Spinning Low Intensity CBT and Treatments for Refugees

How seriously should we take claims for the efficacy of an intervention?  The ‘Risk of bias” assessment tool developed by the Cochrane Collaboration (2011), see slide, helps distinguish clever marketing from the genuine article. All LiCBT intervention studies fail the Tools requirement for the blinding of outcome assessment, suggesting a high risk of bias.  

In LiCBT studies, there are no independent assessments to determine whether those treated were no longer suffering  from the primary disorder for which they first presented.  LiCBT interventions is the most common treatment modality in the Improving Access to Psychological Therapies (IAPT) service.

But the LiCBT studies are not only subject to this detection bias, but in many instances they are also subject to allegiance bias, with the main author of the study evaluating their own manualised intervention e.g Williams et al (2018) evaluation of the Living Life To The Full Classes doi: 10.1192/bjp.2017.18

But the purveyors of LiCBT interventions do not have a monopoly on proclaiming effectiveness were non exists. A just published study by Kip et al (2020) DOI: 10.1002/cpp.2446 in Clinical Psychology and Psychotherapy  claims that ‘psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees’. But of the 14 studies on adult refugees  only in 4 studies was outcome assessed by a ‘gold standard’ semi structured interview (the CAPS). The method of determining the diagnostic status of the refugees at entry to the study is unclear, but of the 9 questions asked to determine the quality of the included studies  the lowest score   was for whether the diagnosis was determined by using a semi structured interview. The next lowest score was for the item referring to fidelity checks i.e did the clients actually receive the treatment that it was purported they receive. Five out of six studies on Narrative Exposure Therapy  involved at least one author of the published manual on NET.  In total half of the trials researchers  were involved in utilising manuals whose development they were involved in. There is clearly a pressing need for independent replication of these findings on refugees. There is also a need to higher the methodological bar, as it is impossible to say from this review what proportion of refugees were no longer suffering from PTSD at the end of treatment, nor how long that improvement persisted.

Like IAPT the understandable wish to further dissemination takes precedence over a determination about whether treatment makes a real world difference to clients lives.

Dr Mike Scott

 

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