Letters

Cognitive behaviour therapy

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7119.1376 (Published 22 November 1997) Cite this as: BMJ 1997;315:1376

Review was unsystematic

  1. Michael Sharpe, Senior lecturer in psychological medicinea,
  2. Simon Wessely, Professor of epidemiological and liaison psychiatryb
  1. a University of Edinburgh, Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF
  2. b Department of Psychological Medicine, King's College Hospital, London SE5 9RS
  3. c Swedish Council on Technology Assessment in Health Care, Postbox 16158, S-103 24 Stockholm, Sweden

    Editor—Cognitive behaviour therapy has an established place within psychiatry1 and is now beginning to make an important contribution to general medicine. Enright's review was disappointing in its coverage of these non-psychiatric applications of cognitive behaviour therapy.

    Despite the author's claim that the review was based on a complete survey of the literature the non-psychiatric applications were addressed only briefly. Readers were instead referred to an unsystematic and incomplete list of trials. For example, this list omitted a well conducted randomised trial of cognitive behaviour therapy for medically unexplained symptoms published recently in the BMJ.2

    The summary comments on these trials were subjective and potentially misleading. For example, the comment on cognitive behaviour therapy for the chronic fatigue syndrome stated “improvements reported, but high refusal; insufficient controlled trials.” In fact, cognitive behaviour therapy was not associated with a high refusal rate in the trial quoted.3 Furthermore, three randomised trials have now been published: the first used brief cognitive behaviour therapy, with negative results; the subsequent two used a more intensive therapy and found large treatment effects.3 4 This literature is not adequately reflected in the review. Indeed, the author has made his personal bias on this topic explicit elsewhere.5

    Ignorance about what cognitive behaviour therapy is and what it might contribute to non-psychiatric aspects of medicine is widespread; consequently there is a need for reviews of the topic for general medical audiences. Sadly, this unsystematic review may mislead as well as inform.

    References

    1. 1.
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    3. 3.
    4. 4.
    5. 5.

    Patients are more likely to be treated with drugs

    1. Sten Thelander, Project directorc
    1. a University of Edinburgh, Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh EH10 5HF
    2. b Department of Psychological Medicine, King's College Hospital, London SE5 9RS
    3. c Swedish Council on Technology Assessment in Health Care, Postbox 16158, S-103 24 Stockholm, Sweden

      Editor—Enright's review of cognitive behaviour therapy included several exaggerations and questionable statements.1 The methods section states that all studies were found. This is impossible without hand searching, and even then there is the problem of unpublished studies. The author does not state which studies were retrieved, and in many cases readers are referred to monographs; he also does not describe in what way, if any, he assessed the quality of the included studies.

      Problems with the representativeness of patient samples are common in psychopharmacological studies, and there is no reason to assume that the situation is different in research into psychotherapy. The fact that cognitive therapy is as effective as pharmacotherapy in mild to moderate depression is well documented in well conducted studies. The question of efficacy in melancholic depression and in patients with high scores on rating scales is not settled.2 The case for combined psychological and pharmacological treatment is weak.2

      In the treatment of panic disorder, the study that the author claims showed superiority of cognitive behaviour therapy over drug treatment was a comparison with relaxation. Since fairly simple and quick forms of behaviour therapy are effective in most monophobias, it seems cost ineffective to use cognitive therapy. I do not agree that behaviour therapy is the treatment of choice for several of the problems in the long list presented in the appendix. Given the high prevalence of depression, dysthymia, and anxiety disorders in the general population3 4 and the ready availability of drug treatment, it seems unrealistic to think that more than a minority of patients could ever be treated with cognitive therapy or any other psychological therapy. For many of the conditions listed in the appendix, the use of cognitive therapy is largely unproved or experimental

      References

      1. 1.
      2. 2.
      3. 3.
      4. 4.
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