Principles for defining adverse events in behavioral intervention research: lessons from a family-focused adolescent drug abuse trial

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.

Development and content validity of EVAD: A novel tool for evaluating and classifying the severity of adverse events for psychotherapeutic clinical trials

OBJECTIVE

Develop and obtain content validity of a new tool for Evaluating and Classifying the Severity of Adverse Events for Psychotherapeutic Clinical Trials (EVAD).

METHOD

Study of the development process of EVAD in four stages: (1) identify the domain and concept definition through a literature review, (2) instrument design, (3) expert judgment of the EVAD items through Gwent's concordance coefficient, and (4) applicability.

RESULTS

In the absence of a consistent conceptual framework of adverse events in psychotherapeutic clinical trials, we have developed a framework and defined it. We have designed EVAD items and their complementary tool for rating adverse events. Content validation by expert judges resulted in CVR = 1.0 for each item and CVI = 0.79 in sufficiency, 0.76 in clarity, 0.91 in coherence and 0.95 in relevance for all items (p < 0.001). Final version of EVAD were applied to three participants for 7 weeks. Overall EVAD seems to be clear and meaningful for participants.

CONCLUSIONS

EVAD is a semistructured interview based on a consistent conceptual framework, and proven content validity following the most important guidelines described in the literature.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03878186.

Effectiveness of Multifaceted Strategies to Increase Influenza Vaccination Uptake: A Cluster Randomized Trial

Importance

Influenza vaccination rates remain low among primary school students and vary by school in Beijing, China. Theory-informed, multifaceted strategies are needed to improve influenza vaccination uptake.

Objective

To evaluate the effectiveness of multifaceted strategies in improving influenza vaccination uptake among primary school students.

Design, Setting, and Participants

This cluster randomized trial was conducted from September 2022 to May 2023 across primary schools in Beijing, China. Schools were allocated randomly in a 1:1 ratio to multifaceted strategies or usual practice. Schools were deemed eligible if the vaccination rates in the 2019 to 2020 season fell at or below the district-wide average for primary schools. Eligible participants included students in grades 2 and 3 with no medical contraindications for influenza vaccination.

Intervention

The multifaceted strategies intervention involved system-level planning and coordination (eg, developing an implementation blueprint, building social norms, and enhancing supervision), school-level training and educating school implementers (eg, conducting a 1-hour training and developing educational materials), and individual-level educating and reminding students and parents (eg, conducting educational activities and sending 4 reminders about vaccination).

Main Outcomes and Measures

The primary outcomes were influenza vaccination uptake at school reported by school clinicians as well as overall vaccine uptake either at school or outside of school as reported by parents at 3 months. Generalized linear mixed models were used for analysis.

Results

A total of 20 schools were randomized. One intervention school and 2 control schools did not administer vaccination on school grounds due to COVID-19, resulting in a total of 17 schools (9 intervention and 8 control). There was a total of 1691 students aged 7 to 8 years (890 male [52.6%]; 801 female [47.4%]) including 915 in the intervention group and 776 in the control group. Of all participants, 848 (50.1%) were in grade 2, and 1209 (71.5%) were vaccinated in the 2021 to 2022 season. Participants in the intervention and control groups shared similar characteristics. At follow-up, of the 915 students in the intervention group, 679 (74.5%) received a vaccination at school, and of the 776 students in the control group, 556 (71.7%) received a vaccination at school. The overall vaccination rates were 76.0% (695 of 915 students) for the intervention group and 71.3% (553 of 776 students) for the control group. Compared with the control group, there was significant improvement of vaccination uptake at school (odds ratio, 1.40; 95% CI, 1.06-1.85; P = .02) and overall uptake (odds ratio, 1.49; 95% CI, 1.12-1.99; P = .01) for the intervention group.

Conclusions and Relevance

In this study, multifaceted strategies showed modest effectiveness in improving influenza vaccination uptake among primary school students, which provides a basis for the implementation of school-located vaccination programs of other vaccines in China, and in other countries with comparable programs.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2200062449.

Recording harms in randomised controlled trials of behaviour change interventions: a qualitative study of UK clinical trials units and NIHR trial investigators

BACKGROUND

Harms, also known as adverse events (AEs), are recorded and monitored in randomised controlled trials (RCTs) to ensure participants' safety. Harms are recorded poorly or inconsistently in RCTs of Behaviour Change Interventions (BCI); however, limited guidance exists on how to record harms in BCI trials. This qualitative study explored experiences and perspectives from multi-disciplinary trial experts on recording harms in BCI trials.

METHODS

Data were collected through fifteen in-depth semi-structured qualitative interviews and three focus groups with thirty-two participants who work in the delivery and oversight of clinical trials. Participants included multi-disciplinary staff from eight CTUs, Chief investigators, and patient and public representatives. Interviews and focus group recordings were transcribed verbatim and thematic analysis was used to analyse the transcripts.

