- Email: [email protected]
Psychosocial treatments in bipolar disorder
Correspondence
Psychosocial treatments in bipolar disorder We read with interest the Comment by Tim Kendall and colleagues, in response to our Personal View on NICE guidance on psychosocial treatments in bipolar disorder.1 We feel that this Comment raises more questions than it answers. Two issues seem particularly important. Despite carrying out almost 200 metaanalyses on fewer than 50 studies, more than half being meta-analyses of single trials, Kendall and colleagues remain unconcerned about multiple comparisons. They refer to Schulz and Grimes,2 who stated that using the sort of correction we propose might sabotage interpretation of clinical trials reporting several endpoints. Few clinical trials, however, contain 200 endpoints and Schulz and Grimes further state that if a trial reports results on, say, 15 endpoints with one being significant, appropriate caution should be displayed. Furthermore, we did not propose using Bonferroni correction (as alluded to by Kendall and colleagues), we recommended the less conservative false discovery rate (FDR) approach. As noted by Matt and Cook,3 “Although research syntheses may combine findings from hundreds of studies and thousands of respondents, they are not immune to inflated type I error when many statistical tests are conducted without adequate control for error rate” and they refer to the threat of “capitalising on chance in meta-analysis”. Kendall and colleagues’ explanation for exclusion of the study by Scott and colleagues4 from the meta-analysis of relapse was that it included patients who were not euthymic at baseline. We considered this, but discounted it after discovering another trial in the same meta-analysis included patients who were explicitly depressed or hypomanic at baseline.5 Two other trials6,7 in the same meta-analysis did not specify whether their patients were euthymic at baseline: it seems www.thelancet.com/psychiatry Vol 3 April 2016
unlikely that such information would be reliably retrievable in one of these studies,6 done over 30 years ago. The response by Kendall and colleagues still does not account for why the study by Scott and colleagues was included in meta-analyses for depressive and manic relapse considered separately, as we pointed out. We declare no competing interests.
*Sameer Jauhar, Peter J McKenna, Keith R Laws [email protected] Department of Psychosis Studies, Institute of Psychiatry, King’s College London, London WC2R 2LS, UK (SJ); FIDMAG Hermanas Hospitalarias Research Foundation, Barcelona, Spain (PJMcK); Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain (PJMcK); and School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK (KRL) 1
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Jauhar S, McKenna PJ, Laws KR. NICE guidance on psychological treatments for bipolar disorder: searching for the evidence. Lancet Psychiatry 2016; 3: 386–88. Schulz KF, Grimes DA. Multiplicity in randomised trials II: subgroup and interim analyses. Lancet 2005; 365: 1657–61. Matt GE, Cook TD. Threats to the validity of generalized inferences. In: Cooper H, Hedges LV, Valentine JC, eds. The handbook of research synthesis and meta-analysis (2nd edn). New York, NY, US: Russell Sage Foundation, 2009: 537–660. Scott J, Paykel E, Morriss R, et al. Cognitive–behavioural therapy for severe and recurrent bipolar disorders. Br J Psychiatry 2006; 188: 313–20. Ball JR, Mitchell PB, Corry JC, Skillecorn A, Smith M, Malhi GS. A randomized controlled trial of cognitive therapy for bipolar disorder: focus on long-term change. J Clin Psychiatry 2006; 67: 277–86. Cochran SD. Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. J Consult Clin Psychol 1984; 52: 873–78. Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ 1999; 318: 149–53.
Student-run free clinics: the USA’s psychiatry recruitment solution? Fewer medical students are considering psychiatry as a profession than before. In the USA, 55% of practising psychiatrists are older than 55 years, and in 2014, only 52% of psychiatry
residency positions were filled by senior US medical students.1 14 of 203 psychiatry programmes did not fill all of their available positions in 2014. To address the declining popularity of psychiatry, medical students should be offered concrete, positive experiences in the psychiatric profession. One promising arena in which this offering of experiences is possible is student-run free clinics (SFRCs) in which students provide primary care to uninsured patients under faculty supervision. Today, in the USA, more than 100 SRFCs exist serving 36 000 patients, and this model has also spread to Canada, Mexico, and the Caribbean.2 A growing body of research suggests that experiences at student-run free clinics can have a lasting impact on medical students’ ambitions in the profession and provide them with valuable skills not taught in the classroom or on clinical rotations.3 Although SFRCs have attracted students to primary care and internal medicine, psychiatry as a profession has yet to take full advantage of the SRFC model. Attending psychiatrists often prefer not to become involved in SFRCs for fear of liability issues and worries that mental health care—unlike medical care—cannot be delivered safely and effectively in an SFRC setting. Several programmes, however, have shown that these worries might be unfounded. At Mount Sinai, New York, USA, medical students working with psychiatrists have shown that universal screening and treatment of depression is possible in an SFRC setting.4 At HAVEN Free Clinic, New Haven, CT, USA, Yale medical students work as so-called lay counsellors and learn to deliver evidence-based psychoeducation and behavioural activation interventions to patients with mild-to-moderate depression. 5 SRFCs represent a valuable opportunity to recruit medical students to psychiatry and reach a patient population that often does not have access to psychiatric care. Additionally, when psychiatric care 321
