NICE guidelines are discrepant with meta analyses and based on political considerations: An exchange

NICE

 

In a recent blog post, Go ahead, former  member of the Journal of Health Psychology editorial board, make my day, I made a passing comment about NICE guidelines

“As been demonstrated with numerous conditions, NICE guidelines often are based on political considerations and are discrepant with the results of meta-analyses and other best evidence.”

The comment elicited a reaction from Professor Paul Salkovskis1 of Bath University.

I posted the comment. I indicated I would respond, but that I would welcome others responding in the interim.

I am actually ended up being quite comfortable with others’ responses and their rich links – Professor Keith Laws and pseudonymous blogger JohntheJack (AKA John Peters).

I feel it would be useful to elevate the exchange from the obscurity of a thread of comments to a full plug post.

Without further ado:

Paul Salkovskis (1)

Hi Jim. Can I ask for clarification of your concerns regarding NICE guidelines? I have been involved in various ways and find one of the key strengths of NICE is its relative freedom and safeguards from political and commercial interests. There is also an important element of service user and PPI input, full publication of the evidence considered and so on. I have seen guidelines conflicting with those of others but as far as I can tell that’s related to relative rigour. It may be that you have strong evidence that I do not for this assertion?

Paul Salkovskis

PS CoI statement: I have participated in NICE work; in common with other participants I have not been paid or received other reward for this work on behalf of the NHS.

I replied:

Thanks. Paul for raising an important question. I will be providing an answer tomorrow, but I thought my readers should not wait for an opportunity to view your post. Some of my readers might want to respond in the interim or maybe after they have seen both our posts.

Best

Professor Keith Laws (2) responded:

The points made here by Jim seem self-evident (at least to me). I can think of at least three NICE guidelines where the above statements are true. In this context the guide on CFS/ME (CG 53) makes claims that are un-evidenced. For example, the claim that CBT reduces distress in CFS/ME – they make the claim with no support whatsoever…indeed some evidence suggests that some psychological interventions may worsen distress in CFS/ME http://journals.sagepub.com/doi/full/10.1177/1359105317710246

It is also clear that in CG53 that they take great pains to dismiss the views of ‘service users’- again see the above short paper, while failing to apply the same gaze on the evidence they propose in favour of CBT.

NICE also present unevidenced claims in the guides for schizophrenia and the guide for bipolar disorder. Here is a Guardian piece I wrote on the NICE Bipolar guide (CG185) relating to our paper in the Lancet Psychiatry https://www.theguardian.com/science/sifting-the-evidence/2016/feb/05/nice-guidelines-for-psychological-therapy-cbt-overstepping-evidence

It is clear the authors of the guide are biased – excluding the largest ever trial and unable to explain why – even in their response to us. Indeed, they NICE have no evidence that CBT reduces mania or -remarkably- even depression (in bipolar patients) …in the short-term or the long-term

Finally NICE are show bias in their advocacy of CBT for schizophrenia/psychosis in CG178- something I wrote on it for the Conversation https://theconversation.com/are-treatment-guidelines-on-schizophrenia-and-bipolar-disorder-just-plain-wrong-54369
NICE CG178 has even been publicly described in the British Journal of Psychiatry by the former SIGN chair (Mark Taylor) responsible for schizophrenia treatment guidance in Scotland as promoting “some psychosocial interventions, especially CBT, beyond the evidence…[and] also make some strong recommendations based on no evidence at all”. http://bjp.rcpsych.org/content/206/5/357.full-text.pdf+html

Yet all three guides promote CBT (despite the lack of evidence. In some cases,NICE committee members advocate CBT as an ‘alternative’ to medication (when not one relevant study exists); nevermind the poverty of evidence in combination with medication. The same guideline had also advocated using CBT to increase insight and to promote medication adherence – when not one study supported either…and then a few years later, they removed both from the guideline (again with no evidence) – this is the whim of the committee…depending upon the way the political wind blows! We might also ask why has the meta-analytic evidence in the schizophrenia guide not been updated with RCTs since 2008? …perhaps the ‘evidence-wind’ has blown in a different direction…and political expediency is to change nothing. So , I would say plenty of evidence shows political bias in NICE decision -making regarding CBT advocacy at least in the three areas that I have examined)

JohntheJack (3) weighed in:

It is interesting that Keith Laws uses ‘self-evident’ as it was a term I was going to use.

