders in the field of psychiatry. New York is a perfect place to host this year’s meeting, given the extraordinary and historic events of the past year, including the launch of DSM-5, the release of the final rule for the Mental Health Parity and Addiction Equity Act, further implementation of the Affordable Care Act, and the emotionally wrenching discussion of mental illness and violence in the media.

The theme of the 2014 annual meeting is aptly titled “Changing the Practice and Perception of Psychiatry,” reflecting the historic transformation in how our profession will be practiced, as well as perceived by our medical colleagues and the public at large. The Scientific Program Committee, chaired by Phil Muskin with Co-Chair Cam Carter, has produced an amazing program with a who’s who of luminaries scheduled to speak. The Opening Session will feature a “Dialogue on Science and the Media” that I will moderate between Nobel Laureate Eric Kandel and the acclaimed actor Alan Alda. The Convocation Lecture will be delivered by a major political figure who is leading major legislative initiatives in mental illness. Look for more information in a future issue. 

I happen to be a huge Alan Alda fan, and that alone is a draw. But my skin is just crawling, and I'm not sure why. 

Here's a link to the full text of above. Many of the sessions are organized into tracks, such as forensics, child/adolescent, ethics. There's a mentoring track for residents. and a track dedicated to military health care.

There's also an integrated care track:

The Integrated Care Track features interactive sessions applicable to every psychiatric physician in this current culture of health care reform and comprehensive patient-centered service. By participating in workshops led by experts like Lori Raney, M.D., you will learn practical skills to prepare for leadership roles of the psychiatrist within a collaborative care team. The CPT coding workshop, chaired by Ronald Burd, M.D., is another educational opportunity relevant to all due to changes in health care financing and reimbursement that occurred at the start of 2014.

"Leadership roles of the psychiatrist within a collaborative care team." This is a definite formicatory sentence. I wanna reply, "You mean, as opposed to psychiatric roles of the psychiatrist within a collaborative care team," because in a collaborative care model, the psychiatrist doesn't see patients, just supervises those who do, and signs off on the charts of these unexamined patients. And as Socrates said, "The unexamined patient is not worth treating." Or something like that. (I was gonna write, "not worth living", but that sounded way harsh.)

I think what bothers me about the meeting is everything that's left unsaid. There's all this, "Yay! DSM-5! Here's how to use it!" Rather than, "DSM-5, let's talk about the controversy". 

And there's, "Yay! RDoc! NIMH!!" as though we're already at an advanced stage of knowing how the brain produces psychiatric illness. 

"Yay! Psychopharm!" as though there are no questions about efficacy and safety, even with Paxil study 329 glaring in everyone's face. 

I also hate the phrase, "Patient Centered Care". 

As opposed to what? Kumquat-Centered Care?

And I'm irritated by the notion that the APA meeting presents, "all information relevant to psychiatric medicine and mental health care." Do they really think there's no valid perspective on psychiatry outside that of the APA?

I glanced at the program, and I was pleased to find a reasonable emphasis on psychotherapy, especially of the psychodynamic variety, and Kernberg and Fonagy will be there. And Kandel is always a welcome presence.

I'm not sure why I find the whole thing so icky, or why I expect anything to be different. I just remember being at the meeting in NYC 10 years ago, and the most impressive thing was all the pharmaceutical presentation areas. Maybe there won't be as many this year. And maybe they're trying to keep them out of the program. 

I found this paragraph on page 7:

Sunshine Act

Some of APA’s non-CME accredited events and some refreshments at APA events are sponsored by pharmaceutical or medical device companies. Participation in these events/ food offerings may be reportable under the Physician Payment in the Sunshine Act.

Just this one little blurb. Like, hey, that's not a herd of elephants we all see traipsing about the Javits Center.

I feel like there's some big issue being sidestepped. That the influence of industry is so integral that no one even bothers to talk about the conflicts of interest. I know there's a lot of excess hype about David Kupfer's ownership of Psychiatric Assessments, Inc., which provides assessment instruments to be used in conjunction with DSM-5 (Link), but it's as if the meeting just goes along its merry way, completely oblivious to Voldemort's shriveled, twisted soul lying under a bench.

As though psychiatry isn't a mess. 

It really bothers me.

Who Needs Who

Check out this article in Psychiatric News, if you haven't already. 

Jeffrey Lieberman, president of the APA, asks us to be nice to poor, little Big Pharma. 

He notes past problems, "including high drug prices, aggressive marketing practices and direct-to-consumer advertising, efforts to buy influence with physicians, and, perhaps most egregiously, the suppression of data on drugs’ dangerous side effects."

He goes on to say:

But let’s face it, they need us and we need them. We must recognize the important, beneficial role that drug companies have long played in all areas of medicine. While not minimizing problems, we simultaneously must remember how products have improved the quality of health care and quality of life in our society, and their funding has helped to advance research, public outreach, and training.

He finishes up with:

We now are moving forward with careful vigilance in ways that recognize the value of industry relationships. Under the auspices of the American Psychiatric Foundation (APF), interactions with industry are helping to restore important relationships. ...I believe that the rules and models for informational, educational, and research engagement can and should be developed and applied in ways that allow for our optimal engagement with companies. Doing so would not only help us learn from the mistakes of the past; it would help us improve the future for our profession and our patients. 

I agree with the fact that we need them. Unless we want to put all our patients on Lithium and St. John's Wart, the meds have to come from someplace. And I don't fault Big Pharma for trying to make a buck or two billion.

But I also agree with the fact that they need us. No prescribers, no sales. So why do we have to be nice to them? And why does the president of the APA have to ask us to do so?

Sorry if I'm skeptical, but:

GlaxoSmithKline has admitted that some of its senior Chinese executives broke the law in a £320m cash and sexual favours bribery scandal.

And:

Big pharma mobilising patients in battle over drugs trials data.

The veracity of this last one is a little controversial, I suspect because Big Pharma intervened (See Eye For Pharma).

The idea is that if pharmaceutical companies make their data transparent for review and interpretation by the world at large, like in RIAT, science may be compromised, and private patient information may be revealed. 

I guess the world at large doesn't understand science as well as pharmaceutical companies do. And oh yeah, data for subjects in drug trials are anonymous.

(Please check out 1boringoldman.com for a more extensive discussion of this controversy)

So, again, why is the APA on a kick to endorse Big Pharma?

To quote Danaerys Targaryen, "I am only a young girl, and know little of such matters."

But I wonder what the APA gets out of the endorsement.

According to Gary Greenberg, regarding the APA's financial picture:

Income from the drug industry, which amounted to more than $19 million in 2006, had shrunk to $11 million by 2009, and was projected to fall even more. Membership was dropping, off by nearly 15% from its highs, and with it income from dues and attendance fees. Journal advertising was off by 50% from its 2006 high of $10 million.

I looked up the APA's 2012 Treasurer's Report, and found the following charts:

What's a picture worth, again?