RESULTS

Five themes were identified, namely perception and understanding of harm, proportionate reporting and plausibility, the need for a multi-disciplinary approach, language of BCI harms and complex harms for complex interventions. Participants strongly believed harms should be recorded in BCI trials; however, making decisions on "how and what to record as harms" was difficult. Recording irrelevant harms placed a high burden on trial staff and participants, drained trial resources and was perceived as for little purpose. Participants believed proportionate recording was required that focused on events with a strong plausible link to the intervention. Multi-disciplinary trial team input was essential for identifying and collecting harms; however, this was difficult in practice due to lack of knowledge on harms from BCIs, lack of input or difference in opinion. The medical language of harms was recognised as a poor fit for BCI trial harms but was familiar and established within internal processes. Future guidance on this topic would be welcomed and could include summarised literature.

CONCLUSIONS

Recording harms or adverse events in behaviour change intervention trials is complex and challenging; multi-disciplinary experts in trial design and implementation welcome forthcoming guidance on this topic. Issues include the high burden of recording irrelevant harms and use of definitions originally designed for drug trials. Proportionate recording of harms focused on events with a strong plausible link to the intervention and multi-disciplinary team input into decision making are essential.

What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports

Background

Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.

Aims

This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.

Methods

Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.

Results

In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.

Conclusion

This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.

Systematic review: Exploring the monitoring and reporting of unwanted events in psychotherapy trials for anorexia nervosa

OBJECTIVE

If a psychotherapeutic intervention has the capacity to produce positive change, the "deterioration effect" theory holds that it must also have the potential for negative effects. However, the definition, measurement, and reporting of unwanted events in psychotherapy is a topic of ongoing discussion. At present this area is under-explored in interventions for anorexia nervosa (AN), a severe mental illness associated with high medical and psychiatric risks. The aim of this article was to undertake a systematic review of published randomized controlled trials (RCTs) evaluating psychotherapeutic interventions for AN, and to assess how unwanted events were defined, monitored, and reported alongside the trial's key findings.

METHOD

Using a systematic review methodology, this article identified 23 RCTs through database searches meeting eligibility criteria. Results are presented using a narrative summary approach.

RESULTS

Unwanted event reporting varied widely, both regarding definitions of key unwanted events (such as non-compliance or symptom deterioration) and in the amount of detail captured in each paper.

DISCUSSION

The review identified two key issues: firstly, a lack of consistent definitions and unclear causality made it difficult to distinguish between unwanted events, and adverse events caused by the interventions. Secondly, it highlighted the difficulty of defining unwanted events where different studies have different populations and goals. Recommendations are made around how the area of defining, monitoring, and reporting unwanted events in RCTs for AN can be taken forward.

PUBLIC SIGNIFICANCE

Whilst psychotherapies can be effective in treating mental health conditions, negative or unwanted events can sometimes occur. This review explored how RCTs examining psychotherapy for AN report how they monitor the safety of participants, and how they report unwanted events. We found that the reporting was often inconsistent or hard to interpret, and we have made recommendations for how this can be improved in the future.

Identifying and Categorizing Adverse Events in Trials of Digital Mental Health Interventions: Narrative Scoping Review of Trials in the International Standard Randomized Controlled Trial Number Registry

BACKGROUND

To contextualize the benefits of an intervention, it is important that adverse events (AEs) are reported. This is potentially difficult in trials of digital mental health interventions, where delivery may be remote and the mechanisms of actions less understood.

OBJECTIVE

We aimed to explore the reporting of AEs in randomized controlled trials of digital mental health interventions.

METHODS

The International Standard Randomized Controlled Trial Number database was searched for trials registered before May 2022. Using advanced search filters, we identified 2546 trials in the category of mental and behavioral disorders. These trials were independently reviewed by 2 researchers against the eligibility criteria. Trials were included where digital mental health interventions for participants with a mental health disorder were evaluated through a completed randomized controlled trial (protocol and primary results publication published). Published protocols and primary results publications were then retrieved. Data were extracted independently by 3 researchers, with discussion to reach consensus when required.

RESULTS

Twenty-three trials met the eligibility criteria, of which 16 (69%) included a statement on AEs within a publication, but only 6 (26%) reported AEs within their primary results publication. Seriousness was referred to by 6 trials, relatedness by 4, and expectedness by 2. More interventions delivered with human support (9/11, 82%) than those with only remote or no support (6/12, 50%) included a statement on AEs, but they did not report more AEs. Several reasons for participant dropout were identified by trials that did not report AEs, of which some were identifiable or related to AEs, including serious AEs.

CONCLUSIONS

There is significant variation in the reporting of AEs in trials of digital mental health interventions. This variation may reflect limited reporting processes and difficulty recognizing AEs related to digital mental health interventions. There is a need to develop guidelines specifically for these trials to improve future reporting.

Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial

Background

People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists.

Methods

Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stress and psychosis symptoms from five mental health Trusts (60 per site) will be randomised to the two groups. Therapy will be manualised, lasting 9 months (m) with trained therapists. We will assess PTSD symptom severity (primary outcome); percentage who show loss of PTSD diagnosis and clinically significant change; psychosis symptoms; emotional well-being; substance use; suicidal ideation; psychological recovery; social functioning; health-related quality of life; service use, a total of four times: before randomisation; 4 m (mid-therapy); 9 m (end of therapy; primary end point); 24 m (15 m after end of therapy) post-randomisation. Four 3-monthly phone calls will be made between 9 m and 24 m assessment points, to collect service use over the previous 3 months. Therapy acceptability will be assessed through qualitative interviews with participants (N = 35) and therapists (N = 5–10). An internal pilot will ensure integrity of trial recruitment and outcome data, as well as therapy protocol safety and adherence. Data will be analysed following intention-to-treat principles using generalised linear mixed models and reported according to Consolidated Standards of Reporting Trials-Social and Psychological Interventions Statement.

Discussion

The proposed intervention has the potential to provide significant patient benefit in terms of reductions in distressing symptoms of post-traumatic stress, psychosis, and emotional problems; enable clinicians to implement trauma-focused therapy confidently in this population; and be cost-effective compared to TAU through reduced service use.

Trial registration

ISRCTN93382525 (03/08/20)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06215-x.

'Like jumping off a ledge into the water': A qualitative study of trauma-focussed imaginal exposure for hearing voices

OBJECTIVE

There is growing evidence of a link between the experience of hearing voices and past traumatic events, and trauma-focussed psychological interventions are being applied to hearing voices as an emerging treatment direction. To inform the ongoing development and implementation of this application, there is a need to understand clients' therapy experiences.

DESIGN

Qualitative study exploring the experience of people who received an intervention for voices linked to a previous traumatic event.

METHOD

Ten participants experiencing voices with some connection to a previous traumatic event participated in individual semi-structured interviews following six sessions of imaginal exposure, an exposure-based trauma-focussed intervention. Participant responses were analysed using thematic analysis.

RESULTS

Participants reported a range of benefits from the intervention, including improved mental health, reduction of distressing voice-hearing experiences, and increased clarity of the traumatic event. The therapy was perceived as distinctly different to previous therapy experiences, and participants noted that therapy could be intense and challenging, yet helpful later. Participants also reported that outside circumstances impacted on their progress in therapy and their voice-hearing experience.

CONCLUSIONS

The findings suggest that exposure-based trauma-focussed therapies may be beneficial for people who hear trauma-related voices. However, this intervention can be intense and clinicians and consumers need to consider the timing of delivery, and pay attention to internal and external resources that can increase participants' sense of safety.

PRACTITIONER POINTS

Imaginal exposure may be an effective intervention for people who hear voices that they perceive to be associated with a past traumatic event. Positive changes associated with the intervention may be highly variable between individuals, and encompass changes in sense of self, changes to internal states, and changes to voice-hearing experience. Imaginal exposure interventions may involve some temporary discomfort and symptom exacerbation, which may affect the acceptability of the intervention. This needs to be considered in both future research and clinical delivery.

Clinical- and Cost Effectiveness of a Guided Internet-Based Intervention for Children (12–18 Years) of Parents With Mental Disorders (iCHIMPS): Study Protocol of a Multicentered Cluster-Randomized Controlled Trial

Introduction

Children of parents with mental disorders have a high chance of developing a mental disorder themselves. However, this at-risk group is regularly overlooked and typically not seen by any mental health professionals. Internet- and mobile-based interventions (IMIs) can provide a means of promoting mental health for children of parents with mental disorders.

Objective

The introduced study will evaluate the clinical- and cost-effectiveness of the iCHIMPS IMI in promoting mental health for children of parents with mental disorders.

Methods

A two-armed multicentered cluster-randomized controlled trial (cRCT) comparing the clinical- and cost-effectiveness of the iCHIMPS IMI in the intervention group (IG) to a treatment-as-usual (TAU) control group will be conducted. Recruitment will be handled at currently 21 adult mental health clinics throughout Germany. Participating families will be randomly divided into the two groups until the final sample size of 306 participating adolescents (age 12–18) has been reached. The adolescents in the intervention group will receive access to the IMI and can take part in up to eight intervention modules. Assessment will be conducted during the recruitment (baseline), 1-month, 2-months, and 6-month post-inclusion. Primary outcome is the mental health of the participating adolescents at 6-months post-inclusion as measured by the Youth Self Report score. Secondary self-report outcomes are mental wellbeing, self-efficacy, coping strategies and negative effects as well as mental health of the adolescents as reported by their parent(s). Included moderators are sociodemographic characteristics, working alliance, social support and the mental health diagnoses of the parents. Statistical analyses will be conducted on the intention-to-treat principle as well as with additional per-protocol analyses. Additionally, the cost-effectiveness as well as qualitative data concerning the adherence, acceptance, and feasibility of the IMI will be analyzed.

Discussion

The iCHIMPS cRCT examines the clinical- as well as cost-effectiveness of the iCHIMPS mental health promotion IMI for children of parents with mental disorders. This provides the opportunity to gain insights into an innovative as well as time- and location-independent form of support for this often-overlooked at-risk group. Additionally, the larger CHIMPS-NET project allows comparisons between internet-based and face-to-face interventions for a similar target group.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: DRKS00025158.

Healthy for My Baby Research Protocol- a Randomized Controlled Trial Assessing a Preconception Intervention to Improve the Lifestyle of Overweight Women and Their Partners

Background: Preconception lifestyle interventions appear promising to reduce pregnancy complications, prevent adult cardiometabolic diseases, and prevent childhood obesity. These interventions have almost exclusively been studied in populations of obese infertile women. The development of preconception lifestyle interventions targeting a broader population of overweight and obese women without a history infertility and their partners is needed.

Methods: This study is a multicenter open label parallel group randomized controlled trial. Sixty-eight non-infertile women with overweight or obesity in the preconception period and their partners will be recruited from the Sherbrooke and Quebec City regions. The couples will be randomized in a 1:1 ratio to receive the Healthy for my Baby intervention or standard care in the preconception period and pregnancy. Women and their partners will be invited to take part in this lifestyle intervention which includes motivational interviews and daily self-monitoring of lifestyle goals through a mobile phone application. The primary endpoint of this study is the diet quality of women during the preconception period, which will be evaluated using the C-HEI 2007 score at baseline, 2, 4- and 6-months following study enrolment. Women's dietary quality will also be evaluated through the measure of urinary biomarkers of habitual dietary intake at baseline and 2 months in preconception, and 24–26 weeks in pregnancy. Additional indicators of women's lifestyle as well as anthropometric measures will be documented in preconception and pregnancy. For the pregnancy period, the main secondary endpoint is the pattern of gestational weight gain. Pregnancy and neonatal complications will also be evaluated. For partners, diet quality, other lifestyle habits, and anthropometric measures will be documented in the preconception and pregnancy periods.

Discussion: This study will evaluate the effectiveness of a low-cost intervention designed to improve diet and other lifestyle characteristics of women in the preconception period who are overweight or obese. If the Healthy for my Baby intervention is efficacious regarding dietary measures, larger trials will be needed to evaluate the impact of this intervention on the rates of pregnancy complications, childhood obesity, and adult cardiometabolic disease.

Clinical Trial Registration:clinicaltrials.gov (NCT04242069).

Defining and measuring meditation-related adverse effects in mindfulness-based programs

BACKGROUND

Research on the adverse effects of mindfulness-based programs (MBPs) has been sparse and hindered by methodological imprecision.

METHODS

The 44-item Meditation Experiences Interview (MedEx-I) was used by an independent assessor to measure meditation-related side effects (MRSE) following three variants of an 8-week program of mindfulness-based cognitive therapy (n = 96). Each item was queried for occurrence, causal link to mindfulness meditation practice, duration, valence, and impact on functioning.

RESULTS

Eighty-three percent of the MBP sample reported at least one MRSE. Meditation-related adverse effects (MRAEs) with negative valences or negative impacts on functioning occurred in 58% and 37% of the sample, respectively. Lasting bad effects occurred in 6-14% of the sample and were associated with signs of dysregulated arousal (hyperarousal and dissociation).

CONCLUSION

Meditation practice in MBPs is associated with transient distress and negative impacts at similar rates to other psychological treatments.

Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders

Introduction: Internet- and mobile-based interventions (IMIs) and their integration into routine psychotherapy (i.e., blended therapy) can offer a means of complementing psychotherapy in a flexible and resource optimized way. Objective: The present study will evaluate the non-inferiority, cost-effectiveness, and safety of two versions of integrated blended psychotherapy for depression and anxiety compared to standard cognitive behavioral therapy (CBT). Methods: A three-armed multicenter cluster-randomized controlled non-inferiority trial will be conducted comparing two implementations of blended psychotherapy (PSYCHOnlineTHERAPYfix/flex) compared to CBT. Seventy-five outpatient psychotherapists with a CBT-license will be randomized in a 1:1:1 ratio. Each of them is asked to include 12 patients on average with depressive or anxiety disorders resulting in a total sample size of N = 900. All patients receive up to a maximum of 16 psychotherapy sessions, either as routine CBT or alternating with Online self-help sessions (fix: 8/8; flex: 0-16). Assessments will be conducted at patient study inclusion (pre-treatment) and 6, 12, 18, and 24 weeks and 12 months post-inclusion. The primary outcome is depression and anxiety severity at 18 weeks post-inclusion (post-treatment) using the Patient Health Questionnaire Anxiety and Depression Scale. Secondary outcomes are depression and anxiety remission, treatment response, health-related quality of life, patient satisfaction, working alliance, psychotherapy adherence, and patient safety. Additionally, several potential moderators and mediators including patient characteristics and attitudes toward the interventions will be examined, complemented by ecological day-to-day digital behavior variables via passive smartphone sensing as part of an integrated smart-sensing sub-study. Data-analysis will be performed on an intention-to-treat basis with additional per-protocol analyses. In addition, cost-effectiveness and cost-utility analyses will be conducted from a societal and a public health care perspective. Additionally, qualitative interviews on acceptance, feasibility, and optimization potential will be conducted and analyzed. Discussion: PSYCHOnlineTHERAPY will provide evidence on blended psychotherapy in one of the largest ever conducted psychotherapy trials. If shown to be non-inferior and cost-effective, PSYCHOnlineTHERAPY has the potential to innovate psychotherapy in the near future by extending the ways of conducting psychotherapy. The rigorous health care services approach will facilitate a timely implementation of blended psychotherapy into standard care. Trial Registration: The trial is registered in the German Clinical Trials Register (DRKS00023973; date of registration: December 28th 2020).

Effect of diabetes self-management education (DSME) on glycated hemoglobin (HbA1c) level among patients with T2DM: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Type 2 Diabetes mellitus (T2DM) has been a global public health issue causing in physical, financial and psychosocial crises. The aim of this systematic review and meta-analysis (SRMA) was to evaluate the Diabetes Self-Management Education or Support (DSME/S) on glycosylated hemoglobin (HbA1c) among T2DM patients.

METHODS

This SRMA was made according to preferred reporting Items for systematic review and Meta-analysis (PRISMA) guidelines. The relevant articles were searched from four databases: Cochrane Library, MEDLINE (EBSCOhost), MEDLINE/PubMed and SCOPUS. Quality assessment was carried out. Pooled standard mean difference in HbA1c were calculated to obtain the effect size with random effect assumption. Subgroup analysis was conducted for assessing heterogeneity among the studies.

RESULTS

A total of 1312 studies were identified from databases. Among these 25 studies met inclusion criteria. From these 20 were included in the meta-analysis. In meta-analysis a pooled standard mean difference in HbA1c was -0.604 (95% confidence interval = -0.854 -0.353, I² = 90.3, p < 0.001). In subgroup analysis a significant reduction was seen among studies with less than four months, upper middle followed by lower middle income countries (LMICs), Western Pacific (WP) followed by Middle Eastern and Northern African (MENA) regions with moderate to substantial heterogeneity.

CONCLUSION

However, there is paucity of studies in underdeveloped countries. Therefore, further studies validated to these contexts are needed to evaluate the DSME effectiveness.

TRIAL REGISTRATION

PROSPERO database CRD42020124236.

Self-management programmes for cirrhosis: A systematic review

BACKGROUND AND AIMS

Liver cirrhosis severely decreases patients' quality of life. Since self-management programmes have improved quality of life and reduce hospital admissions in other chronic diseases, they have been suggested to decrease liver cirrhosis burden.

METHODS

We performed a systematic review and meta-analysis to evaluate the clinical impact of self-management programmes in patients with liver cirrhosis, which followed the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcomes include health-related quality of life (HRQOL) and hospitalisation. We searched MEDLINE, CENTRAL, Embase, CINAHL, PsycINFO and two trial registers to July 2017.

RESULTS

We identified four randomised trials (299 patients) all rated at a high risk of bias. No difference was demonstrated for HRQOL (standardised mean difference -0.01, 95% CI: -0.48 to 0.46) and hospitalisation days (incidence rate ratio 1.6, 95% CI: 0.5-4.8). For secondary outcomes, one study found a statistically significant improvement in patient knowledge (mean difference (MD) 3.68, 95% CI: 2.11-5.25) while another study found an increase in model for end-stage liver disease scores (MD 2.8, 95% CI: 0.6-4.9) in the self-management group. No statistical difference was found for the other secondary outcomes (self-efficacy, psychological health outcomes, healthcare utilisation, mortality). Overall, the quality of the evidence was low. The content of self-management programmes varied across studies with little overlap.

CONCLUSIONS

The current literature indicates that there is no evidence of a benefit of self-management programmes for people with cirrhosis.

RELEVANCE TO CLINICAL PRACTICE

Practitioners should use self-management programmes with caution when delivering care to patients living with cirrhosis. Further research is required to determine what are the key features in a complex intervention like self-management. This review offers a preliminary framework for clinicians to develop a new self-management programme with key features of effective self-management interventions from established models.

