Barkham Michael, Moller Naomi P, Pybis Joanne
Centre for Psychological Services Research University of Sheffield Sheffield UK.
Open University Milton Keynes UK.
Couns Psychother Res. 2017 Dec;17(4):253-268. doi: 10.1002/capr.12141. Epub 2017 Sep 19.
Health guidelines are developed to improve patient care by ensuring the most recent and 'best available evidence' is used to guide treatment recommendations. The National Institute for Health and Care Excellence's (NICE's ) guideline development methodology acknowledges that evidence needed to answer one question (treatment efficacy) may be different from evidence needed to answer another (cost-effectiveness, treatment acceptability to patients). This review uses counselling in the treatment of depression as a case study, and interrogates the constructs of 'best' evidence and 'best' guideline methodologies.
The review comprises six sections: (i) implications of diverse definitions of counselling in research; (ii) research findings from meta-analyses and randomised controlled trials (RCTs); (iii) limitations to trials-based evidence; (iv) findings from large routine outcome datasets; (v) the inclusion of qualitative research that emphasises service-user voices; and (vi) conclusions and recommendations.
Research from meta-analyses and RCTs contained in the draft 2018 NICE Guideline is limited but positive in relation to the effectiveness of counselling in the treatment for depression. The weight of evidence suggests little, if any, advantage to cognitive behaviour therapy (CBT) over counselling once risk of bias and researcher allegiance are taken into account. A growing body of evidence from large NHS data sets also evidences that, for depression, counselling is as effective as CBT and cost-effective when delivered in NHS settings.
Specifications in NICE's updated guideline procedures allow for data other than RCTs and meta-analyses to be included. Accordingly, there is a need to include large standardised collected data sets from routine practice as well as the voice of patients via high-quality qualitative research.
制定健康指南是为了通过确保使用最新的“最佳可得证据”来指导治疗建议，从而改善患者护理。英国国家卫生与临床优化研究所（NICE）的指南制定方法承认，回答一个问题（治疗效果）所需的证据可能与回答另一个问题（成本效益、患者对治疗的可接受性）所需的证据不同。本综述以抑郁症治疗中的咨询为例进行研究，并审视“最佳”证据和“最佳”指南方法的构成。
本综述包括六个部分：（i）研究中咨询不同定义的影响；（ii）荟萃分析和随机对照试验（RCT）的研究结果；（iii）基于试验的证据的局限性；（iv）大型常规结局数据集的研究结果；（v）纳入强调服务使用者声音的定性研究；（vi）结论和建议。
2018年NICE指南草案中包含的荟萃分析和RCT研究有限，但在咨询治疗抑郁症的有效性方面是积极的。证据表明，一旦考虑到偏倚风险和研究者的倾向性，认知行为疗法（CBT）相对于咨询几乎没有优势。来自英国国家医疗服务体系（NHS）大型数据集的越来越多的证据也表明，对于抑郁症，咨询在NHS环境中实施时与CBT一样有效且具有成本效益。
NICE更新后的指南程序规范允许纳入随机对照试验和荟萃分析以外的数据。因此，需要纳入常规实践中大规模标准化收集的数据集，以及通过高质量定性研究获取的患者声音。
