Multimorbidity in randomized controlled trials of behavioral interventions: A systematic review

Substance Use Within Trials of Psychological Interventions for Psychosis: Sample Inclusion, Secondary Measures, and Intervention Effectiveness

INTRODUCTION

Current clinical guidelines recommend that patients with co-occurring psychosis and alcohol or substance use disorders (A/SUD) receive evidenced-based treatment for both disorders, including psychological intervention for psychosis. However, the efficacy of such treatments for individuals with co-occurring psychosis and A/SUD is unclear.

STUDY DESIGN

Randomized controlled trials (RCTs) of psychological interventions for psychosis were systematically reviewed, to investigate how alcohol and substance use has been accounted for across sample inclusion and secondary measures. Findings from trials including individuals with co-occurring alcohol or substance use issues were then narratively summarized using the Synthesis Without Meta-Analysis guidelines, to indicate the overall efficacy of psychological interventions for psychosis, for this comorbid population.

STUDY RESULTS

Across the 131 trials identified, 60.3% of trials excluded individuals with alcohol or substance use issues. Additionally, only 6.1% measured alcohol or substance use at baseline, while only 2.3% measured alcohol or substance use as a secondary outcome. Across trials explicitly including individuals with alcohol or substance use issues, insufficient evidence was available to conclude the efficacy of any individual psychological intervention. However, preliminary findings suggest that psychoeducation (PE) and metacognitive therapy (MCT) may be proposed for further investigation.

CONCLUSION

Overall, co-occurring alcohol and substance use issues have been largely neglected across the recent RCTs of psychological interventions for psychosis; highlighting the challenges of making treatment decisions for these individuals using the current evidence base.

Multimorbidity representation in randomized controlled trials of selective serotonin reuptake inhibitors: A systematic analysis of published trials

BACKGROUND

Previous research has suggested a bidirectional relationship between multimorbidity and depression, with an increasing number of people living with both conditions. Therefore, we investigated how multimorbidity is represented in randomized controlled trials (RCT) of selective serotonin reuptake inhibitors (SSRI).

METHODS

We conducted a comprehensive keyword search in PubMed, Cochrane Central Library, PsycINFO, and EMBASE for RCTs published in 2011 or later. Multimorbidity representation was categorized into 'inclusion' or 'exclusion' within the study with studies including multimorbidity further categorized as conducting 'multivariable adjustment' or 'effect modification/stratification'. Logistic regression was used to examine the association of different study characteristics with multimorbidity representation among the studies.

RESULTS

In total, 183 trials were included for analysis. Nearly 60 %, i.e., 106 trials, excluded people with multimorbidity, and only four studies either conducted multivariable adjustment for baseline health conditions or examined potential effect modifications from multimorbidity. Studies based in Asia had significantly increased odds of multimorbidity exclusion compared to North America (odds ratio 3.18, 95 % confidence interval 1.09-1.39). A larger sample size was estimated to be associated with greater odds of conducting effect modification analysis for multimorbidity (odds ratio 1.006, 95 % confidence interval 1.001-1.011).

LIMITATIONS

Studies are limited to published, English-language studies where the short timespan may hinder the visibility of the multimorbidity trend.

CONCLUSIONS

Only a minority of RCTs on SSRIs considered multimorbidity within their study design. As both mental health awareness and multimorbidity are becoming increasingly ubiquitous within the global population, it is important for future studies to consider multimorbidity.

Illness Perception and the Severity of Depression and Anxiety Symptoms in Patients with Multimorbidity: Observational Cohort Studies

INTRODUCTION

Many studies have shown a correlation between the patient's engagement in treatment and their perception of the illness.

AIM

The aim of this study has been to explore the link between the patient's perception of their illness with anxiety and depression, and to leverage this link to promote health education.

MATERIALS AND METHODS

The study was carried out using the following tools: the Hospital Anxiety and Depression Scale and the Illness Perception Questionnaire-Revised. The study participants included N = 143 patients.