Monitoring adverse social and medical events in public health trials: assessing predictors and interpretation against a proposed model of adverse event reporting

Background

Although adverse event (AE) monitoring in trials focusses on medical events, social outcomes may be important in public or social care trials. We describe our approach to reporting and categorising medical and other AE reports, using a case study trial. We explore predictors of medical and social AEs, and develop a model for conceptualising safety monitoring.

Methods

The Building Blocks randomised controlled trial of specialist home visiting recruited 1618 first-time mothers aged 19 years or under at 18 English sites. Event reports collected during follow-up were independently reviewed and categorised as either Medical (standard Good Clinical Practice definition), or Social (trial-specific definition). A retrospectively developed system was created to classify AEs. Univariate analyses explored the association between baseline participant and study characteristics and the subsequent reporting of events. Factors significantly associated at this stage were progressed to binary logistic regressions to assess independent predictors.

Results

A classification system was derived for reported AEs that distinguished between Medical or Social AEs. One thousand, three hundred and fifteen event reports were obtained for mothers or their babies (1033 Medical, 257 Social). Allocation to the trial intervention arm was associated with increased likelihood of Medical rather than Social AE reporting. Poorer baseline psycho-social status predicted both Medical and Social events, and poorer psycho-social status better predicted Social rather than Medical events. Baseline predictors of Social AEs included being younger at recruitment (OR = 0.78 (CI = 0.67 to 0.90), p = 0.001), receiving benefits (OR = 1.60 (CI = 1.09 to 2.35), p = 0.016), and having a higher antisocial behaviour score (OR = 1.22 (CI = 1.09 to 1.36), p < 0.001). Baseline predictors of Medical AEs included having a limiting long-term illness (OR = 1.37 (CI = 1.01 to 1.88), p = 0.046), poorer mental health (OR = 1.03 (CI = 1.01 to 1.05), p = 0.004), and being in the intervention arm of the trial (OR = 1.34 (CI = 1.07 to 1.70), p = 0.012).

Conclusions

Continuity between baseline and subsequent adverse experiences was expected despite potentially beneficial intervention impact. We hypothesise that excess events reported for intervention-arm participants is likely attributable to surveillance bias. We interpreted our findings against a new model that explicates processes that may drive event occurrence, presentation and reporting. Focussing only upon Medical events may miss the well-being and social circumstances that are important for interpreting intervention safety and participant management.

Trial registration

ISRCTN, ID: ISRCTN23019866. Registered on 20 April 2009.

Participation in HIV Behavioral Research: Unanticipated Benefits and Burdens

HIV behavioral research has provided an invaluable knowledge base for effective approaches to behavioral challenges along the HIV care cascade. Little attention has been paid to tracking unanticipated effects of research participation, whether negative or positive. We used qualitative methods to elicit impressions of unanticipated effects of participation in behavioral research. An instrument was developed and piloted to assess positive (emotional gains, practical gains, HIV prevention knowledge and skills gains) and negative (emotional stress, discomfort with research) unanticipated effects. Participants (N = 25) from five projects, including men who have sex with men, adults who use substances, and youth, reported multiple positive unanticipated effects (sexual and drug risk reduction, goal setting, improvements in self-esteem and mood, relationship gains, health care behavior gains, knowledge and introspection gains) and rare unanticipated negative effects. Developing a systematic tool of unanticipated positive and negative effects of participation in behavioral research is a crucial next step.

School-based interventions for reducing disciplinary school exclusion: a systematic review

This Campbell systematic review examines the impact of interventions to reduce exclusion from school. School exclusion, also known as suspension in some countries, is a disciplinary sanction imposed by a responsible school authority, in reaction to students' misbehaviour. Exclusion entails the removal of pupils from regular teaching for a period during which they are not allowed to be present in the classroom (in-school) or on school premises (out-of-school). In some extreme cases the student is not allowed to come back to the same school (expulsion). The review summarises findings from 37 reports covering nine different types of intervention. Most studies were from the USA, and the remainder from the UK. Included studies evaluated school-based interventions or school-supported interventions to reduce the rates of exclusion. Interventions were implemented in mainstream schools and targeted school-aged children from four to 18, irrespective of nationality or social background. Only randomised controlled trials are included. The evidence base covers 37 studies. Thirty-three studies were from the USA, three from the UK, and for one study the country was not clear. School-based interventions cause a small and significant drop in exclusion rates during the first six months after intervention (on average), but this effect is not sustained. Interventions seemed to be more effective at reducing some types of exclusion such as expulsion and in-school exclusion. Four intervention types - enhancement of academic skills, counselling, mentoring/monitoring, and skills training for teachers - had significant desirable effects on exclusion. However, the number of studies in each case is low, so this result needs to be treated with caution. There is no impact of the interventions on antisocial behaviour. Variations in effect sizes are not explained by participants' characteristics, the theoretical basis of the interventions, or the quality of the intervention. Independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.

