Harvey: Tell me. We're alone here. No witnesses. Art: Tell you? Harvey: A sort of confirmation. Art: Tell you what? Harvey: About ravishment
I am an unintentional psychologist. As teenager, I was persuaded to add Psychology as my final 'A'-level "...probably useful to have a science" I mused. Within days, psychology had consumed me with its easy charm - taking me to places that were simultaneously familiar and exotic - and we duly began a relationship that has persisted for 30 years.
Psychology is the perfect partner - being whatever we want it to be. As a psychology undergraduate, one day I was dissecting brains or measuring social behaviour in cockroaches, the next I was mesmerised by William James' poetic words on emotion or a lecturer telling me that I wanted to have sex with my mother.
Can we really refer to this capacious church of psychology as science?
("its awesome" according to my 5 yr old son Vivek)
For most of my academic life as a psychologist, I have endured a dissonance - never doubting that psychology was a science, but believing it is impossible to define a science. Thirty years on, defining science still seems like counting angels on the head of a pin, though now...I believe it's a mistake to refer to psychology as if it were a unitary discipline - rather we have psychologies. And more recently, reservations about the scientific status of some psychologies have begun to feed my obsessive dissonance. Indeed, I would venture that some of these psychologies are...frankly...anti-science (something I will return to in a later post).
Possibly because of a (righteous) historical fear of introspection, psychologists tend to look outwards rather than inwards...which brings me to my point about how psychology currently operates. Psychologists engage in a version of science that is systemically corrupted and blinkered. The evidence on this issue seems unquestionable to me - as indicated by the lack of published replications and null findings, questionable research practices such as selective reporting, hyperbole, evidence denial and even outright fraud, all combined with the shallow pursuit of the curious.
"...you cannot intellectualise your genes, which make aspects of your life inevitable. You cannot intellectualise yourself out of obsession. You cannot cure yourself of it." Nicolas Roeg
In this context, I am posting a collection of recent pieces where I have discussed problems in the practice of psychology - and the extent to which these issues undermine the scientific status of psychology as it currently practices
It's time for psychologists to put their house in order - My original article in the Guardian where I outline some of the systemic problems inherent in the way that psychology currently operates - especially with regard to publishing and my section editorship at the new journal BMC Psychology, which is addressing some of the issues regarding null findings and replications
Negativland - a home for all findings in psychology - The Open Access paper that I published in BMC Psychology (whichI'm delighted to see has over 10,000 downloads in 2 months). This paper reviews many problems and distortions that beset psychology and how these are longstanding - raising questions about the resistance to change amongst psychologists. One upshot of this unwillingness is how it plays out in the minds of the public - whether we believe psychology is a science or not in any technical intellectual sense becomes redundant if the wider perception of psychology is that it has little credibility and masquerades as a perverse charade of science (see Rupert Read's points below).
BBC Radio3 NightWaves audio recording of debate - Is Psychology a Science? - between myself and the philosopher Rupert Read on BBC Radio 3 Night Waves programme (it was linked to my Guardian article). One point argued by Read, is that it is in fact impossible to replicate experiments in psychology - because of the historical nature of human beings. I am pretty sure no psychologist would agree with this philosophical point - and I explain that we use naive participants. Indeed, Read's argument strikes me as essentially incoherent - at what point does the historical nature of humans kick-in? Presumably, even after one individual has been tested in any experiment - in which case, no experimentation is possible in psychology (nevermind replication)
Why Psychology ain't Science - piece written by Rupert Read following our debate, where he expands on why he thinks psychology is not (and cannot be) a science. This largely seems to consist in his straw-man positioning me as a simplistic Popperian as opposed to his seemingly Kuhnian view of science. "...real science is: roughly, Kuhnian puzzle-solving within a research tradition, in a field that is not one that we construct and inhabit just by virtue (following here Schutz and Garfinkel and Wittgenstein) of being competent social actors"
"Established Psychology is one of those juggernauts that Wittgenstein didn’t like, and rightly so." Rupert Read
Keith Jarrett - The Koln Concert
Storify - this is a collation of the many Tweet discussions that followed our debate on whether Psychology is a Science (compiled by @neurowhoa) - they have been nicely ordered along the line of themes as they emerged in random timeless Twitter space
E=MC2 by Big Audio Dynamite
a paean to Nic Roeg
Even if we psychologists do eventually show the determination to get our house in order - many will still view psychology as a pseudoscience - what is important....is how we psychologists view what we do and how we practice what we do
Our new soap that's peachy keen saves your soul and keeps you clean It's recommended, used by the Queen Gonna improve your IQ, help in everything you do It's economic, don't cost too much.
