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The Lancet Psychiatry

Volume 3, Issue 4, April 2016, Pages 386-388
The Lancet Psychiatry

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NICE guidance on psychological treatments for bipolar disorder: searching for the evidence

https://doi.org/10.1016/S2215-0366(15)00545-3Get rights and content

Summary

The recent National Institute for Health and Care Excellence guidelines for bipolar disorder offer a number of recommendations for the psychological treatment of bipolar disorder. Scrutiny of the evidence on which these guidelines are based reveals significant flaws in the methodology and conduct of the relevant meta-analyses, and calls into question the interpretation of the evidence.

Section snippets

The evidence base

The NICE recommendations for bipolar disorder are based on a series of meta-analyses that were commissioned from the National Collaborating Centre for Mental Health (NCCMH). Perusing this documentation, the first thing that confronts the reader is how many meta-analyses were done—around 170 meta-analyses of individual psychological interventions. Examined therapies included cognitive behavioural therapy (CBT) and mindfulness-based CBT; psychoeducation and therapy for treatment adherence; and

The meta-analyses of acute treatment for bipolar depression

The intervention with the most studies available for meta-analysis was CBT. A meta-analysis of six trials of individual CBT versus treatment as usual gave an effect size in the small range (standardised mean difference [SMD] −0·31) at post-treatment (table). The benefit, however, was not maintained in four trials that included follow-up data. Two meta-analyses of group CBT reported no benefit at post-treatment or follow-up. There were significant findings in two single-trial meta-analyses that

The meta-analyses of relapse prevention

In a meta-analysis of four studies, individual CBT was of significant benefit compared with treatment as usual for the outcome “any relapse” (risk ratio (RR) 0·67, 0·53–0·86). However, this meta-analysis did not include a large trial by Scott and colleagues,3 even though it was included in subsequent meta-analyses examining depressive and manic relapses separately. When this trial, which had negative findings, ie, the overall relapse rates of CBT and treatment as usual were not significantly

The composite meta-analyses

One might be forgiven for wondering where, in this maze of contradictory findings, the evidence supporting the NICE recommendations comes from. The answer seems to lie in the fact that NCCMH undertook more than 30 additional meta-analyses that pooled data from different types of psychological intervention. One of these combined online psychoeducation (two studies) and individual CBT (four studies) and reported a small but significant benefit on depressive symptoms compared with treatment as

Risk of bias

Nowadays, it is considered essential to take study quality into account when interpreting results from meta-analysis.4, 5 A clear consensus of opinion suggests that the different sources of bias, including inadequate randomisation, not blinding outcome evaluations, and failure to control for attrition, should be rated separately, not by means of a single quality score. NCCMH rated various individual aspects of quality for the studies that were included in their meta-analyses, and NICE combined

Are NICE's recommendations for psychological treatments evidence based?

NICE guidelines provide what is in effect a detailed blueprint for good clinical practice. They are not statutory, although making them so has been suggested.6 Via the NICE quality standards, they will almost certainly affect the decisions health commissioners in the UK make about what services they are going to fund.

In the case of psychological treatment of bipolar disorder, the recommendations seem to go beyond the evidence. It seems probable that many clinicians and researchers would not

References (7)

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