Psychological therapies for generalised anxiety disorder

BACKGROUND

Generalised anxiety disorder (GAD) is a highly prevalent condition, characterised by excessive worry or anxiety about everyday events and problems. The effectiveness and effectiveness of psychological therapies as a group has not yet been evaluated in the treatment of GAD.

OBJECTIVES

To examine the efficacy and acceptability of psychological therapies, categorised as cognitive behavioural therapy (CBT), psychodynamic therapy and supportive therapy, compared with treatment as usual/waiting list (TAU/WL) and compared with one another, for patients with GAD.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, LILACS and controlledtrials.com in February 2006. We searched reference lists of retrieved articles, and contacted trial authors and experts in the field for information on ongoing/completed trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials conducted in non-inpatient settings, involving adults aged 18-75 years with a primary diagnosis of GAD, assigned to a psychological therapy condition compared with TAU/WL or another psychological therapy.

DATA COLLECTION AND ANALYSIS

Data on patients, interventions and outcomes were extracted by two review authors independently, and the methodological quality of each study was assessed. The primary outcome was anxiety reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of symptom reduction, using the standardised mean difference (SMD), with 95% confidence intervals.

MAIN RESULTS

Twenty five studies (1305 participants) were included in the review, of which 22 studies (1060 participants) contributed data to meta-analyses. Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at post-treatment (RR 0.63, 95%CI 0.55 to 0.73), and also in reducing anxiety, worry and depression symptoms. No studies conducted longer-term assessments of CBT against TAU/WL. Six studies compared CBT against supportive therapy (non-directive therapy and attention-placebo conditions). No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR 0.86, 95%CI 0.70 to 1.06), however significant heterogeneity was indicated, which was partly explained by the number of therapy sessions.

AUTHORS' CONCLUSIONS

Psychological therapy based on CBT principles is effective in reducing anxiety symptoms for short-term treatment of GAD. The body of evidence comparing CBT with other psychological therapies is small and heterogeneous, which precludes drawing conclusions about which psychological therapy is more effective. Further studies examining non-CBT models are required to inform health care policy on the most appropriate forms of psychological therapy in treating GAD.

Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia

BACKGROUND

Panic disorder can be treated with pharmacotherapy, psychotherapy or in combination, but the relative merits of combined therapy have not been well established.

OBJECTIVES

To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia, in comparison with either therapy alone.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 11/10/2005, together with a complementary search of the Cochrane Central Register of Controlled Trials and MEDLINE, using the keywords antidepressant and panic. A reference search, SciSearch and personal contact with experts were carried out.

SELECTION CRITERIA

Two independent review authors identified randomised controlled trials comparing the combined therapy against either of the monotherapies among adult patients with panic disorder with or without agoraphobia.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data using predefined data formats, including study quality indicators. The primary outcome was relative risk (RR) of "response" i.e. substantial overall improvement from baseline as defined by the original investigators. Secondary outcomes included standardised weighted mean differences in global severity, panic attack frequency, phobic avoidance, general anxiety, depression and social functioning and relative risks of overall dropouts and dropouts due to side effects.

MAIN RESULTS

We identified 23 randomised comparisons (representing 21 trials, 1709 patients), 21 of which involved behaviour or cognitive-behaviour therapies. In the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR 1.24, 95% confidence interval (CI) 1.02 to 1.52) or psychotherapy (RR 1.17, 95% CI 1.05 to 1.31). The combined therapy produced more dropouts due to side effects than psychotherapy (number needed to harm (NNH) around 26). After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. After termination of the acute phase and continuation treatment, the combined therapy was more effective than pharmacotherapy alone (RR 1.61, 95% CI 1.23 to 2.11) and was as effective as psychotherapy (RR 0.96, 95% CI 0.79 to 1.16).

AUTHORS' CONCLUSIONS

Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.