Know Your Product (The Saints)
Hutton P and Taylor PJ. Cognitive behavioural therapy for psychosis prevention: a systematic review and meta-analysis. Psychological Medicine (2013): 1-20
In January I blogged on a meta-analysis by Stafford, Jackson, Mayo-Wilson , Morrison & Kendall published in the BMJ - My post - Its Just a Story: Transition to Psychosis & CBT - concerns whether CBT may prevent transition to psychosis.
Cut ups
Three months on and we have another meta-analysis on the same topic from one author (Hutton) who coincidentally works in the lab of one author (Morrison) on the earlier paper
It's a mash-up (Pistols meet Madonna)
As noted, I have already covered some problems with the original BMJ paper and much of what I said there applies here. Nonetheless, the current meta-analysis makes greater claims for CBT preventing transition to psychosis e.g. over longer periods of time.
At every time point, the relative risk of transition was reduced by more than 50% for those receiving CBT. (Hutton & Taylor 2013)
The Saints (1978, Know your Product)
A fine Australian export
"Where's the Professor...we need him now"
Why do Hutton & Taylor come to somewhat grander conclusions in favour of CBT? One reason is because they included a study not included by Stafford et al. The study is by Bechdolf et al. (2012) "Preventing progression to first-episode psychosis in early initial prodromal states." As Figure 2 (below) from Hutton & Taylor shows, this Bechdolf paper is the most favourable towards CBT preventing transition (with largest risk ratio here at 6 months, but also in their 12 month (0 and 9 transitions for Experimental and controls respectively) and 18-24 month analyses (1 and 10 transitions) - so is worth looking at in more detail
Its not that Stafford et al were unaware of the Bechdolf paper, so why did they not include it...?
Crucially, Bechdolf et al used Integrated Psychological Intervention (IPI), which does include individual CBT, but also group skills training, cognitive remediation and multifamily psychoeducation. So, even if changes in transition rates emerge - they are no more attributable to CBT than any other component of the IPI intervention. Unsurprisingly then, in their meta analysis, Stafford et al examined IPI studies including the Bechdolf study separately from their CBT analyses.
Jim Morrison (& the Doors) duets with Amy Whinehouse
Some mash-ups are made in heaven
Its also worth noting that Bechdolf et al also differs from the all other studies as their participants were prodromal, i.e. had self-reported symptoms which they describe as preceding the subthreshold psychotic symptoms typically used as entry conditions in the other studies. Finally, Stafford et al rated study quality using the GRADE system (for risk of bias, inconsistency, indirectness, imprecision, and publication bias) and classed the Bechdolf et al study as 'very low' quality evidence - indeed, the lowest possible in that framework.
You can't fake quality any more than you can fake a good meal
William Burroughs
A second difference concerns the inclusion of McGorry et al (2012) by Hutton & Taylor. Again its worth examining this study in more detail
First, what is the design of the McGorry et al study? Well...participants were randomly assigned to the following groups:
Cognitive Therapy + Risperidone
Cognitive Therapy + Placebo
or Supportive Therapy + Placebo.
