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BABCP spring meeting: the conference - an overview & why no uproar (over Ost's findings)?

So Friday was the "conference proper" - seven talks and a plethora of 'introducers'.  Sometimes 'introducers' introducing chair people who then introduced the speakers.  What a lot of different faces/different voices.

Professor Andrew Steptoe of University College, London, spoke about "Depression, anxiety and physical illness".  He talked about the three classic ways that psychological and physical illness can be related - psychological illness contributes to physical illness, physical illness contributes to psychological illness, and that some underlying factor (for example low grade inflammatory processes) contributes to both.  He quoted the 2002 Cuijpers & Smit paper "Excess mortality in depression: a meta-analysis of community studies" with its conclusion that "There is an increased risk of mortality in depression. An important finding of this study is that the increased risk not only exists in major depression, but also in subclinical forms of depression. In many cases, depression should be considered as a life-threatening disorder."  He also mentioned the more recent 2009 Grossardt et al study "Pessimistic, Anxious, and Depressive Personality Traits Predict All-Cause Mortality: The Mayo Clinic Cohort Study of Personality and Aging" which reported "Pessimistic, anxious, and depressive personality traits were associated with increased all-cause mortality in both men and women. In addition, we observed a linear trend of increasing risk from the first to the fourth quartile for all three scales." Andrew Steptoe talked too about the many links between physical illness and subsequent increased risk of psychological illness - for example with cardiac disease, neurological disorders, chronic pain, rheumatoid arthritis, diabetes, and so on.  And he spoke about how "sickness behaviour" - where immune stimulation results in decreased appetite, increased sleepiness, social withdrawal, fatigue, aching joints, fever and dysphoria - prompts adaptive withdrawal but may also overlap with and increase depressive symptoms.  He made a whole series of insightful comments from a highly informed overview of the field.  I was interested that he highlighted the value of intervention for psychological distress in physical illness as primarily being about improvement of life quality rather than reducing mortality risk.  I'm sure he's right that the vast majority of positive studies show life quality rather than mortality benefits.  However there are papers now emerging also showing improvements in life expectation (via improvements in health management as well as psychological state) - for example Andersen et al's "Psychologic intervention improves survival for breast cancer patients" , Orth-Gomer & colleagues' "Stress Reduction Prolongs Life in Women With Coronary Disease", and this year, Gulliksson et al's "Randomized Controlled Trial of Cognitive Behavioral Therapy vs Standard Treatment to Prevent Recurrent Cardiovascular Events in Patients With Coronary Heart Disease".

There were then a couple of talks under the general heading of "CBT and physical health".  John Green & Georgina Smith presented on "CHAMP: A randomised controlled trial of CBT for health anxiety in secondary acute care".  They discussed issues of training non-specialist therapists to use a short manualised treatment package for a broad range of patient presentations (to reflect "real life" in the clinic).  The intervention both looked at how well any treatment gains were maintained and also at cost-effectiveness.  Myra Hunter then spoke on "Menopause: From social meanings to bodily experience" noting that "Recent prospective studies highlight the complex ways in which lifestyle and cultural factors influence women's experience of the menopause."  She described a cognitive-behavioural intervention for hot flushes and results so far from two randomised controlled trials (MENOS1 and MENOS2).  The conclusion, at the moment, seems to be "These interventions might offer those women who have problematic hot flushes and night sweats a safe and acceptable treatment choice"