RESULTS

The participants' age was statistically significantly associated with the expected duration of the illness (p < 0.01), the conviction that the treatment was effective (p < 0.01), and the perception of the severity of the disease symptoms (p < 0.05). The employment status was statistically significantly associated with the illness perception (p < 0.01). Anxiety and depression levels were statistically significantly associated with the perceived impact of the illness on life (p < 0.001) and emotional status (p < 0.001), the perceived control over the illness (p < 0.01), the potential for recovery (p < 0.001), the concern about the illness (p < 0.001), and the impact of the illness on emotional well-being (p < 0.001).

CONCLUSIONS

Individuals who perceived a high severity of illness symptoms also assessed that the illness significantly impacted their life and emotional state. The authors demonstrate a strong link of a "negative" perception of the illness with depression and anxiety. A better understanding of the illness predicted a less severe depression and lower anxiety.

IMPLICATIONS FOR PRACTICE

The results suggest that the study of illness perception holds significant potential to contribute effectively to educational and psychotherapeutic practices.

CHRONIC MULTIMORBIDITY OF LOW BACK PAIN OR OTHER CHRONIC BACK DISORDERS IN THE REPUBLIC OF CROATIA

The aim was to assess the prevalence of chronic multimorbidity in patients with chronic low back pain or other chronic back disorders (BD). We analyzed data from the population-based cross-sectional European Health Interview Survey (EHIS) performed in the Republic of Croatia 2014-2015 by the Croatian Institute of Public Health. Outcome was the point-prevalence of chronic multimorbidity defined as having ≥2 chronic illnesses out of 14 contained in the EHIS questionnaire, after adjustment for ten sociodemographic, anthropometric and lifestyle confounders. Amoung fourteen targeted illnesses were asthma, allergies, hypertension, urinary incontinence, kidney diseases, coronary heart disease or angina pectoris, neck disorder, arthrosis, chronic obstructive pulmonary disease, diabetes mellitus, myocardial infarction, stroke, depression, and the common category "other". We analyzed data on 268 participants with BD and 511 without it. Participants with BD had a significantly higher relative risk of any chronic multimorbidity (RRadj=2.12; 95% CI 1.55, 2.99; p<0.001), as well as of non-musculoskeletal chronic multimorbidity (RRadj=2.29; 95% CI 1.70, 3.08; p=0.001) than participants without BD. All chronic comorbidities except for asthma and liver cirrhosis were significantly more prevalent in participants with BD than in participants without BD. In the population with BD, the participants with multimorbidity had three to four times higher odds for unfavorable self-reported health outcomes than the participants with no comorbid conditions, whereas the existence of only one comorbidity was not significantly associated with a worse outcome compared to the population with no comorbidities. In conclusion, the population suffering from BD has a higher prevalence of chronic multimorbidity than the population without BD and this multimorbidity is associated with unfavorable health outcomes.

Associations between daily step count trajectories and clinical outcomes among adults with comorbid obesity and depression

Purpose

To examine the relationship between features of daily measured step count trajectories and clinical outcomes among people with comorbid obesity and depression in the ENGAGE-2 Trial.

Methods

This post hoc analysis used data from the ENGAGE-2 trial where adults (n=106) with comorbid obesity (BMI ≥30.0 or 27.0 if Asian) and depressive symptoms (Patient Health Questionnaire-9 score ≥10) were randomized (2:1) to receive the experimental intervention or usual care. Daily step count trajectories over the first 60 days (Fitbit Alta HR) were characterized using functional principal component analyses. 7-day and 30-day trajectories were also explored. Functional principal component scores that described features of step count trajectories were entered into linear mixed models to predict weight (kg), depression (Symptom Checklist-20), and anxiety (Generalized Anxiety Disorder Questionnaire-7) at 2-months (2M) and 6-months (6M).