Venlafaxine versus other anti-depressive agents for depression

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the efficacy of venlafaxine in comparison with other anti-depressive agents in alleviating the acute symptoms of major depressive disorder.To review acceptability of treatment with venlafaxine in comparison with other anti-depressive agents.To investigate the adverse effects of venlafaxine in comparison with other anti-depressive agents.

Paroxetine versus other anti-depressive agents for depression

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the efficacy of paroxetine in comparison with other anti-depressive agents in alleviating the acute symptoms of major depressive disorder.To review acceptability of treatment with paroxetine in comparison with other anti-depressive agents.To investigate the adverse effects of paroxetine in comparison with other anti-depressive agents.

Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: systematic review

BACKGROUND

Panic disorder can be treated with psychotherapy, pharmacotherapy or a combination of both.

AIMS

To summarise the evidence concerning the short- and long-term benefits and adverse effects of a combination of psychotherapy and antidepressant treatment.

METHOD

Meta-analyses and meta-regressions were undertaken using data from all relevant randomised controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response.

RESULTS

We identified 23 randomised comparisons (21 trials involving a total of 1709 patients). In the acute-phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR=1.24,95% CI1.02-1.52) or psychotherapy (RR=1.16,95% CI1.03-1.30). After termination of the acute-phase treatment, the combined therapy was more effective than pharmacotherapy alone (RR=1.61,95% CI1.23-2.11) and was as effective as psychotherapy (RR=0.96, 95% CI 0.79-1.16).

CONCLUSIONS

Either combined therapy or psychotherapy alone may be chosen as first-line treatment for panic disorder with or without agoraphobia, depending on the patient's preferences.

Comparison of large versus smaller randomized trials for mental health-related interventions

OBJECTIVE

The extent of disagreement between large and smaller randomized, controlled trials on mental health issues is unknown. The authors aimed to compare the results of large versus smaller trials on mental health-related interventions.

METHOD

The authors screened 161 Cochrane and 254 Database of Abstracts of Reviews of Effectiveness systematic reviews on mental health-related interventions. They identified 16 meta-analyses with at least one "large" randomized trial with sample size >800 and at least one "smaller" trial. Effect sizes were calculated separately for large and smaller trials. Heterogeneity was assessed between all studies, within each group (large and smaller studies), and between large and smaller studies.

RESULTS

Significant between-study heterogeneity was seen in five meta-analyses. By random-effects calculations, the results of large and smaller trials differed beyond chance in four meta-analyses (25%). In three of these disagreements (effect of day care on IQ, discontinuation of antidepressants, risperidone versus typical antipsychotics for schizophrenia), the smaller trials showed greater effect sizes than the large trials. The inverse was seen in one case (olanzapine versus typical antipsychotics for schizophrenia). With fixed-effects models, disagreements beyond chance occurred in five cases (31%). In four meta-analyses, the effect size differed over twofold between large and smaller trials. Various quality and design parameters were identified as potential explanations for some disagreements.

CONCLUSIONS

Large trials are uncommon in mental health. Their results are usually comparable with the results of smaller studies, but major disagreements do occur. Both large and smaller trials should be scrutinized as they offer a continuum of randomized evidence.

Effect sizes in cumulative meta-analyses of mental health randomized trials evolved over time

BACKGROUND AND OBJECTIVE

Meta-analyses of randomized trials may incorporate new evidence, and estimated treatment effects changeover time. We evaluated whether the certainty and estimates of efficacy and tolerability of mental health interventions change over time, as more trials appear on the same topics.

METHODS

One hundred meta-analyses (1,024 trial entries; 99,303 participants) with an outcome of death, relapse, failure or dropout and with five or more trials published in three or more different years were examined with cumulative meta-analysis and recursive cumulative meta-analysis.

