McQueen D, Smith P St John
West London Mental Health NHS Trust, London.
National Health Service, Redditch, UK.
Psychiatriki. 2015 Jul-Sep;26(3):188-97.
In 2009/10 NICE partially updated its guidelines on the treatment and management of depression in adults. Due to methodological shortcomings the recommendations for psychotherapy must be treated with caution. Despite recognising the heterogeneous and comorbid nature of depression, and the limitations of depression as a unitary diagnostic category, NICE treats depression as if it were a unitary entity differentiated only by severity. The guidance ignores important aetiological factors such as trauma, loss and maltreatment, personality and interpersonal difficulties. It excludes the largest naturalistic studies on clinical populations treated in the National Health Service on the grounds that they are observational studies conducted in heterogeneous groups with mixed neurotic disorders. It unquestioningly accepts that the "brand" of psychotherapy has construct validity, and ignores psychotherapy process research indicating significant commonalities, and overlap, between treatment modalities and evidence that individual practitioner effects are larger than the differences between treatment modalities. It fails to consider patient differences and preferences, which are known to influence uptake, completion and response. It takes an exclusively short-term perspective on a chronic relapsing disorder. It does not consider the evidence for longer-term treatments. It is of special concern that NICE misrepresents the findings of its own systematic review by implying that CBT and IPT are superior treatments. NICE's systematic review actually found no evidence of superiority between CBT, IPT, psychodynamic psychotherapy, or counselling. Based on the exclusion of much clinically relevant research demonstrating the effectiveness of psychodynamic psychotherapy and counselling many commentators have alleged a bias towards CBT in the guidance. With regard to service delivery NICE proposes the replacement of psychiatric assessment and individualised treatment plans, with an unproven stepped-care model. These clinical and theoretical limitations, perceived bias in the selection of studies, neglect of patient differences, preferences and values, misrepresentation of results of the systematic review, and the proposal for an unproven service delivery model together seriously undermine the validity of the guidance. The guidance, lacking validity is of questionable use, it undermines patient autonomy, professional expertise and, ultimately, patient welfare.
2009/10年度，英国国家卫生与临床优化研究所（NICE）对成人抑郁症的治疗与管理指南进行了部分更新。由于方法学上的缺陷，心理治疗的相关建议必须谨慎对待。尽管认识到抑郁症具有异质性和共病性，且抑郁症作为单一诊断类别存在局限性，但NICE将抑郁症视为仅由严重程度区分的单一实体。该指南忽视了诸如创伤、丧失和虐待、人格及人际困难等重要病因因素。它排除了关于国民医疗服务体系（NHS）中临床人群治疗的最大规模自然主义研究，理由是这些研究是在患有混合神经症的异质性群体中进行的观察性研究。它毫无质疑地接受心理治疗的“品牌”具有构想效度，忽视了心理治疗过程研究表明不同治疗方式之间存在显著的共性和重叠，以及个体从业者效应大于治疗方式差异的证据。它没有考虑已知会影响接受度、完成率和反应的患者差异及偏好。对于一种慢性复发性疾病，它仅采取短期视角。它没有考虑长期治疗的证据。特别令人担忧的是，NICE错误表述了其自身系统评价的结果，暗示认知行为疗法（CBT）和人际心理治疗（IPT）是更优的治疗方法。NICE的系统评价实际上并未发现CBT、IPT、心理动力心理治疗或咨询之间存在优越性的证据。基于排除了许多证明心理动力心理治疗和咨询有效性的临床相关研究，许多评论家称该指南对CBT存在偏向。关于服务提供，NICE提议用未经证实的逐步照护模式取代精神科评估和个体化治疗计划。这些临床和理论上的局限性、研究选择中存在的明显偏向、对患者差异、偏好和价值观的忽视、系统评价结果的错误表述以及未经证实的服务提供模式提议，共同严重损害了该指南的有效性。该指南缺乏有效性，其用途存疑，它损害了患者自主权、专业知识，最终还损害了患者福祉。