Plain language summary

Interventions can reduce school exclusion but the effect is temporary: Some interventions - enhancement of academic skills, counselling, mentoring/monitoring, and skills training for teachers - appear to have significant effects on exclusion.The review in brief: Interventions to reduce school exclusion are intended to mitigate the adverse effects of this school sanction. Some approaches, namely those involving enhancement of academic skills, counselling, mentoring/monitoring and those targeting skills training for teachers, have a temporary effect in reducing exclusion. More evaluations are needed to identify the most effective types of intervention; and whether similar effects are also found in different countries.What is this review about?: School exclusion is associated with undesirable effects on developmental outcomes. It increases the likelihood of poor academic performance, antisocial behavior, and poor employment prospects. This school sanction disproportionally affects males, ethnic minorities, those who come from disadvantaged economic backgrounds, and those with special educational needs.This review assesses the effectiveness of programmes to reduce the prevalence of exclusion.What are the main findings of this review?: What studies are included? Included studies evaluated school-based interventions or school-supported interventions to reduce the rates of exclusion. Interventions were implemented in mainstream schools and targeted school-aged children from four to 18, irrespective of nationality or social background. Only randomised controlled trials are included.The evidence base covers 37 studies. Thirty-three studies were from the USA, three from the UK, and for one study the country was not clear.School-based interventions cause a small and significant drop in exclusion rates during the first six months after intervention (on average), but this effect is not sustained. Interventions seemed to be more effective at reducing some types of exclusion such as expulsion and in-school exclusion.Four intervention types - enhancement of academic skills, counselling, mentoring/ monitoring, and skills training for teachers - had significant desirable effects on exclusion. However, the number of studies in each case is low, so this result needs to be treated with caution.There is no impact of the interventions on antisocial behaviour.Variations in effect sizes are not explained by participants' characteristics, the theoretical basis of the interventions, or the quality of the intervention. Independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.What do the findings of this review mean?: School-based interventions are effective at reducing school exclusion immediately after, and for a few months after, the intervention (6 months on average). Four interventions presented promising and significant results in reducing exclusion, that is, enhancement of academic skills, counselling, mentoring/monitoring, skills training for teachers. However, since the number of studies for each sub-type of intervention was low, we suggest these results should be treated with caution.Most of the studies come from the USA. Evaluations are needed from other countries in which exclusion is common. Further research should take advantage of the possibility of conducting cluster-randomised controlled trials, whilst ensuring that the sample size is sufficiently large.How up-to-date is this review?: The review authors searched for studies published up to December 2015. This Campbell systematic review was published in January 2018.