After lunch we had a major keynote address from Lars-Goran Ost - "Progress in CBT: lessons from empirical reviews".  Using impressive systematic reviewing of all the relevant research he could find (409 studies involving 23,891 subjects), Ost tried to answer three questions - 1.)  Have the effects of CBT for anxiety disorders increased over 40 years of research?  2.)  Are the effects of CBT for anxiety disorders maintained in the long-term?  3.)  Does CBT work in routine clinical care or only in the ivory towers of the researchers?  First the good news - 2.)  Long term outcomes (1 to 2 years) after CBT interventions for anxiety disorders look surprisingly good.  "The mean follow-up period across more than 200 studies was 2.1 years and at that point 86% of the patients who completed therapy were assessed.  For 86% of the studies the mean treatment effect was maintained; 11% of patients who were clinically improved at post-treatment had relapsed but 22% of those who did not reach clinical improvement criteria at post-treatment did so at follow-up".  This looks good to me (better than I would have predicted).  Hurray!  And also good - 3.)  "Studies performed in routine clinical settings ... were included in a meta-analysis ... results show that the effect sizes (ES) for effectiveness studies (in routine clinical settings) were as high as those for efficacy studies (ivory tower research settings) across all adult diagnoses".   Tremendous.  Now for the bad news - 1.)  " ... the within-group effect sizes do not, with the exception of specific phobias, show an improvement across four decades of research.  A possible explanation for this lack of improvement is that the samples of patients are gradually getting more severe across time.  However, the overall treatment effects are very good for all anxiety disorders".   The "king's new clothes" or what?!  And just as impressive was the crashing lack of verbal response from the conference audience.  Not a peep.  Admittedly the chairperson was rushing us on to the next two presentations on "New developments" although Ost's systematic reviewing threw the any potential "new developments" excitement into a more cautious light.  Still there was, for me, a dramatic lack of acknowledgement or debate about these very challenging findings.  Great that we're providing real, significant benefit for people suffering from anxiety disorders.  Great that the effects transfer so very well to routine clinical settings and hold up so well at follow-up.  What about the lack of progress in making CBT treatments more effective though?  Is this true?  Are we still only as helpful as we were thirty or forty years ago?  It reminds me of decades of research on antidepressants.  Millions of pounds/dollars have been spent on research by pharmaceutical companies with minimal improvements in antidepressant effectiveness.  And why wasn't the audience in uproar?  This is important territory. 

We moved on, but when it came to the teabreak I scampered after Ost and caught him on the stairs.  I asked something like "So do you think we're wasting our time coming to conferences like this?  It sounds like we should just learn basic CBT approaches for anxiety disorders and then simply keep using them without expecting that anything useful will emerge from all the beavering away by researchers trying to improve the results we can obtain."  And his reply?  Pretty much that an awful lot of the new interventions (e.g. so-called third wave approaches) aren't - so far - living up to the claims of their advocates.  See, for example, Ost's meta-analysis "Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis"See too his paper "Cognitive behavior therapy for anxiety disorders: 40 years of progress." which covers much of the material in this talk.  Dear Professor Ost seemed to me a little like a large party-pooping Scandinavian troll who was being ignored by the happy UK audience in the hope that his message would simply go away.  Ost went on to say to me, over a cup of tea, that many experienced therapists - in his opinion - get sloppy as they age.  They take on shiny new developments that are not adequately tried & tested, and may start to cut corners with the more solidly based bread & butter approaches.  His systematic review had however found that "If the single studies that gave the highest ES (effect sizes) each decade were compared, all anxiety disorders besides panic disorder and obsessive-compulsive disorder showed a positive development."  Maybe we can do better by carefully looking at who is reporting the very best results in the best high quality research studies and only altering our interventions to take on board these more Rolls Royce developments.  We probably would do well also to rigorously review our personal clinical practice - asking ourselves if we're really adequately making sure we focus on what is evidence-based and taking good care not to get seduced by every Johnny-come-lately new idea.  A good bucket of cold water to wake up my critical thinking.  Thank you Professor Ost.   

There had been two further talks before the tea break - Paul Chadwick speaking on "Mindfulness, CBT and psychosis" and Mick Power on "Emotion-focussed cognitive therapy".  I guess for me, Ost's findings underlined the importance of hearing these lectures and saying something like "Interesting stuff, but until you report the well done randomised controlled trials that show these ideas genuinely add something to what we can offer clients, I'll simply hear what you say from a somewhat detached, I'll-watch-this-space viewpoint".

The final keynote address was David Barlow's "The origins, diagnosis, and treatment of neuroticism: Back to the future".  Barnstorming stuff ... and I've touched on a good deal of this territory in the more extended blog posts I've written about the one day workshop I'd done with David the previous day.  In his talk he highlighted " ... research has delineated empirically supported common dimensions shared by all anxiety, mood, and related emotional disorders, including higher-order temperaments, mood distortions and dysregulations, and extent and types of avoidance.  In this presentation, I suggest a new integrative diagnostic scheme for the emotional disorders, as well as a unified transdiagnostic treatment addressing shared higher-order temperamental factors".  This might all appear laughingly grandiose, if it wasn't for the fact that David Barlow and his team have been at the centre of research into anxiety disorders for decades.  What he has to say is coming from one of the most informed understandings of where we have come from and how far we have reached in the last forty years of trying to treat these emotional problems better.  It was a privilege to hear what he had to say ... still challenging, intelligent, and exciting after all these years in the field.  Great stuff! 

 

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