RESULTS

Eight meta-analyses reached formal statistical significance (P < .05) at some point, but lost this significance eventually when more trials were published; typically large effect sizes in early trials were dissipated with further evidence. With 500 randomized subjects,95% of the time, subsequent changes in odds ratio might be up to 1.5-fold. For death, relapse, and failure outcomes, a decrease in effect size was somewhat more common than an increase, when more data became available (157 vs. 125, P = .06). This was most clear for comparisons of pharmacotherapies versus placebo (79 vs. 51, P = .009).

CONCLUSIONS

Evidence based on a small number of randomized subjects should be interpreted cautiously. Early treatment efficacy of pharmacotherapies is occasionally overestimated.

Safety reporting in randomized trials of mental health interventions

OBJECTIVE

The authors aimed to evaluate the adequacy of the reporting of safety information in publications of randomized trials of mental-health-related interventions.

METHOD

The authors randomly selected 200 entries from the PsiTri registry of mental-health-related controlled trials. This yielded 142 randomized trials that were analyzed for adequacy and relative emphasis of their content on safety issues. They examined drug trials as well as trials of other types of interventions.

RESULTS

Across the 142 eligible trials, 103 involved drugs. Twenty-five of the 142 trials had at least 100 randomly chosen subjects and at least 50 subjects in a study arm. Among drug trials, only 21.4% had adequate reporting of clinical adverse events, and only 16.5% had adequate reporting of laboratory-determined toxicity, while 32.0% reported both the numbers and the reasons for withdrawals due to toxicity in each arm. On average, drug trials devoted 1/10 of a page in their results sections to safety, and 58.3% devoted more space to the names and affiliations of authors than to safety. None of the trials of nondrug interventions had adequate or even partially adequate reporting of either clinical adverse events or laboratory-determined toxicity. In multivariate modeling, long-term trials and trials conducted in the United States devoted even less space to safety, while schizophrenia trials devoted more space to safety than did trials in other areas.

CONCLUSIONS

Safety reporting is largely neglected across trials of mental-health-related interventions, thus hindering the assessment of risk-benefit ratios for rational decision making in mental health care.

Psychotherapeutic interventions for adults with asthma

BACKGROUND

Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease.

OBJECTIVES

To assess the effectiveness of psychological interventions for adults with asthma.

SEARCH STRATEGY

The Cochrane Airways Group specialised register and PsycINFO were searched with pre-defined terms until September 2003.

SELECTION CRITERIA

Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a form of control in adult participants were included in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted.

MAIN RESULTS

Twelve studies were included in the review, however study quality was poor and sample sizes were frequently small. No meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. Findings between studies were conflicting. This may have been due to the different types of interventions used and the deficiencies in trial design.

REVIEWER'S CONCLUSIONS

This review was unable to draw firm conclusions for the role of psychological interventions in asthma due to the absence of an adequate evidence base. Large, well-conducted and reported randomised trials are required in this area, in order to determine the effects of these techniques in the treatment of asthma in adults.

Dysfunctional attitudes and the common mental disorders in primary care

BACKGROUND

Dysfunctional attitudes may predispose to episodes of depression, although the evidence for this is poor. Most previous studies have been cross-sectional, or have followed up clinical samples. The aim of the study was to test the hypothesis that dysfunctional attitudes are associated with the onset and repeat prevalence of episodes of the common mental disorders among primary care attenders.

METHODS

A 12-month prospective cohort study of 305 consecutive primary care attenders at a health centre in south London.

RESULTS

Linear associations were found between (high) score on the Dysfunctional Attitude Scale (DAS) and both the onset and repeat prevalence of episodes of the common mental disorders over 12 months (unadjusted OR for episode onset 1.05, 95% CI 1.01-1.09) (P = 0.009). The association with episode onset, but not with repeat prevalence, remained statistically significant after adjusting for CIS-R score at baseline (OR 1.05, 95% CI 1.00-1.09) (P = 0.03).

LIMITATIONS

This study was based in a single general practice, and had limited power to detect statistically significant interactions between DAS score and socio-economic adversity.

