• Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

      das Nair, Roshan (2021)
      Background: Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials. Objectives: This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy. Data sources: The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019. Review methods: Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I-2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality. Results: A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I-2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I-2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I-2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions. Limitations: Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them. Conclusion: Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes. Future work: Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality. Study registration: This study is registered as PROSPERO CRD42017078690.
    • Reviews of Trauma and Spider

      Baker, Charley (2010)
      Reviews the books, Trauma by Patrick McGrath (2009) & Spider by Patrick McGrath (2002). Spider is narrated by an individual with schizophrenia, released into the community following the reduction in asylum beds, who experiences scant 'care' in the community and retreats back into the psychosis that saw him admitted to hospital originally. Taking the literary trope of the unreliable narrator to the extreme, this novel teaches us much about the fallibility of memory, the alteration of perspectives and memory with psychosis, and crucially the experience of a terrifying psychosis. Trauma is narrated by a psychiatrist, who slowly deteriorates psychologically following the death of his mother. The complexity of his personal relationships-with his brother, his ex-wife (with whom he beings having sex with again after his mother's funeral) and his daughter-are made further difficult by his burgeoning relationship with the strange, chaotic and damaged Nora, who he feels needs psychiatric treatment that he cannot provide. This is a multilayered tale-he attempted to treat his ex-wife's brother Danny for post-traumatic stress disorder, or PTSD following the Vietnam War, ending his relationship with his wife after finding Danny dead through suicide. This unresolved trauma begins to encroach upon his post-Mother's-death existence as he begins to re-examine his fractured memories of childhood. The text contains much on the clinical syndrome PTSD, but also on the trauma of life and loss en masse, the psychological effects of which can be far reaching in individuals who fail, because of semi-abusive childhoods, to develop necessary mental resources to cope. McGrath combines believable and understandable characters with mental health problems, empathy towards experiences and clinically recognizable syndromes and symptoms. His novels are not only enjoyable, but striking, emotive and serve as examples of material useful for medical education. (PsycINFO Database Record (c) 2016 APA, all rights reserved)