Background: Understanding complex psychological treatment mechanisms is important in order to refine and improve treatment. Mechanistic theories can be evaluated using mediation analysis methods. The Pacing, Graded Activity, and Cognitive Behaviour Therapy: A Randomised Evaluation (PACE) trial studied complex therapies for the treatment of chronic fatigue syndrome. The aim of the project was to study different mediation analysis methods using PACE trial data, and to make trial design recommendations based upon the findings. Methods: PACE trial data were described using summary statistics and correlation analyses. Mediation estimates were derived using: the product of coefficients approach, instrumental variable (IV) methods with randomisation by baseline variables interactions as IVs, and dual process longitudinal structural equation models (SEM). Monte Carlo simulation studies were done to further explore the behaviour of IV estimators and to examine aspects of the SEM. Results: Cognitive and behavioural measures were mediators of the cognitive behavioural and graded exercise therapies in PACE. Results were robust when accounting for correlated measurement error and different SEM structures. Randomisation by baseline IVs were weak, giving imprecise and sometimes extreme estimates, leaving their utility unclear. A flexible version of a latent change SEM with contemporaneous mediation effects and contemporaneous correlated measurement errors was the most appropriate longitudinal model. Conclusions: IV methods using interaction IVs are unlikely to be useful; designs with randomised IV might be more suitable. Longitudinal SEM for mediation in clinical trials seems a promising approach. Mediation estimates from SEM were generally robust when allowing for correlated measurement error and for different model classes. Mediation analysis in trials should be longitudinal and should consider the number and timing of measures at the design stage. Using appropriate methods for studying mediation in trials will help clarify treatment mechanisms of action and allow for their refinement, which would maximize the information gained from trials and benefit patients.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:628447 |
| Date | January 2014 |
| Creators | Goldsmith, Kimberley |
| Publisher | King's College London (University of London) |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
| Source | https://kclpure.kcl.ac.uk/portal/en/theses/instrumental-variable-and-longitudinal-structural-equation-modelling-methods-for-causal-mediation-the-pace-trial-of-treatments-for-chronic-fatigue-syndrome(413e5fb0-03b9-40bc-b993-0465b1bcbdee).html |
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