Psychosocial treatments in bipolar disorder We read with interest the Comment by Tim Kendall and colleagues, in response to our Personal View on NICE guidance on psychosocial treatments in bipolar disorder.1 We feel that this Comment raises more questions than it answers. Two issues seem particularly important. Despite carrying out almost 200 metaanalyses on fewer than 50 studies, more than half being meta-analyses of single trials, Kendall and colleagues remain unconcerned about multiple comparisons. They refer to Schulz and Grimes,2 who stated that using the sort of correction we propose might sabotage interpretation of clinical trials reporting several endpoints. Few clinical trials, however, contain 200 endpoints and Schulz and Grimes further state that if a trial reports results on, say, 15 endpoints with one being significant, appropriate caution should be displayed. Furthermore, we did not propose using Bonferroni correction (as alluded to by Kendall and colleagues), we recommended the less conservative false discovery rate (FDR) approach. As noted by Matt and Cook,3 “Although research syntheses may combine findings from hundreds of studies and thousands of respondents, they are not immune to inflated type I error when many statistical tests are conducted without adequate control for error rate” and they refer to the threat of “capitalising on chance in meta-analysis”. Kendall and colleagues’ explanation for exclusion of the study by Scott and colleagues4 from the meta-analysis of relapse was that it included patients who were not euthymic at baseline. We considered this, but discounted it after discovering another trial in the same meta-analysis included patients who were explicitly depressed or hypomanic at baseline.5 Two other trials6,7 in the same meta-analysis did not specify whether their patients were euthymic at baseline: it seems www.thelancet.com/psychiatry Vol 3 April 2016
unlikely that such information would be reliably retrievable in one of these studies,6 done over 30 years ago. The response by Kendall and colleagues still does not account for why the study by Scott and colleagues was included in meta-analyses for depressive and manic relapse considered separately, as we pointed out. We declare no competing interests.
*Sameer Jauhar, Peter J McKenna, Keith R Laws [email protected] Department of Psychosis Studies, Institute of Psychiatry, King’s College London, London WC2R 2LS, UK (SJ); FIDMAG Hermanas Hospitalarias Research Foundation, Barcelona, Spain (PJMcK); Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Spain (PJMcK); and School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK (KRL) 1
2
3
4
5
6
7
Jauhar S, McKenna PJ, Laws KR. NICE guidance on psychological treatments for bipolar disorder: searching for the evidence. Lancet Psychiatry 2016; 3: 386–88. Schulz KF, Grimes DA. Multiplicity in randomised trials II: subgroup and interim analyses. Lancet 2005; 365: 1657–61. Matt GE, Cook TD. Threats to the validity of generalized inferences. In: Cooper H, Hedges LV, Valentine JC, eds. The handbook of research synthesis and meta-analysis (2nd edn). New York, NY, US: Russell Sage Foundation, 2009: 537–660. Scott J, Paykel E, Morriss R, et al. Cognitive–behavioural therapy for severe and recurrent bipolar disorders. Br J Psychiatry 2006; 188: 313–20. Ball JR, Mitchell PB, Corry JC, Skillecorn A, Smith M, Malhi GS. A randomized controlled trial of cognitive therapy for bipolar disorder: focus on long-term change. J Clin Psychiatry 2006; 67: 277–86. Cochran SD. Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. J Consult Clin Psychol 1984; 52: 873–78. Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ 1999; 318: 149–53.
Student-run free clinics: the USA’s psychiatry recruitment solution? Fewer medical students are considering psychiatry as a profession than before. In the USA, 55% of practising psychiatrists are older than 55 years, and in 2014, only 52% of psychiatry
residency positions were filled by senior US medical students.1 14 of 203 psychiatry programmes did not fill all of their available positions in 2014. To address the declining popularity of psychiatry, medical students should be offered concrete, positive experiences in the psychiatric profession. One promising arena in which this offering of experiences is possible is student-run free clinics (SFRCs) in which students provide primary care to uninsured patients under faculty supervision. Today, in the USA, more than 100 SRFCs exist serving 36 000 patients, and this model has also spread to Canada, Mexico, and the Caribbean.2 A growing body of research suggests that experiences at student-run free clinics can have a lasting impact on medical students’ ambitions in the profession and provide them with valuable skills not taught in the classroom or on clinical rotations.3 Although SFRCs have attracted students to primary care and internal medicine, psychiatry as a profession has yet to take full advantage of the SRFC model. Attending psychiatrists often prefer not to become involved in SFRCs for fear of liability issues and worries that mental health care—unlike medical care—cannot be delivered safely and effectively in an SFRC setting. Several programmes, however, have shown that these worries might be unfounded. At Mount Sinai, New York, USA, medical students working with psychiatrists have shown that universal screening and treatment of depression is possible in an SFRC setting.4 At HAVEN Free Clinic, New Haven, CT, USA, Yale medical students work as so-called lay counsellors and learn to deliver evidence-based psychoeducation and behavioural activation interventions to patients with mild-to-moderate depression. 5 SRFCs represent a valuable opportunity to recruit medical students to psychiatry and reach a patient population that often does not have access to psychiatric care. Additionally, when psychiatric care 321