Plus
a 'Monitoring' group - or those people who refused random assignment - so are not -in fact - part of a randomised trial (but self-selecting controls!)
McGorry et al then have no CBT group (as such) and no randomised control group (as such)...
So, its difficult to see how the studies by Bechdolf et al and McGorry et al could be described as assessing the impact of CBT per se
and when they are removed them from the equation ...the effect is non-existent
As mentioned, I have covered the Stafford et al meta analysis and some of the studies and issues in my other post. Nevertheless, I would conclude by reiterating:
a) the extremely low transition rates (<10%) of Ultra High Risk individuals
b) CBT shows no evidence of preventing transition - indeed, no single study shows a significant and reliable effect; and finally,
c) even if CBT did prevent transition to psychosis ...How would it actually be preventing psychosis? The whole approach is bereft of any theoretical ideas on this notion - one thing is sure - it is NOT via the reduction of symptoms - as both meta analyses definitely show that symptoms do not change from before to after CBT
~
When Brion Gysin spoke about his 'Dream Machine', he said it was "The worlds only artwork that you look at with eyes tightly closed" - I wonder if the same might be said of CBT for psychosis.
...then supposin' your legs just
withered away & you had to somehow slide around on your backside - for the rest of your days. "Imagine"... that you're happy now. "It's easy if you try" - because we're all caught up in a mortifying loop - LIFE Song Without An Ending
A brief Twitter conversation led me recently to reminisce about Burning
Blue Soul. Although attributed to The the, it was in fact the first
album released on September 7th 1981 under Matt Johnson's own name on the
then fledgling 4AD
label.
Why mention it some 32 years later? Well... I know a little about the
making of this album...'back in the day' Matt Johnson and I were close friends.
I thought I would share a few increasingly fragmentary memories of the making of - what I
believe is a - seminal album - not to everyone's taste, but then it wouldn't
be seminal if it were to everyone's taste. This unique record has been over-shadowed
by the later - more accessible work that reached an international audience.
I'm wasting away with worry
& my heart just skipped a beat
But then again...
I felt much calmer
I opened up a can of 'Instant Karma'
a yoga posture for self awareness
& the devil rides out of
YOUR LIFE!!! (Like a) Sun Rising
Through My Garden
Nobody could doubt the invention and courage of Burning Blue Soul - of an 18/19 year old opening his psyche not indulgently to an established adoring audience, but to any other person experiencing life as ununderstandable. The album is a trip from the meandering quasi-orchestral Can and Faust-like tribal rhythmic loops of 'Red Cinders in the Sand', to the chirping grasshopper percussion and sound of the Pungi (as played by snake charmers [*correction my Indian wife assures me it is Shennai - music played at Indian weddings - & may be for the groom leaving!]) in '(Like a) Sun Rising through my Garden', the layered forward and backward guitars of 'Icing up' and several visits from the ghost of John Lennon - especially on 'Bugle Boy' (and various lyrical nods to 'Imagine', 'Instant Karma' and "Ive got a million Beatles under my skin" on other songs), add the lyrical whimsy of Syd Barrett, and occasional vocal nods to Tim Buckley ....until the closing echoic oriental lament of 'Another Boy Drowning' ...."we all know we edging our way toward the end" - so odd for someone so young (unless you knew Matt) ..with the final words of Burning Blue Soul being:
Movin' on, opening new doors...Life just doesn't seem that simple anymore.
In case I don't see you again...I hope you'll feel glad that you know me while I was here
Summer Nights 1981
Its worth thinking about what was happening in the summer of '81? We had
entered the first of Margaret Thatcher's terms of office, unemployment had
risen to nearly 3 million, the warm nights were lit up by the so-called 'Race
riots' in Brixton, Toxteth, Chapeltown and Hansworth. I recall many smaller
disturbances happening all around me in London at the time. Charles and Diana
married, MTV launched, the Maze 'hunger strikes' came to their inevitable conclusion. The first recognized cases of AIDS appeared and Pope
John Paul II was shot. Most of these events were chronicled in the snapshot of
1981 that is Burning Blue Soul.
Almost every lyric can be traced to specific autobiographical events - for example
I like you... I
think that you're pretty good
But I think that you think, that I...
Well... that I'm a bit undercooked...
...100,000 people today were burned.
I felt a pang of concern,
- what are we waitin' for - a message of hope.
- from the... POPE!
I think he got shot... as well!
Song Without An Ending
The "I like you...I think you're pretty good" was I believe derived from a voice recording that Matt had made of his youngest brother Gerard (probably no more than 3 at the time). Gerard has grown from cute small boy to the writer and director of the acclaimed movie Tony. As always, being a magpie, Matt incorporated news events into his lyrical content - Pope John Paul II had indeed been shot while the album was being recorded
It was a paean to the past - albeit one that had become part of our past
in the future - nothing is new, nothing is old. The influences are
psychedelic, although psychedelia had long gone to be replaced by the creative darkness of the late 70s and early 80. - all added to a high degree of existential anxiety,
hypochondria and the fearless experimentation of someone with nothing much
to lose (no job, no major record contract) - it is a proverbial musical
DSM (Diagnostic and Statistical Manual of Mental Disorders),
but carries within each song... the cure for a disorder
I
have no future, for I've had no past
I'm just sittin' here
Pullin' arrows
Out of my heart
History repeats itself
Within the realms of my inexperience
Icing Up
Now I have had a past, memories do come to mind - Matt had not
long passed his driving test and we spent long summer days in 1981 listening to
early and final version of the songs on a cassette player in his car (I vaguely
recall it wasn't even built into the dashboard, but a portable - so the quality
was impeccable). We would drive around the sunny Essex countryside, in the days
when seatbelts were unrequired, smoking cigarettes (almost always mine...as recorded in a later lyric for Waiting for the Upturn).
The album was recorded in fits and starts in different studios, with different
producers and engineers over the best part of that year - and some of this
explains the eclectic feel and broad sweep ...of the album and how it coalesces
or not into a single coherent piece. As an aside 10 years later, I remember
similar journeys in the early 90s listening to early drafts of songs from Dusk
in Matt's car (e.g. without the vocals), travelling out to his parents
lovely countryside home. I think the car was a place for Matt to reflect on and
hone his songs.
Red Cinders in the
Sand
The album opens with Red Cinders in the Sand - if this isn't an English
version of Faust's Krautrock, then what is? The piece starts quietly with Matt
whispering 'an hallucination' . It is a set of rhythms, the like of
which would later become de rigeur for many tribal bands - all mostly
through the use of tape loops (Matt worked at De Wolfe studios in Wardour
Street - so was constantly putting tapes together), overlaid with sitars,
'broken' guitar sounds and what can only be described as the kinds of brass
sounds you hear in epic Roman movies plus the simple sound of stuff crashing
(for want of a better description)
Bugle Boy
The country is
riddled with social ills & aches,
But my heart is calmed by her embrace,
I'm trying to tell something to the world,
- But my words are slurred & slow,
Have you ever been caught up in a dream,
where your legs were froze.
I was left alone, with my thoughts and my guitar.
But it felt hopeless,
Like the desire of the moth - for a star.
Sometimes... nothing seems unreal,
this strange little boy said
"Mister, play us your guitar" & I said -
"No... I can't"
& put my guitar in the car-
Listening to the music of heaven & earth,
Have you ever thought you were the
- Most important thing in the universe.
I didn't know whether to strengthen my
Weaknesses - or play to my strengths.
Yeah...
I was trapped in the triviality of- everydayness.
I said.
"There's magic in my head, girl.
but I only use it when I'm depressed"
I don't suppose she heard me.
She was too busy admiring her dress.
She said I was
pretentious
I said - just young - & - well intentioned,
Who can save us now
- the world rots...
I did know the secret of the universe
... only I forgot!!
The album is often described as a refrain from bedsit land - only partly
true as Matt still lived in his parents' pub in Loughton (The Crown). Aside
form the car, the cellar of the Crown was a prominent site for listening to,
playing music and just trying out stuff - bear in mind that the music which populates
BBS is not the product of someone going into the studio with an album of songs
in mind and simply recording them Rather it was the evolution of many months
(or years of teenage gestation) - indeed, parts of songs frequently migrated
from one track to another.
The Crown (Loughton, Essex) - Below ground level, amongst the beer barrels, Burning Blue Soul was
conceived and born
Its important to bear in mind that Matt was not a 'musician' in the
traditional sense - he was reasonably comfortable on keyboards having had some
lessons, but most of the time he stuck to the guitar ....in an open-E tuning.
He was not confident about the songs on BBS, and I recall conversations with
him about various pieces - which all sounded great to me and over three decades
later....you know what....they still sound fresh and relevant to me - from the
prescient musical styles through to the remarkable personal, social and
political lyrical voice for someone so young.
Whispering
sadness, like a mild form of madness,
or a line from a meaningful song,
Turn your eyes to the lord,
but the churches are empty,
they're is now no escape from your longing.
Things are gonna start getting good,
...you hear them call,
You captured the unspoken feelings of my heart,
... which gave me a start.
I know I'm nowhere near perfection
...I'm pointing in the wrong direction
Delirious
Where did the Burning
Blue Soul cover idea come from? I might claim some influence: the name 'Burning
Blue Soul' and the cover design came from me and was heavily and obviously
influenced by The Psychedelic Sounds of the 13th Floor Elevators. I also
believe I suggested the half laminate cover to give a 60s feel and finally, the
original cover photography for the sleeve and insert was done by my brother.
The internal sleeve notes indicate the various influences around at the time. A major one was Wire - present physically in the guise of Bruce Gilbert and Graham Lewis - and spiritually through the massive affection for their album 154 released at that time. Credits also appear for other close friends- Tom Johnston,renowned cartoonist for the Sun newspaper; Peter Ashworth, whose name you may not recognise, but almost certainly your record collection contains covers that he photographed (check out his link); Stevo (Steve Pearce) the creator of Some Bizzare records and manager of Soft Cell amongst others; Andrew Johnson, Matt's brother and responsible for the later distinctive artwork for The the as well as a painting of Matt on the reverse cover; and finally Pete Maben, who was a recording engineer who dealt with some of the sessions (and ran a little recording studio in Forest Gate East London)
Another Boy
Drowning
There are no voices
- as the time approaches,
I wanted to be like Bob Dylan
Until I discovered Moses
Saturday night & I was lying in my bed
The window was open & raindrops
Were bouncing off my head
When it HIT me like a Thunderbolt!!!
"I don't know nothing- & I'm scared
that I never will"
While writing this blog, I found this image on the web - it dates from 1980/81 and shows the youthful Matt Johnson on the left, peeking over someones shoulder; Charlie Blackburn holding the first the The single on 4AD (CB and MJ were in a band called the Marble Index prior to the The). Sadly I cant recollect the other two people.... but my good self is on far right wearing my distinctive pyjamas and leather jacket combo -
I have no recollection of where it was taken or what we were doing - I'm innocent!
Dipping swords in metaphors yeah but what does he know? We're always one step behind him he's Brian Eno Brian Eno! He promised pretty worlds and all the silence I could dream of Brian Peter George St John Le Baptiste De La Salle Eno Brian Eno by MGMT
Scientists are geeks and artists and musicians are cool ....aren't they?
Science and scientists are viewed as somewhat controlled, controlling, rule-bound, formulaic (the Scientific Method) and emotionally bereft Mr Spocks. By contrast, artists are seen as inspired, more random, often troubled and free souls who free us and our imaginations
These stereotypes are a view of the seemingly quiescent surface of science. Scrape beneath the tranquil surface though ...and you often find a festering, turbulent and creative underbelly.
It is important to acknowledge and embrace the art of science, embrace the random....but being scientists and perhaps self-defeating...we might like some rules to help us control this random (ha!) creative process!
In this context, let me introduce Brian Peter George St John Le Baptiste De La Salle Eno or as he is more commonly known - Brian Eno. Eno is, of course, best know for producing many famous bands (U2, Bowie, Talking Heads) and was a founder member of Roxy Music. His influence on electronica has featured in my blog previously.
Here I mention his Oblique Strategies (Over One Hundred Worthwhile Dilemmas) - a deck of simple printed cards created by Brian Eno and artist Peter Schmidt and first published in 1975.Each card contains an aphorism intended to help artists break creative blocks.
"By This River" (Eno, Roedelius, Moebius) from Before & After Science
The idea of Oblique Strategies is to select cards at random - here is a program that does this for you
The cards contain a phrase or cryptic remark that may be used to overcome a creative impasse or dilemma. Some are specific to music composition and Eno has used them throughout his own recordings and his production of others - the cards were a key part of the production of David Bowie's seminal Berlin trilogy of Low, Heroes and Lodger.
"We used oblique strategies a lot. Sense of Doubt was done almost entirely
using the cards, and we did talk about work methods. But no, I don't think we
[Eno & Bowie] have that much in common. But that's fine, so long as there's give and take"
Working on Sense Of Doubt, Bowie and Eno each
pulled out an Oblique Strategy card and kept it a secret from the other. As Eno
described it:
It was like a game. We took turns working on it; he'd do one overdub and I'd do the next. The idea was that each was to observe his Oblique Strategy as closely as he could. And as it turned out they were entirely opposed to one another. Effectively mine said, 'Try to make everything as similar as possible.' … and his said, 'Emphasize differences.
"Sense of Doubt" by David Bowie - incipient alien hand syndrome
Many of the cards are however more general and useful in many situations - I have often found them to act as catalysts for creative ideas both in a previous more artistic career and now as a scientist.
Science and art are not mutually exclusive and most, if not all, of us engage with both ...the struggle between structure and serendipity and not a reduction of one to the other
As Eno says
Of course, the chances of you getting a great piece of music are quite remote....But the chances of you getting a seed for something are quite strong.
Oblique Strategies will not give you a high H-Index or guarantee a successful scientific career, but may provide that lacking creative spark at the many overly-analytical stages of the scientific process
In this context, it is worth noting that the Oblique Strategy cards are a simple stimulus open to massive interpretation - not unlike inkblot cards from the Rorschach test. Research shows that the number of unique responses to random figures (like the one above) is linked to having larger amygdalae. Asari et al (2010) asked healthy participants to report what the figure looked like the number of responses correlated positively with amygdala size.
The authors suggest of course that amygdalar enlargement in the normal population might be related to creative mental activity. Indeed, unique Rorschach responses are observed at higher frequency in the artistic population (e.g. Ramachandra, 1994; Rorschach, 1921) as well as more frequently in those with psychosis (e.g. Exner, 2003)....So, perhaps Oblique Strategies will enlarge your amygdalae
To finish with a random, creative amygdala-Brain Eno connection - here is 'Through Hollow Lands' from Eno's Before and After Science album. The psychology link? This piece was co-arranged by and features Fred Frith - one of the founding members of the illustrious and wonderfully monickered Henry Cow - an art group that came out of Cambridge University in the late 1960s/early 1970s. Fred Frith is, of course, the brother of the psychologist Chris Frith... who has written extensively on the Social Brain? (mentioning the amygdala a lot) and here is Henry Cow with their track Amygdala
Here we have another, in press at Journal of Behavior Therapy and Experimental Psychiatry. While Morrison et al referred to theirs as 'exploratory', Staring et al provide us with the ubiquitous .... 'pilot'
Satellite of Love by Lou Reed
What did Staring et al do?
In an open trial 21 adult outpatients with a schizophrenia spectrum disorder with negative symptoms received an average of 17,5 sessions of CBT-n (CBT for negative symptoms). At baseline and end-of-treatment, they assessed negative symptoms. They claim that "Intention-to-treat analyses showed a within group effect size of 1.26 on negative symptoms"
An effect size of 1.26 is, of course, massive - if only it meant something. As noted previously nonblind (open) studies are prone to large bias and without a control group, who knows why they changed. To be fair to the authors, they do have a limitations section - and it is quite large! Here is part of it:
"This was an uncontrolled study. Therefore the efficacy findings are biased. Patients may have improved over the course of the study by self-initiated change or because other treatments were helpful. The lack of a control group means that this effect was not controlled for."
"Second, also as a consequence of the uncontrolled design, measurements were not blind. We mostly used self-report measurements, and patients were fully aware that they had received an active treatment for their negative symptoms. This may have caused efficacy to be overestimated"
One thing we may be sure of is that the effect is overestimated...why? Because studies meeting acceptable quality i.e. RCTs that are blind and with controls suggest an effect size of at most .20 and nonsignificant (Wykes et al 2008) - Seems an overestimation is likely - by about 6 fold!
Anyway, my point here is that we need to have some monitoring of studies that are essentially uninterpretable. To borrow a phrase from Lou Reed, I see them as "Satellites of Love" - autopilot research - probably done out of love - but ultimately clutter-up the science atmosphere.
The authors finish with:
"Randomized controlled trials with sufficient statistical power will need to be performed in order to confirm or refute our results"
This is somewhat odd because, as noted, many RCTs have already shown CBT to be ineffective for negative symptoms - as such... the study was refuted at conception
...All such satellites should engage auto-pilot and return to 'Llama land'
p.s. ask youself - would the study have been published if the results were negative?
I've been living through changes...And I could swing for you I can see the veins in my hands...Are showing through
But if you disguise what...These things are doing to me If you criticize them...I'll know that you can see... Until you realise It's just a story
The Teardrop Explodes (Treason)
Stafford MR, Jackson H, Mayo-Wilson E, Morrison AP, & Kendall T. (2013). Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ, 346, f185
Oh the irony ....just as many (often in the UK) were clamouring for the DSM-5 to dispense with so-called Attenuated Psychosis Syndrome (which they did reject), the Brits sneaked it in through the back door as (Ultra) High Risk for Psychosis in the new NICE guidelines for Psychosis and Schizophrenia in Children and Young People. In their 485 page guide, NICE advise on 'treatment' for those aged between under 18 (estimates suggest a 0.4% prevalence of psychotic disorders in children aged between 5 and 18 years)
The cliche states that 'An ounce of prevention is worth a pound of cure' and a recent meta-analysis (Open Access in BMJ) examines whether various interventions might prevent or delay transition to psychotic disorders for people at 'High Risk'. The paper was written by some members of the NICE committee who prepared the guideline for children and young people; and underpins some of their decision making process...so, is worthy of closer inspection
I want to focus on their recommendation - CBT - as their conclusion implies CBT is the best course of 'action' for preventing transition to psychosis
Stafford et al declare that "Among people at “ultra high risk” of psychosis, about 22% to 40% transition within 12 months [and that]Interventions that delay or prevent transition to psychosis from this prodromal syndrome could be clinically and economically important." Unquestionably, if up to 40% of those who would go on to develop psychosis (schizophrenia) could receive an intervention to delay or even prevent such a transition, this might be viewed as a worthy ambition.
What is (Ultra) High Risk and what did Stafford et al do?
