Critical evaluation of a metaanalysis of CBT

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In preparing this study,3 we made a number of a priori assumptions and exclusions. First, chronic pain was accepted as a label for a heterogeneous group of pain problems in which diagnosis, site of pain, or medical findings were not apparent major sources of variance in any of the targets of treatment. This probably reflects the assumptions made in many PMPs in clinical settings. Second, we excluded studies of psychological treatments of headache because the episodic nature of chronic headache is markedly different from nonheadache. Third, we also excluded trials reporting the effectiveness of psychological treatments for children with chronic pain, see Ref. 48[I]. The study was designed to answer two questions.

1. Absolute efficacy - is CBT an effective treatment for chronic pain, i.e. is it "better" than no treatment?

2. Relative efficacy - is CBT more effective than alternative active treatments?

To answer the first question, we compared active CBT with waiting list control groups, and to answer the second question we identified active non-CBT treatments as the contrast. We identified papers in the English language reporting 25 trials containing controlled comparisons of CBT and data suitable for analysis. Information from the trials was extracted and coded using criteria developed for the study including details of trial design, participants, the treatments, and outcome measures used, and statistical data on differences in outcomes. As an ideal, all trials would use the same outcome measures and have similar design features, e.g. identical treatment and control conditions, homogeneous diagnostic groups. While pharmacological treatments approximate this (comparison between active and placebo groups and a single "simple" outcome such as pain reduction), the situation is substantially different where complex interventions such as psychological treatments are concerned. Meta-analysts face a number of problems concerning the methods of how to aggregate and combine information.

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