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The wrong advice

January 10, 2008

The national clinical guideline on depression is flawed, acts as a mouthpiece for pharmaceutical firms and pays lip service to the views of service users. We must challenge it, says Malcolm Learmonth


According to the recent Layard report, "crippling
depression and chronic anxiety are the biggest
causes of misery in Britain today."

Both this report and the National Institute for Health and Clinical Excellence (NICE) clinical guideline on depression are shaping policy and having a major impact on what help
is available to people. And both claim that cognitive
behaviour therapy (CBT) is the "evidence based"
psychological treatment.

I came to the NICE guideline from the point of view of
analysing it to help approaches such as the arts therapies
make a case for their continued existence. The task turned out to be one of the most depressing I have ever undertaken professionally.

The full NICE guideline runs to 358 pages, but it is also
available in three shortened versions for the public and
professionals. Unsurprisingly, few people ? including those
who implement the guideline ? read the full version. Yet it
is only in the full version that the flaws show themselves.

The shortened versions simply remove all the complexities,
caveats and doubts. What is presented to the world as
'Now we know the facts we can tell you what?s good for
you? turns out to be highly questionable, even within its
own terms.

Let?s start with service user participation. The guideline
claims that "For any guideline on the treatment of
depression to be credible it has to be informed at every
stage of its development by the perspective of patients"
(p.31).Yet the service user perspective takes up less than
one page out of 358.This is mere lip service: there is no
evidence of service user participation having taken place
beyond this statement.

The (sole) patient quoted clearly says that "the provision of
alternative therapies is paramount, instead of the reliance
on medication as an ongoing first line defence" (p.32).Yet
medication (and CBT) are exactly what the guideline
recommends as a "first line of defence".

Then there?s the question of whether "depression" is valid at
all as a catch-all description for hugely variable experiences
of distress. The guideline?s development group themselves
don?t believe that it is. Their view is that "it is too broad and
heterogeneous a category, and has limited validity as a
basis for effective treatment plans. A focus on symptoms
alone is not sufficient because a wide range of biological,
psychological and social factors have a significant impact
on response to treatment and are not captured by the
current diagnostic systems" (p.54).

If, as the guideline suggests, depression as a category doesn?t mean very much, why are only psychological therapies "specifically adapted" to this chimera included? And why are holistic approaches like the arts therapies excluded?
The apparent logic and coherence of the guideline?s approach breaks down under scrutiny.

Then there is the question of what constitutes "evidence".
NICE works with what they call a "hierarchy" of evidence.
Grade A evidence is obtained from randomised controlled
trials (RCTs). Grade B evidence, in descending order of value,
are well-designed controlled study without randomisation,
well-designed quasi-experimental study and lastly well designed descriptive studies (comparative, correlation and
case studies). Grade C evidence is expert opinion.
It is extraordinary to claim that the guideline is based on
the clinical experience of healthcare professionals, when
only doctors and psychologists are members of the
professional group and it is they who define who they
regard as expert authorities (other doctors and
psychologists) and what constitutes evidence. As we have
seen, evidence that is service user or carer narrative based
doesn?t count, making a nonsense of previous claims that
these perspectives are central.

RCTs (Grade A evidence) assume that a single variable can
be isolated and measured against another single factor.
That?s how they work. But trying to apply this psychological
approach is about as sophisticated as trying to dismantle a
watch with a meat cleaver. As the guideline puts it, "there
are a number of difficulties with the use of RCTs in the
evaluation of interventions in mental health" (p.38).

We know that with psychological approaches, relationship
is key: "One of the most robust findings in psychotherapy
research is that a good therapeutic alliance is the best
predictor of outcome in psychotherapy" (See ref 2 below) NICE knows this too. The guideline itself acknowledges that the quality of the relationship with the practitioner significantly affects the outcome of any intervention: "Therapeutic relationship is at times more important than the specific treatments offered" (p.8). So how can factors as subtle as the relationship between two people be illuminated by the RCT? How can you ?isolate? kindness, listening, understanding, validation and being alongside a person?

And then there are the vested interests of those who
manufacture evidence. "Stakeholders who have contributed
to and commented on the guideline at key stages in its
development" (p.49) include "commercial stakeholders: the
companies that manufacture medicines used in the
treatment of depression". These stakeholders have a clear
commercial interest in the promotion of their products and,
as the guideline acknowledges, may produce unreliable
evidence in order to do so. ("Most studies of the effects of
drugs are sponsored by the drug industry, and these have
been shown to be more than 4 times as likely to
demonstrate positive effects of the sponsor?s drug as
independent studies" (p.179).)

So the stakeholders who stand to make money out of
depression manufacture not just drugs but also evidence.
The writers of the guideline know that this evidence is
distorted, and say so. And yet it is still presented as Grade A
evidence. Even this evidence for drugs and CBT is a lot
weaker than the abbreviated guideline would have us
believe. Read the shortened guideline and you could believe
that antidepressants and CBT are the "facts" of what
" works". Read the full version or try talking with a few
people and you get a different picture.

Having suffered from depression myself, I have found
nothing in the guideline that relates to the complexity or
the depth of my experience or that of the sufferers that I
work with every day in my NHS practice. I conclude that the
guideline is a logically flawed mouthpiece for the professional
and commercial vested interests that have created it.

The process for its review has started. If we want humane and
effective mental health services to survive we must challenge
NICE?s approach to mental health, root and branch.

Malcolm Learmonth is a senior art psychotherapist with the creative therapies team, Devon Partnership NHS Trust. He is also arts and health lead for the British Association of Art Therapists. This article also appeared in Openmind magazine

1. The depression report: a new deal for depression and anxiety disorders, The Centre for Economic Performance?s Mental Health Policy Group, June 2006.
2. All page numbers cited in the text above are from the full version of Depression: management of depression in primary and secondary care, National Clinical Practice Guideline 23, National Institute for Health and Clinical Excellence.
Note: The full text of this critique, and a shorter document with suggestions for arts therapists about how to make a case based on the guideline, are available to members of the British Association of Art Therapists from the BAAT website and to anyone from the documents page of the Insider Art website

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See also:
Mental health comment:
Oct 31, 2007: Getting personal - Stop the psychological therapy "brand warfare" and recognise a therapist's personal qualities are more important than their model, argues
Martin Seager, who helps advise the government on how to make mental health services more therapeutic

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