Stafford et al meta-analysed 5 studies examining people "judged to be at risk of developing psychosis on the basis on a clinical assessment identifying prodromal features."
and they conclude that Cognitive Behavioural Therapy has the effect of "reducing transition to psychosis at 12 months (risk ratio 0.54 (95% confidence interval 0.34 to 0.86); risk difference −0.07 (−0.14 to −0.01)."
Teardrop Explodes (Treason 1980) - Julian Cope as popstar and unfortunate dancing
A few of my observations:
1) The authors report that the Risk Difference is -0.07. This means that CBT produces a 7% reduced risk for transition to psychosis compared to control. To translate this into another common metric, the Number Needed to Treat (NNT), an average of 14 people need to be treated with CBT to prevent one person developing psychosis - this NNT is somewhat larger than typically claimed by individual studies!
Figure 1. Risk Ratios for Number of transitions to psychosis in CBT vs supportive counselling
2) As can be seen in Fig 1, the small significant effect reflects the pooling of 5 studies; however, none of the five studies were themselves significant! The wonderful world of meta analysis (I have referred to this phenomenon previously in my blogs on using LSD to treat alcholism and how to deal with negative findings
Figure 1 also shows that the transition rate is extremely small in these studies - nowhere near the heights of 40% but closer to 10% on average. In other words, 90% of the identified High Risk individuals do not develop psychosis at all! In this context, we need to seriously consider the risks of labelling 9/10 people as High Risk when they are not! The stigma of being labelled High Risk was one major complaint about adding Attenuated Psychosis Syndrome to the DSM-5. As McGorry et al (2003) rightly state "most cases of first episode psychosis still come from the low-risk and undetected groups" (p.784) - not from the ironically entitled 'Ultra High Risk'!
3) Although the NNT and Risk Difference figures are not overly impressive, they do appear to record a significant effect. Nonetheless, the difference between CBT and control in conversion rates disappears beyond 12 months i.e. the point at which this meta-analysis terminates. As the authors state:
"At 18 months, there was low quality evidence that CBT is associated with fewer transitions (0.63 (0.40 to 0.99)), and the effect did not remain significant in sensitivity analysis (0.55 (0.25 to 1.19))."
If a small effect of CBT disappears beyond 12 month comparisons - how useful is it? And why stop at 12 months?
4) Analysis of the effects of CBT on symptoms of psychosis is also worth considering in transition studies and the authors did examine this.
"Combined effects for positive symptoms of psychosis, depression, and quality of life were not significant at any time point."
To reiterate, CBT did not impact symptoms at all!
5) Finally, the authors claim that all of the 5 included studies were high quality (having excluded others for example, for lack of blinding for raters at outcome). Their Figure 2 (see below) indicates that the 5 CBT studies (Addington 2011; Morrison 2004; Morrison 2011; Phillips 2009 and van der Gaag 2011), were all blind at outcome assessment (see blinding of outcome assessment column)
However, the Morrison et al (2004) study was not blinded at outcome - as they say in that 2004 paper
"Assessors were intended to be masked to the condition to which the patient was allocated; however, this proved difficult in practice because the participants often divulged information about their therapist, or used language that suggested they were receiving cognitive therapy...It proved impossible fully to maintain masking to treatment allocation for assessment of the primary outcome" Morrison et al (2004)
It seems somewhat odd to make such a mistake- as Morrison one of the authors of this current meta-analysis! Removing Morrison et al (2004) from the analysis reduces the Risk Ratio (RR=.60 [.37 to 0.99) which now becomes marginally significant (p=.044) and suggests that the NNT with CBT would be 22 to stop one psychosis transition.
To conclude, it seems that Ultra High Risk for Psychosis, which has been sneaked into NICE guidelines for children and the young, has a limited application - probably less than 1 in 10 individuals actually convert. Moreover, the claim that CBT provides the best form of 'treatment' also seems unsubstantiated. As usual, I am sure we will hear claims for further, better, larger trials - to justify the conclusion already made!
