Subgroup Analysis: “What Works Best for Whom and Why?”

Moderators and mediators of outcomes of parents with substance use problems: further evaluation of the Parents under Pressure programme

BACKGROUND AND AIMS

Family-focused interventions can improve family functioning when parents have substance use problems. However, there has been little focus upon potential predictors of change and analysis of mechanisms of change. This study aims to identify mediators and moderators of change in a pragmatic, multi-site, randomized controlled trial of the Parents under Pressure (PuP) programme, a family-focused intervention for parents with substance use and other problems, and treatment-as-usual (TAU).

DESIGN

Secondary analysis of data: multi-level modelling was used to investigate moderators of treatment outcome; mediation was tested with cross-lagged models.

SETTING

Community-based family support services in the United Kingdom.

PARTICIPANTS

Parents (n = 100) attending community-based addiction services with children aged 2.5 years or younger.

MEASUREMENTS

Predictors of the primary outcome, child abuse potential, were: baseline child age and gender, composite family risk score, parental substance use and parental emotional dysregulation. Mediation was tested across three time-points with the observed variables parental emotion dysregulation and child abuse potential.

FINDINGS

Increased child age [Z = 2.14, 95% confidence interval (CI) = 0.01, 0.33] at baseline was associated with greater reductions in child abuse potential for PuP programme participants compared with TAU. Poorer parental emotional regulation (Z = 2.48, 95% CI = -2.76, -0.32) was associated with greater reductions in child abuse potential for all participants. Parental substance use (either recent use or primary substance of concern) did not alter any treatment effects on child abuse potential. The mediation analysis showed that PuP produced greater improvements in emotional regulation at post-treatment (P < 0.001) compared with TAU, which predicted lower child abuse potential at 6-month follow up (P < 0.05).

CONCLUSIONS

For UK parents enrolled in a family-focused intervention, baseline measurements of higher child age appear to be associated with greater reductions in child abuse potential at 6-month follow-up in PuP participants compared with treatment as usual (TAU). Poorer parental emotional regulation and, potentially, higher family risk, appears to be associated with greater reductions in child abuse potential at 6-month follow-up in PuP and TAU. Emotional regulation appeared to act as a mediator as improvements in parental emotional regulation post-treatment appeared to be associated with greater reductions in child abuse potential at 6-month follow up. Notably, participation in the PuP programme led to better parental emotional regulation compared with TAU.

Challenging the association between health literacy and health: the role of conversion factors

Previous studies have found substantial correlations between health literacy and various health outcomes. However, the role of social and personal factors in those links remains understudied. Applying a moderation approach, we assume that these factors function as conversion factors on the associations between health literacy and health outcomes. Consequently, we test if associations between health literacy and health outcomes are stronger among young male adults who score high in conversion factors compared to those who score low. Cross-sectional data from the Young Adult Survey Switzerland were used for the analyses (n = 9339, age = 18-25). Multiple logistic regression analyses were applied to estimate associations between health literacy and health. Moderator analyses with three conversion factors and five health outcomes were conducted. For each health outcome at least one conversion factor moderated the association between health literacy and health according to the hypothesis. Although strength and form of the moderation effect differ across analyses, generally stronger associations were found among groups with beneficial social or personal factors. The present findings support the hypothesis that conversion factors play a crucial role in the associations between health literacy and health. The findings, thus, point towards a potential risk of linear health literacy approaches that assume equal benefits from increased health literacy. Individuals with beneficial social and personal factors (those already privileged) may enjoy greater health benefits from interventions improving health literacy.

The neuroleptic malignant syndrome-a systematic case series analysis focusing on therapy regimes and outcome

INTRODUCTION

Neuroleptic malignant syndrome (NMS) is a rare, potentially life-threatening antipsychotic-associated disorder that requires an efficient and timely therapy. The aim of the study was to compare the effectiveness of different NMS therapies and to analyze its outcome depending on NMS severity.

METHOD

Systematic search for NMS cases in biomedical databases. The focus of the analysis was on therapy with dantrolene, bromocriptine, and electroconvulsive therapy (ECT) when each was compared with symptomatic therapy. Primary outcomes were the survival rate and the duration of treatment.

RESULT

405 case reports were included. Overall, no statistically significant differences regarding mortality rate or duration of treatment were found between dantrolene, bromocriptine, or ECT compared to supportive care. A subgroup analysis regarding NMS severity showed that the mortality under specific NMS pharmacotherapy (dantrolene, bromocriptine) and under ECT was significantly lower than under purely symptomatic therapy in severe NMS (P = 0.018). The difference was not significant in mild and moderate cases.

DISCUSSION

An overall superiority of the specific NMS therapy (dantrolene, bromocriptine, and ECT) was not found in this study. When regarding severity classification, specific therapies were superior but only in severe cases, and ECT showed the lowest mortality rate. In previous case series, an effect on survival or the duration of the disease could only be observed in part for specific therapies, but the evidence available is inconsistent. The results of this study support our hypothesis that NMS treatment with dantrolene, bromocriptine, and ECT is advantageous over purely symptomatic therapy in severe NMS cases.