Results

Features of 60-day step count trajectories were interpreted as overall sustained high, continuous decline, and disrupted decline. Overall sustained high step count was associated with low anxiety (2M, β=-0.78, p<.05; 6M, β=-0.80, p<.05) and low depressive symptoms (6M, β=-0.15, p<.05). Continuous decline in step count was associated with high weight (2M, β=0.58, p<.05). Disrupted decline was not associated with clinical outcomes at 2M or 6M. Features of 30-day step count trajectories were also associated with weight (2M, 6M), depression (6M), and anxiety (2M, 6M); Features of 7-day step count trajectories were not associated with weight, depression, or anxiety at 2M or 6M.

Conclusions

Features of step count trajectories identified using functional principal component analysis were associated with depression, anxiety, and weight outcomes among adults with comorbid obesity and depression. Functional principal component analysis may be a useful analytic method that leverages daily measured physical activity levels to allow for precise tailoring of future behavioral interventions.

Multimorbidity in a 35-Year-Old Female Patient Treated with Homeopathy: A Case Report

Background Multimorbidity, a prevailing trend in the primary care population of all ages, is a challenge for health care systems that are largely configured for single disease management. Homeopathy has shown competence in the management of chronic diseases, whether they occur as a single ailment or as a multimorbidity.

Case History A 35-year-old female patient presenting with hemorrhoids, low back pain, hypothyroidism, fibroadenosis breasts (bilateral), and fibroid uterus was given homeopathic treatment for 33 months at Nandigama AYUSH Lifestyle Disorders Clinic, Andhra Pradesh. She was prescribed the homeopathic medicines Lachesis mutus and Thyroidinum at different time intervals based on the totality of symptoms.

Results Following treatment, a reduction in the size of the uterine fibroid and complete regression of breast lumps in ultrasonography were noted. The modified Naranjo criteria total score was 10 out of 13. Further, significant improvement in symptoms and laboratory parameters, such as triiodothyronine (T3), tetra-iodothyronine (T4), and thyroid-stimulating hormone (TSH), indicated that a well-chosen homeopathic medicine may be beneficial in managing multimorbidity.

Conclusion This case study reveals a positive role of homeopathic treatment in multimorbidity. More case studies and well-designed controlled should be used to further investigate homeopathic intervention in multimorbidity.

Comparing clinical trial population representativeness to real-world populations: an external validity analysis encompassing 43 895 trials and 5 685 738 individuals across 989 unique drugs and 286 conditions in England

BACKGROUND

Randomised controlled trials (RCTs) inform prescription guidelines, but stringent eligibility criteria exclude individuals with vulnerable characteristics, which we define as comorbidities, concomitant medication use, and vulnerabilities due to age. Poor external validity can result in inadequate treatment decision information. Our first aim was to quantify the extent of exclusion of individuals with vulnerable characteristics from RCTs for all prescription drugs. Our second aim was to quantify the prevalence of individuals with vulnerable characteristics from population electronic health records who are actively prescribed such drugs. In tandem, these two aims will allow us to assess the representativeness between RCT and real-world populations and identify vulnerable populations potentially at risk of inadequate treatment decision information. When a vulnerable population is highly excluded from RCTs but has a high prevalence of individuals actively being prescribed the same medication, there is likely to be a gap in treatment decision information. Our third aim was to investigate the use of real-world evidence in contributing towards quantifying missing treatment risk or benefit through an observational study.

METHODS

We extracted RCTs from ClinicalTrials.gov from its inception to April 28, 2021, and primary care records from the Clinical Practice Research Datalink Gold database from Jan 1, 1998, to Dec 31, 2020. We referred to the British National Formulary to classify prescription drugs into drug categories. We conducted descriptive analyses and quantified RCT exclusion and prevalence of individuals with vulnerable characteristics for comparison to identify populations without treatment decision information. Exclusion and prevalence were assessed separately for different age groups, individual clinical specialities, and for quantities of concomitant conditions by clinical specialities, where multimorbidity was defined as having two or more clinical specialties, and medications prescribed, where polypharmacy was defined as having five or more medications prescribed. Population trends of individuals with multimorbidity or polypharmacy were assessed separately by age group. We conducted an observational cohort study to validate the use of real-world evidence in contributing towards quantifying treatment risk or benefit for patients with dementia on anti-dementia drugs with and without a contraindicated clinical speciality. To do so, we identified the clinical specialities that anti-dementia drug RCTs highly excluded yet had corresponding high prevalence in the real-world population, forming the groups with highest risk of having scarce treatment decision information. Cox regression was used to assess if the risk of mortality outcomes differs between both groups.

FINDINGS

43 895 RCTs from ClinicalTrials.gov and 5 685 738 million individuals from primary care records were used. We considered 989 unique drugs and 286 conditions across 13 drug-category cohorts. For the descriptive analyses, the median RCT exclusion proportion across 13 drug categories was 81·5% (IQR 76·7-85·5) for adolescents (aged <18 years), 26·3% (IQR 21·0-29·5) for individuals older than 60 years, 40·5% (IQR 33·7-43·0) for individuals older than 70 years, and 52·9% (IQR 47·1-56·0) for individuals older than 80 years. Multimorbidity had a median exclusion proportion of 91·1% (IQR 88·9-91·8) and median prevalence of 41·0% (IQR 34·9-46·0). Concomitant medication use had a median exclusion proportion of 52·5% (IQR 50·0-53·7) and a median prevalence of 94·3% (IQR 84·3-97·2), and polypharmacy had a median prevalence of 47·7% (IQR 38·0-56·1). Population trends show increasing multimorbidity with age and consistently high polypharmacy across age groups. Populations with cardiovascular or otorhinolaryngological comorbidities had the highest risk of having scarce treatment decision information. For the observational study, populations with cardiovascular or psychiatric comorbidities had highest risk of having scarce treatment decision information. Patients with dementia with an anti-dementia prescription and contraindicated cardiovascular condition had a higher risk of mortality (hazard ratio [HR] 1·20 [95% CI 1·13-1·28 ; p<0·0001]) compared with patients with dementia without a contraindicated cardiovascular condition. Patients with dementia with comorbid delirium (HR 1·25 [95% CI 1·06-1·48]; p<0·0088), intellectual disability (HR 2·72 [95% CI 1·53-4·81]; p=0·0006), and schizophrenia and schizotypal delusional disorders (HR 1·36 [95% CI 1·02-1·82]; p=0·036) had a higher risk of mortality compared with patients with dementia without these conditions.

INTERPRETATION

Overly stringent RCT exclusion criteria do not appropriately account for the heterogeneity of vulnerable characteristics observed in real-world populations. Treatment decision information is scarce for such individuals, which might affect health outcomes. We discuss the challenges facing the inclusivity of such individuals and highlight the strength of real-world evidence as an integrative solution in complementing RCTs and increasing the completeness of evidence-based medicine assessments in evaluating the effectiveness of treatment decisions.

FUNDING

Wellcome Trust, National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre, Academy of Medical Sciences, and the University College London Overseas Research Scholarship.

Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome

Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially "treatable traits" that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.

Proof of Concept of a 6-Month Person-Oriented Exercise Intervention 'MultiPill-Exercise' among Patients at Risk of or with Multiple Chronic Diseases: Results of a One-Group Pilot Trial

Physical exercise has been shown to be effective in the treatment of non-communicable chronic diseases. However, patients with multiple chronic diseases (multimorbidity) have received little attention in health policy. This pilot trial served as a proof of concept of a 6-months person-oriented exercise intervention for people at risk of or with diagnosed cardiovascular diseases, diabetes mellitus type 2, overweight and/or hip/knee osteoarthritis, regarding effects on health outcomes as well as adherence and safety. The intervention (‘MultiPill-Exercise’) was designed to promote physical exercise participation, considering an individual perspective by addressing personal and environmental factors. Outcomes were assessed at baseline (t0) and after three- (t3) and six-months (t6). The primary outcome was self-reported physical exercise participation in minutes/week comparing t3 and t6 vs. t0. Secondary outcomes included cardio-respiratory fitness (maximum oxygen uptake VO2peak during incremental cycling ergometry), isometric peak torque of knee extensors and flexors, health-related quality of life (Veterans Rand 12 with its subscales of perceived general health (GH), mental health (MCS), and physical health (PCS)) and blood levels. Adherence to exercise (% of attended sessions during the first 12-weeks of the intervention) and adverse events were monitored as well. Data were analyzed using a non-parametric procedure for longitudinal data, estimating rank means (MRank) and relative treatment effects (RTE) as well as linear-mixed effect models for parametric data. The primary endpoint of physical exercise participation was significantly higher at t3 and t6 compared to baseline (t3 vs. t0: MRank = 77.1, p < 0.001, RTE: 0.66; t6 vs. t0: MRank = 70.6, p < 0.001, RTE = 0.60). Improvements at both follow-up time points compared to t0 were also found for relative VO2peak (t3 vs. t0 = 2.6 mL/kg/min, p < 0.001; t6 vs. t0 = 2.0 mL/kg/min, p = 0.001), strength of knee extensors (t3 vs. t0 = 11.7 Nm, p = 0.007; t6 vs. t0= 18.1 Nm, p < 0.001) and GH (t3 vs. t0 = 16.2, p = 0.003; t6 vs. t0 = 13.4, p = 0.008). No changes were found for MCS, PCS and for blood levels. Overall exercise adherence was 77%. No serious adverse events were recorded. Results of this pilot trial represent a first proof of concept for the intervention ‘MultiPill-Exercise’ that will now be implemented and evaluated in a real-world health care setting.

Developing a Medication Self-management Program to Enhance Medication Adherence among Older Adults with Multimorbidity Using Intervention Mapping

BACKGROUND AND OBJECTIVES

Suboptimal medication adherence is prevalent in older adults with multimorbidity. However, intervention programs for enhancing adherence in this population are limited. This study describes the development process of a medication self-management program for older adults with multimorbidity.

RESEARCH DESIGN AND METHODS

We adopted the first four steps of the Intervention Mapping to develop the program: (1) needs assessment, including a literature review, a systematic review, and a cross-sectional study, (2) development of program outcomes and objectives, (3) selection of theory-based intervention methods and practical applications, and (4) development of the program.

RESULTS

We conducted a needs assessment to identify factors affecting medication adherence among older adults with multimorbidity and created a logic model of the adherence problem in Step 1. In Step 2, we developed the specific program outcomes and objectives and then selected adherence information, personal motivation, social motivation, behavioral skills, and treatment experiences as modifiable and important targets that needed to change in this program. In Step 3, we chose several theory-based methods and strategies for practical applications. We finally created a nurse-led medication self-management program in Step 4. Feedback from relevant stakeholders refined the intervention protocol and materials.

DISCUSSION AND IMPLICATIONS

The newly developed medication self-management program incorporated theory and evidence from literature and empirical studies with the engagement of multiple stakeholders, making it a contextually and culturally appropriate intervention. This study provides insights into strategies for geriatrics healthcare professionals to support medication self-management among older adults with multimorbidity.

Making Pain Research More Inclusive: Why and How

Current knowledge about mechanisms and interventions for pain has largely been derived from samples that are healthier, wealthier, younger, and more likely to be White than the general population. Failure to conduct inclusive pain research not only restricts generalizability and application of findings, but also hampers the discovery of mechanisms and the development of measures and interventions that are valid across population subgroups. Most of all, inclusive practices are critical to ensure that underrepresented groups derive equitable benefit from pain research. Here, we provide guidance for the pain research community on how to adopt inclusive research practices. We define "inclusion" to encompass a range of identities and characteristics, including racialized group/ethnicity, disability status, gender identity, sexual orientation, and age. We first describe principles relevant to promoting inclusion in pain research, including attention to: 1) stakeholder engagement; 2) structural factors underlying inequities; 3) the limitations of "disparity" research; 4) intersectionality; and 5) universal design. Next, we provide checklists with practical strategies for making studies more inclusive at each stage of the research process. We conclude by calling for system-level changes to ensure that the future of pain research is socially just, scientifically productive, and responsive to the needs of all people. PERSPECTIVE: This paper offers guidance on promoting inclusion of underrepresented groups in pain research. We describe principles relevant to conducting more inclusive research; eg, attention to stakeholder engagement, structural factors, and universal design. We provide checklists with practical strategies for inclusion at each stage of the research process.

Interventions for improving medication adherence in community-dwelling older people with multimorbidity: A systematic review and meta-analysis

BACKGROUND

Multimorbidity is highly prevalent amongst older people. Compared with those with a single disease, older people with multimorbidity are more susceptible to medication nonadherence, which causes adverse health outcomes and increased health care costs. The effectiveness of interventions for improving medication adherence in this population is still unclear.

OBJECTIVE

To evaluate the effectiveness of interventions to improve medication adherence for community-dwelling older people with multimorbidity.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ten databases: Airiti Library, China National Knowledge Infrastructure, Cochrane CENTRAL, EBSCO CINAHL, OVID EMBASE, OVID MEDLINE, Proquest Central, PsycINFO, Wanfang Database and Web of Science Core Collection.

REVIEW METHODS

Studies evaluating the effects of interventions on medication adherence in community-dwelling older people with multimorbidity were included. Two researchers independently performed the study selection, data extraction and risk assessment. Intervention effects were pooled by random-effects meta-analysis.

RESULTS

A total of nine studies with 3,292 participants were included. Studies on self-management interventions revealed a significant and modest improvement in medication adherence (n = 3 studies; SMD 0.52; 95% CI 0.04 to 0.99; p = 0.03, I² = 43%). Studies using electronic health interventions demonstrated a small yet significant benefit for medication adherence (n = 2 studies; SMD 0.22; 95% CI 0.02 to 0.42; p = 0.03, I² = 0%). There was no pooled significant effect of medication review on medication adherence (n = 4 studies; SMD -0.03; 95% CI -0.21 to 0.15; p = 0.74, I² = 68%). Most of the studies failed to yield a significant improvement in patients' health outcomes.

CONCLUSIONS

Self-management interventions and electronic health interventions might be effective in improving medication adherence for older people with multimorbidity. Future adherence interventions are needed to demonstrate improvements in medication adherence and health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020150500.

'Just keep taking them, keep hoping they'll work': A qualitative study of adhering to medications for multimorbidity

OBJECTIVE

Compared to single diseases, health psychology reflects many areas of medical research by affording relatively less attention to the experiences of people self-managing multiple co-occurring conditions and, in particular, the experience of managing the associated complex medication regimens. This study aimed to explore the experience of self-managing multimorbidity among older adults, with a focus on medication adherence.

DESIGN

A qualitative approach was taken, using individual semi-structured interviews.

METHODS

Sixteen people with complex multimorbidity aged 65 years or older were recruited through general practice to take part in semi-structured interviews. Data were analysed following guidelines for reflexive thematic analysis.

RESULTS

Two themes were generated, with each theme comprising three subthemes. Theme one represents the amplified burden arising from multimorbidity that leads to unique challenges for self-management, such as integrating multiple medications into daily life, accumulating new symptoms and treatments, and managing evolving medication regimens. Theme two represents pathways towards relief that reduce this burden and promote medication adherence, such as prioritising certain conditions and treatments, resigning to the need for multiple medications, and identifying and utilising adherence supports.

CONCLUSIONS

We identified factors relevant to medication adherence for older adults with multimorbidity that go beyond single-disease influences and account for the amplified experience of chronic disease that multimorbidity can produce for some people. While evidence of single-disease influences remains fundamental to tailoring behavioural interventions to individuals, the impact of multimorbidity on medication adherence should be accounted for in research and practice.

Experimental Designs to Optimize Treatments for Individuals: Personalized N-of-1 Trials

Conventional randomized clinical trials (RCTs) compare treatment effectiveness to provide support for evidence-based treatments that can be generalized to the average patient. However, the information obtained from RCTs may not always be useful for selecting the best treatment for individual patients. This article presents a complementary approach to identifying optimized treatments using experimental designs that focus on individuals. Personalized, or N-of-1, designs provide both a comparative analysis of treatments and a functional analysis demonstrating that changes in patient symptoms are likely because of the treatment implemented. This approach contributes to the zeitgeist of personalized medicine and provides clinicians with a paradigm for investigating optimal treatments for rare diseases for which RCTs are not always feasible, identifying personally effective treatments for patients with comorbidities who have historically been excluded from most RCTs, handling clinical situations in which patients respond idiosyncratically (either positively or negatively) to treatment, and shortening the time lag between identification and implementation of an evidence-based treatment. These designs merge experimental analysis of behavior methods used for decades in psychology with new methodological and statistical advances to assess significance levels of changes in individual patients, and they can be generalized to larger populations for meta-analytic purposes. This article presents a case for why these models are needed, an overview of how to apply personalized designs for different types of clinical scenarios, and a brief discussion of challenges associated with interpretation and implementation of personalized designs. The goal is to empower pediatricians to take personalized trial designs into clinical practice to identify optimal treatments for their patients.

The value of a second reviewer for study selection in systematic reviews

BACKGROUND

Although dual independent review of search results by two reviewers is generally recommended for systematic reviews, there are not consistent recommendations regarding the timing of the use of the second reviewer. This study compared the use of a complete dual review approach, with two reviewers in both the title/abstract screening stage and the full-text screening stage, as compared with a limited dual review approach, with two reviewers only in the full-text stage.

METHODS

This study was performed within the context of a large systematic review. Two reviewers performed a complete dual review of 15 000 search results and a limited dual review of 15 000 search results. The number of relevant studies mistakenly excluded by highly experienced reviewers in the complete dual review was compared with the number mistakenly excluded during the full-text stage of the limited dual review.

RESULTS

In the complete dual review approach, an additional 6.6% to 9.1% of eligible studies were identified during the title/abstract stage by using two reviewers, and an additional 6.6% to 11.9% of eligible studies were identified during the full-text stage by using two reviewers. In the limited dual review approach, an additional 4.4% to 5.3% of eligible studies were identified with the use of two reviewers.

CONCLUSIONS

Using a second reviewer throughout the entire study screening process can increase the number of relevant studies identified for use in a systematic review. Systematic review performers should consider using a complete dual review process to ensure all relevant studies are included in their review.

Multimorbidity: Implications and directions for health psychology and behavioral medicine

The increasing prevalence of multimorbidity in the United States and the rest of the world poses problems for patients and for health care providers, care systems, and policy. After clarifying the difference between comorbidity and multimorbidity, this article describes the challenges that the prevalence of multimorbidity presents for well-being, prevention, and medical treatment. We submit that health psychology and behavioral medicine have an important role to play in meeting these challenges because of the holistic vision of health afforded by the foundational biopsychosocial model. Furthermore, opportunities abound for health psychology/behavioral medicine to study how biological, social and psychological factors influence multimorbidity. This article describes three major areas in which health psychologists can contribute to understanding and treatment of multimorbidity: (a) etiology; (b) prevention and self-management; and (c) clinical care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).