I don’t question Psychonoclast’s experience. I’m sure there are times when the system works well. I think there are bound to be problems when a false consensus has taken root, as with ME, or when proponents of a certain view have captured the process, as in Professor Law’s examples.

The answers are always going to depend on who is asked to provide them.

The current NICE guidelines for ME were set out in 2007. They were endorsed in a review commenced in 2010. They use the broadest possible criteria for the illness and recommend CBT and GET as effective treatment.

The committee which decided on these guidelines is available here
https://www.nice.org.uk/guidance/cg53/documents/guideline-development-group-members2

I’m not sure how these committees are drawn up, but I think it’s noteworthy that members include a psychiatrist, a psychologist,a physiotherapist, a dietitian and an occupational therapist. I wonder if the same sort of people would be involved in a committee on, for example, encephalitis.

What I think does throw doubt on the whole process is the conflict of interest of many of those involved.

There is an update on conflicts of interest here. There is presumably an earlier document, but this list in itself is revealing.
https://www.nice.org.uk/guidance/CG53/documents/chronic-fatigue-syndrome-myalgic-encephalomyelitis-gdg-members-declaration-of-interests2

The PACE trial was ongoing when these guidelines were drawn up. The review, started in 2010, claimed the 2007 findings were ‘supported by the recently published PACE trial comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome’.
https://www.nice.org.uk/guidance/cg53/documents/chronic-fatigue-syndrome-myalgic-encephalomyelitis-review-decision2

A comprehensive look at the committee was done in 2008 by Margaret Williams.

https://meagenda.wordpress.com/2008/12/19/a-nice-dilemma-by-margaret-williams-part-two/

and

https://meagenda.wordpress.com/2008/12/19/a-nice-dilemma-by-margaret-williams-part-three/

Almost all the members of the committee were linked in some way with a particular view of ME.

Bavinton after her work in PACE is now in private practice offering GET for ME.
http://vitality360.co.uk/fatigue-pain/about-us-2/about-us/our-team/

Crawley had not long been working in the field in 2007. She recently described Peter White, one of the main proponents of CBT-GET and principal investigator for the PACE trial, as important to her career.
https://soundcloud.com/university-of-bristol/fatigue-and-me-a-story-of-research-in-a-controversial-area
She has developed a paediatric centre for ME. She continues to use very broad criteria and to use CBT-GET. Her most recent research has included a study of the quack Lightning Process
https://www.coyneoftherealm.com/blogs/news/bristol-uni-refuses-to-disclose-how-much-money-paid-for-quack-therapy-in-smile-clinical-trial
and one on GET.
http://bmjopen.bmj.com/content/6/7/e011255.full?sid=507feb97-e40e-4693-a7ce-74ef3a62f240

‘Minister, two basic rules of government: Never look into anything you don’t have to. And never set up an inquiry unless you know in advance what its findings will be.’

Cast of Characters

(1) Paul Salkovskis [] is Professor of Clinical Psychology and Applied Science. In 2010 he was appointed Programme Director for the Clinical Psychology Doctorate Programme at Bath. Previously he was Professor of Clinical Psychology and Applied Science and Clinical Director in the Centre for Anxiety Disorders and Trauma at the Institute of Psychiatry (2000-2010)

(2) Keith Laws is Professor of neuropsychology at the School of Psychology at the University of Hertfordshire.[1] Professor Laws’ research centers on cognitive functioning in people suffering from neurological and psychiatric disorders. He has been a strong critic of the use of CBT for treating the psychotic symptoms associated with schizophrenia. I highly recommend following his blog LawsDystopia

(3) JohntheJack (AKA JohnPeters -he gave me permission to out him) is a pseudononymous blogger whom I have never met, but feel like I have. I highly recommend his blog, JohntheJack which I sometimes excerpt.  John regularly provides behind-the-scenes feedback on my blog posts at Quick Thoughts and PLOS Mind the Brain. His Twitter bio is

John Peters