Skip to main content Accessibility help
×
Home

NICE v. SIGN on psychosis and schizophrenia: Same roots, similar guidelines, different interpretations

  • Tim Kendall (a1), Craig J. Whittington (a2), Elizabeth Kuipers (a3), Sonia Johnson (a4), Max J. Birchwood (a5), Max Marshall (a6) and Anthony P. Morrison (a7)...

Summary

A recent editorial claimed that the 2014 National Institute for Health and Care Excellence (NICE) guideline on psychosis and schizophrenia, unlike its equivalent 2013 Scottish Intercollegiate Guidelines Network (SIGN) guideline, is biased towards psychosocial treatments and against drug treatments. In this paper we underline that the NICE and SIGN guidelines recommend similar interventions, but that the NICE guideline has more rigorous methodology. Our analysis suggests that the authors of the editorial appear to have succumbed to bias themselves.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      NICE v. SIGN on psychosis and schizophrenia: Same roots, similar guidelines, different interpretations
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      NICE v. SIGN on psychosis and schizophrenia: Same roots, similar guidelines, different interpretations
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      NICE v. SIGN on psychosis and schizophrenia: Same roots, similar guidelines, different interpretations
      Available formats
      ×

Copyright

Corresponding author

Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, UK. Email: tim.kendall@shsc.nhs.uk

Footnotes

Hide All

See invited commentary, pp. 320–321, this issue.

Declaration of interest

T.K. receives £1.2 million per year from NICE to develop NICE guidelines in mental health, and chaired the original NICE guideline (2002). He has facilitated 18 NICE guidelines, including the NICE guideline on schizophrenia (2009), psychosis and schizophrenia in children and young people (2013) and psychosis and schizophrenia in adults (2014). He is now leading the introduction of Improving Access and Waiting Times (NICE implementation) programme for NHS England. T.K. has lead a NICE collaboration with The Netherlands, Turkey and Georgia to share or develop national guidelines programmes and declares he has an ‘allegiance bias' in favour of NICE but not against SIGN. C.J.W. was the lead systematic reviewer for the NICE guidelines on schizophrenia (2002 and 2009) and on psychosis and schizophrenia (2014), as well as numerous other NICE guidelines. E.K. chaired the NICE guidelines on schizophrenia (2009) and on psychosis and schizophrenia (2014). She is a cognitive–behavioural therapy for psychosis (CBTp) practitioner and family intervention for psychosis practitioner, and has researched and written many articles on both. S.J. was a member of the NICE guideline committee on psychosis and schizophrenia (2014). M.J.B. was a member of the NICE guideline on psychosis and schizophrenia in children (2013) and in adults (2014), and is a CBTp practitioner. M.M. was a member of the NICE guidelines on schizophrenia (2002) and on psychosis and schizophrenia (2014). A.P.M was a member of the NICE guideline on psychosis and schizophrenia in children and young people (2013) and in adults (2014). He is also a practitioner of cognitive therapy and delivers this intervention within the UK National Health Service. He also receives royalties from texts or books published on cognitive therapy, and has received fees for delivering workshops on cognitive therapy.

Footnotes

References

Hide All
1 Scottish Intercollegiate Guidelines Network. Management of Schizophrenia (SIGN 131). SIGN, 2013.
2 National Collaborating Centre for Mental Health. Psychosis and Schizophrenia in Adults: The NICE Guideline on Treatment and Management (Updated Edition) (Clinical Guideline CG178). National Institute for Health and Care Excellence, 2014.
3 Taylor, M, Perera, U. NICE CG178 Psychosis and Schizophrenia in Adults: Treatment and Management – an evidence-based guideline? Br J Psychiatry 2015; 206: 357–9.
4 National Institute for Clinical Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care (Clinical Guideline CG82). NICE, 2009.
5 Gaebel, W, Weinmann, S, Sartorius, N, Rutz, W, McIntyre, JS. Schizophrenia practice guidelines: international survey and comparison. Br J Psychiatry 2005; 187: 248–55.
6 National Institute for Health and Care Excellence. The Guidelines Manual. NICE, 2012.
7 National Institute for Health and Care Excellence. Psychosis with Substance Misuse in Over 14s: Assessment and Management (Clinical Guideline CG120). NICE, 2011.
8 National Institute for Health and Care Excellence. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance (Clinical Guideline CG192). NICE, 2014.
9 The Schizophrenia Commission. The Abandoned Illness: A Report by the Schizophrenia Commission. The Schizophrenia Commission, 2012.
10 Jauhar, S, McKenna, PJ, Radua, J, Fung, E, Salvador, R, Laws, KR. Cognitive–behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry 2014; 204: 20–9.
11 Burns, AMN, Erickson, DH, Brenner, CA. Cognitive–behavioral therapy for medication-resistant psychosis: a meta-analytic review. Psychiatr Serv 2014; 65: 874–80.
12 Turner, DT, van der Gaag, M, Karyotaki, E, Cuijpers, P. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry 2014; 171: 523–38.
13 van der Gaag, M, Valmaggia, LR, Smit, F. The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: a meta-analysis. Schizophr Res 2014; 156: 30–7.
14 Velthorst, E, Koeter, M, van der Gaag, M, Nieman, DH, Fett, A-K J, Smit, F, et al. Adapted cognitive–behavioural therapy required for targeting negative symptoms in schizophrenia: meta-analysis and meta-regression. Psychol Med 2015; 45: 453–65.
15 Peters, E. An oversimplification of psychosis, its treatment, and its outcomes? Br J Psychiatry 2014; 205: 159–60.
16 Kendall, T, Glover, N, Taylor, C, Pilling, S. Quality, bias and service user experience in healthcare: 10 years of mental health guidelines at the UK National Collaborating Centre for Mental Health. Int Rev Psychiatry 2011; 23: 342–51.
17 Morrison, AP, Turkington, D, Pyle, M, Spencer, H, Brabban, A, Dunn, G, et al. Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial. Lancet 2014; 383: 1395–403.
18 Morrison, AP, French, P, Stewart, S, Birchwood, M, Fowler, D, Gumley, AI, et al. Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2): a multisite randomised controlled trial of cognitive therapy for at risk mental states. BMJ 2012; 344: e2233.
19 National Institute for Health and Care Excellence. Psychosis and Schizophrenia in Children and Young People: Recognition and Management (Clinical Guideline CG155). NICE, 2013.
20 Stafford, MR, Jackson, H, Mayo-Wilson, E, Morrison, AP, Kendall, T. Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ 2013; 346: f185.
21 Hutton, P, Taylor, PJ. Cognitive behavioural therapy for psychosis prevention: a systematic review and meta-analysis. Psychol Med 2013; 44: 449–68.
22 van der Gaag, M, Smit, F, Bechdolf, A, French, P, Linszen, DH, Yung, AR, et al. Preventing a first episode of psychosis: meta-analysis of randomized controlled prevention trials of 12 month and longer-term follow-ups. Schizophr Res 2013; 149: 5662.
23 Bola, JR, Kao, DT, Soydan, H. Antipsychotic medication for early-episode schizophrenia. Schizophr Bull 2012; 38: 23–5.
24 National Institute for Clinical Excellence. Service User Experience in Adult Mental Health (Clinical Guideline CG136). NICE, 2011.
25 Kendall, T. Treating negative symptoms of schizophrenia. BMJ 2012; 344: e664.

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

NICE v. SIGN on psychosis and schizophrenia: Same roots, similar guidelines, different interpretations

  • Tim Kendall (a1), Craig J. Whittington (a2), Elizabeth Kuipers (a3), Sonia Johnson (a4), Max J. Birchwood (a5), Max Marshall (a6) and Anthony P. Morrison (a7)...
Submit a response

eLetters

NICE; at risk of bias?

Sameer Jauhar, Consultant Psychiatrist, King's College, London.
Peter J McKenna, Research Psychiatrist, FIDMAG Germanes Hospitalàries Research Foundation and CIBERSAM, Spain.
Keith Laws, Professor, Department of Psychology, School of Life and Medical Sciences, Universit
21 April 2016

Kendall et al’s response to the charges of bias by Taylor and Perera itself seems to show evidence of bias.

In the section headed ‘CBT as a panacea’ they argue that our meta-analysis1 has been criticized for using ‘…idiosyncratic inclusion criteria and drawing conclusions unjustified by the evidence.’ We responded to these criticisms and were able to show by means of further analysis that altering the inclusion criteria did not materially affect the results. Yet Kendall et al do not cite our response – isn’t this…idiosyncratic and unjustified?



Kendall et al further state that ‘there were another four reviews of CBTp published last year and four of the five (including Jauhar et al) concluded that there were significant benefits’. This seems a perverse interpretation of what we found, which was that effect sizes for CBT at end-of-trial were small and smaller still in blind studies, becoming non-significant for positive and for negative symptoms.

Among the other meta-analyses cited, one examined CBT for negative symptoms and also found no evidence of effectiveness at end of trial or follow-up3. Another4 found an effect size of 0.16 for positive symptoms at end-of trial which lost significance when researcher allegiance was controlled for. The other two meta-analyses mentioned by Kendall and colleagues were small and selective and could genuinely be held up as examples of using idiosyncratic inclusion criteria (see http://ebmh.bmj.com/content/17/3/67/reply#ebmental_el_12207). Incidentally, as far as we can tell, none of these meta-analyses was pre-registered.

Ironically, our findings were not as unfavourable as those in the meta-analyses used by NICE in CG178, which failed to show a significant effect of CBT on positive and negative symptoms at end-of-trial and follow-up. There is also an elephant in the room here, in the shape of the 2012 Cochrane Collaboration systematic review5. This concluded there is no clear and convincing evidence that CBT was superior to other psychological interventions in schizophrenia. Why do Kendall et al not cite this high-profile publication?

Finally, Kendall et al state that NICE guidelines have played a leading role in reducing the impact of bias including from selective publishing. In this context it seems legitimate to ask what they intend to do about the POSITIVE trial, a large, well-controlled trial of CBT for positive symptoms that remains unpublished six years after analysis of major outcomes was expected to begin (see http://tinyurl.com/jzonnf3 ). Did NICE contact the authors of this study before deciding not to update their 2009 guideline? Will they be getting in touch with them when they next update it?

References

1 Jauhar S., McKenna P. J., Radua J., Fung E., Salvador R. ,Laws K. R. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry 2014; 204: 20-9.

2 McKenna P. J., Radua J., Laws K. R. ,Jauhar S. Author's reply. Br J Psychiatry 2014; 205: 160-1.

3 Velthorst E., Koeter M., van der Gaag M., Nieman D. H., Fett A. K., Smit F., et al. Adapted cognitive-behavioural therapy required for targeting negative symptoms in schizophrenia: meta-analysis and meta-regression. Psychol Med 2015; 45: 453-65.

4 Turner D. T., van der Gaag M., Karyotaki E. ,Cuijpers P. Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies. Am J Psychiatry 2014.

5 Jones C., Hacker D., Cormac I., Meaden A. ,Irving C. B. (2012) Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database Systematic Review, Issue 4: CD008712.

... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *