Recommendations on cognitive behavioural therapyNo recommendations.
Future research recommendations
27.

Does a psoriasis-specific cognitive behavioural therapy intervention improve distress, quality of life and psoriasis severity compared with standard care?

Relative values of different outcomesThe following outcomes were considered by the GDG and given equal weight:
  • Reduced distress/anxiety/depression
  • Reduced stress
  • Improved quality of life
  • Reduced psoriasis severity
Trade off between clinical benefits and harmsThere was only one small UK CBT study that was situation specific to people with psoriasis. The GDG noted that whilst the data did not suggest any major effect on PASI, importantly CBT reduced the HADS score and distress. The GDG had low confidence in the study results, all outcomes were considered to be of low or very low quality. Given this the GDG made a future research recommendation.
Economic considerationsNo economic evidence was available to inform the GDG on the cost-effectiveness of cognitive behavioural therapy in the management of patients with psoriasis. The GDG discussed the significant psychological impact psoriasis can have on patients’ quality of life and generally believed that CBT or other psychological interventions may help some patients; however, on the basis of inconclusive clinical evidence, they could not be sure that this would represent good value for NHS resources. They felt that further research was warranted in order to measure clinical and quality of life benefits associated with psychological interventions and also to better identify patients who might gain the most from such interventions.
Quality of evidenceThere was a paucity of data as only one study was identified (Fortune 2002B). This study used a patient preference allocation design, which means participants were given the choice as to which arm of the study to enter. This method is often used in psychological trails to reduce drop outs. All participants were given CBT sessions at the same site with the same people delivering the CBT.
 The GDG noted the following issues with the quality of the study:
  • The groups were not matched at baseline for disability scores
  • There were substantial drop outs in both groups
  • There were differences in the prescribed treatments, which potentially may confound some of the results
  • Incomplete reporting (actual changes scores were not reported for some scales)
  • Very low quality evidence rating for all outcomes.
Additionally, more people in the CBT group converted from topicals to systemic therapies, while the proportions did not change much in the standard care group. Therefore, improvement in PASI could be due to changes in treatment. The GDG acknowledged that moving to systemic treatment could explain the improved PASI, but this does not mean that CBT has not helped.
There appeared to be a discrepancy between the small difference in final PASI and the clinically significant improvement in the numbers achieving PASI75 in the CBT group. It was discussed that this may be explained by a high percentage of people achieving 71–74% improvement in the control group and being classified as not achieving PASI75; alternatively it may be due to the difference in baseline PASI between the two groups (1.3 points higher in the CBT group).
The GDG did not wish to make a national recommendation due to the lack of evidence.
The GDG agreed to make a future research recommendation on whether CBT is of value. Future research should take into account disease severity and distress at baseline.
Other considerations
  • The GDG discussed whether it is possible to separate the impact of the educational component from other aspects of CBT. The GDG were aware that in cardiovascular disease and diabetes, it is known that an educational component is not enough to manage psychological distress and poor coping. Although educational strategies will help alleviate distress, a clinical effect may not be achieved without a cognitive-behavioural element. The separate effects of education and CBT are unknown for psoriasis.
  • The GDG discussed whether improvement in anxiety and depression may help self-management, or vice versa. The GDG were aware of research work investigating whether managing depression dampens the psoriasis inflammatory response.

From: 14, Cognitive behavioural therapy

Cover of Psoriasis
Psoriasis: Assessment and Management of Psoriasis.
NICE Clinical Guidelines, No. 153.
National Clinical Guideline Centre (UK).
Copyright © National Clinical Guideline Centre - October 2012.

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