Tuesday 17 July 2018

Patricia Casey: No treatment is without side effects - even talking therapy

A picture is emerging that no treatment, pharmacological or psychological, is without side effects, says psychiatrist Patricia Casey. Stock photo
A picture is emerging that no treatment, pharmacological or psychological, is without side effects, says psychiatrist Patricia Casey. Stock photo

Patricia Casey

Psychiatrists are distrusted by many. We are (wrongly) seen as purveyors of dangerous drugs for those with mental health problems. The preferred option for many is talking therapy to explore 'root causes' and allow the ventilation of emotions. So medication and psychotherapy as pitted against each other.

The concerns about medication are linked, among other things, to their side effects and to the role of the global pharmaceutical industry in promoting their products.

Thus, for many, psychiatrists are seen as potentially tainted by the producers of the medicines we prescribe. This thesis ignores the reality that it was these medications which allowed the unlocking of psychiatric institutions, facilitated the discharge of patients to their homes and brought about the eventual closure of most of the psychiatric hospitals on these islands.

The clear separation of the medical profession from the pharmaceutical industry has rightly been encouraged. By law, conflicts of interest must be revealed when psychiatrists publish their research in learned journals. This means that grants received or talks given at conferences sponsored by drug companies must be disclosed.

Medications are overseen by the Health Product Regulatory Authority (HPRA) in Ireland and the Food and Drugs Administration (FDA) in the US and when they are prescribed, their side effects are detailed on the packaging and should be discussed with the patient. This transparency is welcome and is now an accepted element in our work.

But is the same standard applied to psychological therapies when neither the HPRA nor the FDA has any oversight of these?

A recent study of financial disclosures regarding psychosocial interventions was published in JAMA Psychiatry from Stanford University, California. The lead author was psychologist Ioana Alina Cristea.

Disclosures regarding financial conflicts of interest in scientific papers relating to four commercially-backed parenting skills interventions varied from 11pc to 73pc, with an average of 32pc overall. One problem is that talking therapies are seldom developed by large corporations and are not patented, so translating the standards of the pharmaceutical industry to psychosocial therapies is problematic.

Stock photo: Katarzyna Bialasiewicz
Stock photo: Katarzyna Bialasiewicz

Nevertheless, some such interventions require training and this can generate cash for specific organisations or institutions.

Even when there is little financial gain but a strong researcher allegiance to a particular therapy, this could influence the type of statistical analysis that is conducted and be a source of bias.

Action regarding conflict of interest and therapeutic allegiance in psychological therapies is prescient, as the debate about the quality of such studies has been questioned recently. This has been highlighted in several journals and most recently in February 2018 in 'Frontiers in Psychology' by Dr Michael Hengartner from the University of Zurich.

One of his conclusions is that because only studies with positive outcomes are published, allowances must be made for this, resulting in a reduction in the reported efficacy of talking therapy overall.

Similarly, he suggested that studies conducted by authors who have a commitment to a particular therapy will identify greater efficacy for it. One approach to this is to make the data widely available to others for re-analysis and this has resulted in an inability to replicate the findings. He also questioned the methodological quality of some of the trials to study these interventions. Some had small samples, they used changeable outcome measures and were aware of who was receiving the treatment and its comparator.

What about the side effects of psychological therapies? In the public mind, talking therapies are much safer than medication and patients adopt the attitude that they "won't do any harm so why not?".

The data doesn't support this and there are two aspects to be considered: inappropriate use of therapy and emergent side effects. In the first category there is now evidence that the use of psychological therapy for normal grief may delay the healing process and single session critical incident stress debriefing following traumatic incidents has been shown to increase the risk of post-traumatic stress disorders.

In the second group, representing emergent side effects, is the risk of self-harm in the early stages of therapy for child abuse, the danger of excessive dependence on the therapist and of false memories occurring in those who are suggestible. Interpersonal and family problems arise in some instances, particularly in those who become very self-focused.

Roughly 5pc of participants in one study reported long-term negative effects of therapy, while another reported that up to 10pc were adversely affected.

A picture is emerging that no treatment, pharmacological or psychological, is without side effects. This isn't surprising since both modalities aim to deal with serious personal symptoms and interpersonal difficulties. Similar standards to enhance transparency, minimise conflicts of interest and recognised side effects should apply to all treatments in the best interests of our patients.

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