CONCLUSIONS

Dysfunctional attitudes may be a risk factor for the onset (but not the outcome) of episodes of moderately severe, typically comorbid, anxiety and depression found in primary care settings.

Improving referrals for glue ear from primary care: are multiple interventions better than one alone?

OBJECTIVES

To evaluate the effect of a risk factor checklist and training video for general practitioners in reducing inter-practice variation and improving the appropriateness of referrals (assessed by their positive predictive value or PPV) of patients with suspected otitis media with effusion (OME or 'glue ear') to secondary care.

METHODS

Fifty general practices (177 practitioners) from the NHS Trent region and the West of Scotland were cluster-randomised either to a control group (n = 12) or to one of three intervention groups (training video (n = 16), checklist (n = 11), or both (n = 11)). Data on all paediatric ear, nose and throat (ENT) referrals and diagnostic results at ENT clinics were collected for a one-year period pre- and post-intervention. Referral rates for OME and for closely related conditions were calculated for children aged 0-15 years, based on each practice's list size. PPV was defined as the proportion of referrals resulting in bilateral hearing loss > or = 20 dB at the ENT outpatient department.

RESULTS

There was a significant improvement in the PPV, adjusted for patients' waiting time between general practitioner (GP) referral and being seen at the ENT department. The improvement in PPV pre- and post-intervention was 15% (95% confidence interval, CI: -12.1% to 41.7%) for the practices receiving both interventions, compared with a degradation of 20% pre- and post-intervention (95% CI: -32.9% to -6.4%) for practices receiving only one intervention and a degradation of 34% for those receiving no intervention.

CONCLUSIONS

Disseminating a risk factor checklist and training video on glue ear to GPs using a multi-channel approach can improve the quality of referrals to ENT.

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

OBJECTIVES

To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference.

DESIGN

Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes.

SETTING

31 general practices in Trent region.

PARTICIPANTS

Patients aged 18-70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms.

MAIN OUTCOME MEASURES

Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria.

RESULTS

At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval -2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist's overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse.

CONCLUSIONS

Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment.

Do the attitudes and beliefs of young teenagers towards general practice influence actual consultation behaviour?

BACKGROUND

Teenagers are believed to have health concerns that are not adequately addressed in primary care because of perceived barriers that inhibit them from consulting a general practitioner (GP). We report the results of a study examining links between potential attitudinal barriers and actual help-seeking behaviour.

AIM

To determine whether the attitudes of teenagers towards general practice are associated with differences in consultation patterns.

METHOD

Results of a postal questionnaire survey of attitudes to general practice, performed among teenage patients aged 13 to 15 years registered with five general practices in the East Midlands, were analysed in relation to consultation data from retrospective casenote analysis for the preceding 12 months.

RESULTS

Matched questionnaire and consultation data were available for 678 teenagers. We found few significant differences in overall consultation rates between teenagers expressing differing attitudes about aspects of general practice. Differences did exist in relation to perceived difficulty in getting an appointment, feeling able to confide in a GP, and perception of adequate time being given in the consultation. Fear of embarrassment was associated with lower consultation rates for gynaecological problems and contraception.

CONCLUSIONS

Negative perceptions of general practice by teenagers may have less of an influence on actual consultation behaviour than previously believed. However, there are some aspects of care that merit further attention if teenagers are to feel able to consult their GP more easily.

Treating depression in general practice: factors affecting patients' treatment preferences

We performed a cross-sectional survey of general practice attenders to determine their preferences regarding treatment for depression and characteristics associated with such preferences. Counselling was more popular than drug therapy (antidepressants), particularly among women, those who believed antidepressants are addictive, and those who had received such treatment in the past.

Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial

BACKGROUND

There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor.

AIMS

To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response.

METHOD

A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms.

RESULTS

There were 103 randomised and 220 preference patients in the trial. We found: no differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome.

CONCLUSIONS

These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting.