Do no harm: Balancing the costs and benefits of patient outcomes in health psychology research and practice

Recording harms in randomized controlled trials of behavior change interventions: a scoping review and map of the evidence

OBJECTIVES

Randomized controlled trials evaluate diverse interventions. This can include medical interventions such as drugs or surgical procedures, or behavior change interventions (BCIs) that aim to change a habit, belief, or attitude to improve health, for example, healthy eating, psychological wellbeing. Harms are often recorded poorly or inconsistently within randomized controlled trials of BCIs. This scoping review aimed to collate and describe literature on categories, definitions, and mechanisms of harms from BCIs; methods of identifying plausible harms; and recommendations for recording harms.

STUDY DESIGN AND SETTING

A scoping review was conducted. Three databases (MEDLINE, PsycINFO, and CINAHL) were searched. Reference list checking and citation searching were performed. Articles were included if they discussed (1) interventions that aimed to modify behavior, (2) categories or mechanisms of harms, and (3) methods or recommendations for recording harms. All research designs were included. One reviewer reviewed titles, abstracts, and full texts; queries were checked with another reviewer. Data were extracted and synthesized descriptively by one reviewer and checked by another reviewer. A thematic map was constructed to summarize the review findings. Harms described from specific BCIs were identified, and examples were selected and summarized.

RESULTS

The review included 37 articles. Nineteen of 37 articles contributed to a thematic review. Three articles described categories of harms; categories of harm included physical, psychological, group and social interactions, cultural, equity, opportunity cost, environmental, and economic. Seven articles included mechanisms or underlying factors for harms including feelings of failure leading to shame or stigma, and group interventions enabling knowledge exchange on unhealthy behaviors. Twelve articles provided recommendations for recording harms, including taking a proportionate approach by focusing on the most plausible and important harms, collecting different perspectives on whether harms had occurred (eg, caregivers and family members), and using qualitative research methods to identify harms. One article described a three-step method to identify plausible harms from an intervention, and six articles supported aspects of the method. Eighteen of 37 articles contributed to a review which collated harms arising from specific interventions, for example, a peer support intervention in inflammatory bowel disease caused distressing conversations which might lead to anxiety and confrontation with a possible negative future.

CONCLUSION

BCIs can cause harm. This review identified categories and proposed mechanisms of harms, as well as methods and recommendations for identifying and recording harms in BCIs for inclusion in forthcoming recommendations.

Temporary abstinence challenges: What do we need to know?

Participation in temporary abstinence challenges (TAC) continues to increase with campaigns established in several countries. Temporarily abstaining from alcohol as part of such challenges is associated with ongoing benefits including reductions to alcohol consumption after the TAC. We identified three research priorities regarding TACs which are outlined in this paper. First, the role of temporary abstinence itself is unclear with post-TAC reductions in alcohol consumption still apparent among participants who do not remain fully abstinent throughout the challenge. It is necessary to establish to what degree temporary abstinence itself, rather than the combination of abstinence and the additional supports provided by TAC organisers (e.g., mobile applications, online support groups), contributes to changes in consumption after the TAC. Second, little is known about the psychological changes underlying these changes in alcohol consumption, with conflicting evidence as to whether increases in someone's belief in their ability to avoid drinking mediates the association between participation in a TAC and reductions in consumption afterwards. Other potential psychological and social mechanisms of change have been subjected to little, if any, scrutiny. Third, evidence of increased consumption post-TAC among a minority of participants indicates a need to establish for whom or in what circumstances participation in a TAC may result in unintended negative consequences. Focussing research in these areas would increase the confidence with which participation could be encouraged. It would also enable campaign messaging and additional supports to be prioritised and tailored to be as effective as possible in facilitating long-term change.

Psychology's medicalization of male baldness

Male baldness is physically benign though it is increasingly described as a “disease” based on claims that it is profoundly distressing. The medicalization of baldness was assessed using data extracted from a review of 37 male baldness psychosocial impact studies. Findings revealed most studies likely had commercial influences (78%), represented baldness as a disease (77%), were conducted on biased samples (68%), and advocated for baldness products/services (60%), omitting their limitations (68%). Health psychologists should challenge baldness medicalization so that men can make informed choices about what, if anything, they do with their baldness.

Adverse event recording failed to reflect potential harms: a review of trial protocols of behavioral, lifestyle and psychological therapy interventions

OBJECTIVE

To explore how potential harms are assessed in trials of behavioral, lifestyle and psychological therapy interventions.

STUDY DESIGN AND SETTING

This study was a review of protocols from the National Institute of Health Research Health Technology Assessment and Public Health Research programmes. Protocols were included if the study was a randomized controlled trial and the intervention intended to change lifestyle or behavior to improve health or improve psychological outcomes.

RESULTS

95 of 151 protocols planned to record adverse events (AEs). Definitions of AEs were often not given and varied widely. Serious AEs were mostly defined using standards originally devised for pharmacological trials. Twenty-two protocols listed expected AEs. Few protocols described assessment of causation between AEs and intervention. Examples of useful AE recording practice were identified.

CONCLUSION

Monitoring and recording AEs in behavioral intervention trials was variable and frequently based on reporting guidelines for pharmacological trials. This may mean potential harms are being missed. Future trials should consider: 1) Potential harms posed by the intervention 2) How to define serious AEs 3) What are expected AEs. Further research to achieve consensus on AE recording is required, including identification of core adverse outcomes in clinical areas or caused by interventions.

Psychological Intervention and COVID-19: What We Know So Far and What We Can Do

The coronavirus COVID-19 and the global pandemic has already had a substantial disruptive impact on society, posing major challenges to the provision of mental health services in a time of crisis, and carrying the spectre of an increased burden to mental health, both in terms of existing psychiatric disorder, and emerging psychological distress from the pandemic. In this paper we provide a framework for understanding the key challenges for psychologically informed mental health care during and beyond the pandemic. We identify three groups that can benefit from psychological approaches to mental health, and/or interventions relating to COVID-19. These are (i) healthcare workers engaged in frontline response to the pandemic and their patients; (ii) individuals who will experience the emergence of new mental health distress as a function of being diagnosed with COVID-19, or losing family and loved ones to the illness, or the psychological effects of prolonged social distancing; and (iii) individuals with existing mental health conditions who are either diagnosed with COVID-19 or whose experience of social distancing exacerbates existing vulnerabilities. Drawing on existing literature and our own experience of adapting treatments to the crisis we suggest a number of salient points to consider in identifying risks and offering support to all three groups. We also offer a number of practical and technical considerations for working psychotherapeutically with existing patients where COVID-19 restrictions have forced a move to online or technologically mediated delivery of psychological interventions.

Common mental disorders in Taiwanese consumers of commercial low-dose computed tomography lung cancer screening: Comparison with a nationally representative sample

BACKGROUND/PURPOSE

We examined the prevalence of probable common mental disorders (CMDs) in commercial low-dose computed tomography (LDCT) lung cancer screening consumers relative to the general population and to determine the correlates of probable CMDs among screening participants.

METHODS

Commercial LDCT lung cancer screening consumers (N = 1323) were compared with a nationally representative sample from the Taiwan Social Change Survey (TSCS) (N = 2034). Respondents scoring ≥3 on the Chinese Health Questionnaire were classified as having a probable CMD. Logistic regression was used to investigate differences between the two groups and correlates of probable CMDs among LDCT lung cancer screening participants.

RESULTS

The prevalence of probable CMDs was higher among LDCT lung cancer screening participants (25.47%) than among TSCS adults (21.56%). Compared with the TSCS sample, the screening participants had a higher probability of CMDs (OR = 1.40, 95% CI = 1.13-1.73), higher education levels (OR = 7.95, 95% CI = 6.00-10.53), and a history of drinking (OR = 11.85, 95% CI = 9.45-14.85) or betel-quid use (OR = 5.43, 95% CI = 3.98-7.42) but were less likely to smoke (OR = 0.52, 95% CI = 0.40-0.68). Among the screening participants, being female (OR = 1.37, 95% CI = 1.02-1.84) and a current smoker (OR = 1.74, 1.19-2.54) and living near ≥2 smoking family members (OR = 2.30, 95% CI 1.57-3.38) were associated with an increased likelihood of having CMDs.

CONCLUSION

Commercial LDCT lung cancer screening users may have a positive association with probable CMDs compared to the general population. Screening programs should consider including criteria and providing psychoeducation to improve the physical and mental outcomes of participants.

CLINICAL TRIAL REGISTRATION

Purely observational studies (those in which the assignment of the medical intervention is not at the discretion of the investigator) do not require registration.

I Am Quite Mellow But I Wouldn't Say Everyone Else Is": How UK Students Compare Their Drinking Behavior to Their Peers'

BACKGROUND

Excessive drinking is commonplace at UK Universities. Individuals may misperceive how much they drink compared to others and are less likely to think that they will suffer adverse consequences. Young people often distance themselves and their friends from 'problem drinkers'.

OBJECTIVES

The aim of the study was to explore how student drinkers compared their own drinking behaviors to the drinking behaviors of others.

METHODS

An online survey was completed by 416 students aged 18-30 (68.5% female). They were asked 'how do you think your drinking compares with other people like you?' and 'how do you think your behavior when you drink compares with other people like you?' Answers were subjected to thematic analysis.

RESULTS

The first main theme was about 'identification as a 'good' drinker'. Participants suggested their own behavior when drinking was similar to their sober behavior. Further, they viewed themselves as more able to maintain a balance between staying in control and having fun while drinking. The second main theme was about 'distancing from being a 'bad' drinker. Participants distanced themselves from negative prototypical drinkers, such compulsive or anti-social drinkers. They also attributed their own drinking behaviors to situational factors, but described other people as intentionally violent or aggressive. Conclusions/Importance: These findings may explain the failure of some health messages to change drinking behaviors. If drinkers perceive that their behavior when they drink is better than other people's then they may discount intervention messages. Targeting these biases could be incorporated into future interventions.

You have to be prepared to drink

Purpose

Many existing interventions to reduce excessive drinking in university students attempt to target individual cognitions, which ignore the wider contextual features that drive excessive drinking and mark this as an important aspect of university life. The purpose of this paper is to explore students’ views about preventing excessive drinking at university, specifically by using frameworks that take into both account individual and social influences.

Design/methodology/approach

In all, 23 young adults aged 20-30 (12 females; M age=22.91; SD=2.57; 18 students, five recent graduates) took part in semi-structured interviews to explore their views about drinking and measures to reduce excessive consumption. Transcripts were analysed using thematic analysis.

Findings

There were three themes identified in the analysis. These themes were named “the role of alcohol in student life”, drinking transitions’, and “prevention challenges” and each had related sub-themes.

Practical implications

Targeting students before they commence their course and highlighting aspects of university life that do not involve alcohol may help to reduce the pressure often felt to drink in social situations. Providing novel, credible alternative socialising options that do not involve alcohol should be explored to determine their acceptability, and their potential to reduce excessive drinking.

Originality/value

Few studies explore what students themselves think about reducing alcohol consumption and most interventions focus on changing individual cognitions rather than features of the social environment. This study highlights that changing social practices related to drinking in combination with targeting individuals may be more fruitful avenue to reduce excessive alcohol consumption.