Executive Summary/Abstract

BACKGROUND: Schools are important institutions of formal social control (Maimon, Antonaccio, & French, 2012). They are, apart from families, the primary social system in which individuals are socialised to follow specific codes of conduct. Violating these codes of conduct may result in some form of punishment. School punishment is normally accepted by families and students as a consequence of transgression, and in that sense school isoften the place where children are first introduced to discipline, justice, or injustice (Whitford & Levine-Donnerstein, 2014).A wide range of punishments may be used in schools, from verbal reprimands to more serious actions such as detention, fixed term exclusion or even permanent exclusion from the mainstream education system. It must be said that in some way, these school sanctions resemble the penal system and its array of alternatives to punish those that break the law.School exclusion, also known as suspension in some countries, is defined as a disciplinary sanction imposed by a responsible school authority, in reaction to students' misbehaviour. Exclusion entails the removal of pupils from regular teaching for a period during which they are not allowed to be present in the classroom or, in more serious cases, on school premises.Based on the previous definition, this review uses school exclusion and school suspension as synonyms, unless the contrary is explicitly stated. Most of the available research has found that exclusion correlates with subsequent negative sequels on developmental outcomes. Exclusion or suspension of students is associated with failure within the academic curriculum, aggravated antisocial behaviour, and an increased likelihood of involvement with punitive social control institutions (i.e., the Juvenile Justice System). In the long-term, opportunities for training and employment seem to be considerably reduced for those who have repeatedly been excluded. In addition to these negative correlated outcomes, previous evidence suggest that the exclusion of students involves a high economic cost for taxpayers and society.Research from the last 20 years has concluded quite consistently that this disciplinary measure disproportionally targets males, ethnic minorities, those who come from disadvantaged economic backgrounds, and those presenting special educational needs. In other words, suspension affects the most vulnerable children in schools.Different programmes have attempted to reduce the prevalence of exclusion. Although some of them have shown promising results, so far, no comprehensive systematic review has examined these programmes' overall effectiveness.OBJECTIVES: The main goal of the present research is to systematically examine the available evidence for the effectiveness of different types of school-based interventions aimed at reducing disciplinary school exclusion. Secondary goals include comparing different approaches and identifying those that could potentially demonstrate larger and more significant effects.The research questions underlying this project are as follows: Do school-based programmes reduce the use of exclusionary sanctions in schools?Are some school-based approaches more effective than others in reducing exclusionary sanctions?Do participants' characteristics (e.g., age, gender, ethnicity) affect the impact of school-based programmes on exclusionary sanctions in schools?Do characteristics of the interventions, implementation, and methodology affect the impact of school-based programmes on exclusionary sanctions in schools? SEARCH METHODS: The authors conducted a comprehensive search to locate relevant studies reporting on the impact of school-based interventions on exclusion from 1980 onwards. Twenty-seven different databases were consulted, including databases that contained both published and unpublished literature. In addition, we contacted researchers in the field of school-exclusion for further recommendations of relevant studies; we also assessed citation lists from previous systematic and narrative reviews and research reports. Searches were conducted from September 1 to December 1, 2015.SELECTION CRITERIA: The inclusion and exclusion criteria for manuscripts were defined before we started our searches. To be eligible, studies needed to have: evaluated school-based interventions or school-supported interventions intended to reduce the rates of suspension; seen the interventions as an alternative to exclusion; targeted school-aged children from four to 18 in mainstream schools irrespective of nationality or social background; and reported results of interventions delivered from 1980 onwards. In terms of methodological design, we included randomised controlled trialsonly, with at least one experimental group and onecontrol or placebo group.DATA COLLECTION AND ANALYSIS: Initial searches produced a total of 42,749 references from 27 different electronic databases. After screening the title, abstract and key words, we kept 1,474 relevant hits. 22 additional manuscripts were identified through other sources (e.g., assessment of citation lists, contribution of authors). After removing duplicates, we ended up with a total of 517 manuscripts. Two independent coders evaluated each report, to determine inclusion or exclusion.The second round of evaluation excluded 472 papers, with eight papers awaiting classification, and 37 studies kept for inclusion in meta-analysis. Two independent evaluators assessed all the included manuscripts for risk of quality bias by using EPOC tool.Due to the broad scope of our targeted programmes, meta-analysis was conducted under a random-effect model. We report the impact of the intervention using standardised differences of means, 95% confidence intervals along with the respective forest plots. Sub-group analysis and meta-regression were used for examining the impact of the programme. Funnel plots and Duval and Tweedie's trim-and-fill analysis were used to explore the effect of publication bias.RESULTS: Based on our findings, interventions settled in school can produce a small and significant drop in exclusion rates (SMD=.30; 95% CI .20 to .41; p<.001). This means that those participating in interventions are less likely to be suspended than those allocated to control/placebo groups. These results are based on measures of impact collected immediately during the first six months after treatment (on average). When the impact was tested in the long-term (i.e., 12 or more months after treatment), the effects of the interventions were not sustained. In fact, there was a substantive reduction in the impact of school-based programmes (SMD=.15; 95%CI -.06 to .35), and it was no longer statistically significant.We ran analysis testing the impact of school-based interventions on different types of exclusion. Evidence suggests that interventions are more effective at reducing expulsion and in-school exclusion than out-of-school exclusion. In fact, the impact of intervention in out-of-school exclusion was close to zero and not statistically significant.Nine different types of school-based interventions were identified across the 37 studies included in the review. Four of them presented favourable and significant results in reducing exclusion (i.e., enhancement of academic skills, counselling, mentoring/monitoring, skills training for teachers). Since the number of studies for each sub-type of intervention was low, we suggest that results should be treated with caution.A priori defined moderators (i.e., participants' characteristics, the theoretical basis of the interventions, and quality of the intervention)showed not to be effective at explaining the heterogeneity present in our results. Among three post-hoc moderators, the role of the evaluator was found to be significant: independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.Two researchers independently evaluated the quality of the evidence involved in this review by using the EPOC tool. Most of the studies did not present enough information for the judgement of quality bias.AUTHORS' CONCLUSIONS: The evidence suggests that school-based interventions are effective at reducing school exclusion immediately after, and for a few months after, the intervention. Some specific types of interventions show more promising and stable results than others, namely those involving mentoring/monitoring and those targeting skills training for teachers. However, based on the number of studies involved in our calculations, we suggest that results must be cautiously interpreted. Implications for policy and practice arising from our results are discussed.

Effectiveness and cost-effectiveness of a guided internet- and mobile-based depression intervention for individuals with chronic back pain: protocol of a multi-centre randomised controlled trial

INTRODUCTION

Depression often co-occurs with chronic back pain (CBP). Internet and mobile-based interventions (IMIs) might be a promising approach for effectively treating depression in this patient group. In the present study, we will evaluate the effectiveness and cost-effectiveness of a guided depression IMI for individuals with CBP (eSano BackCare-D) integrated into orthopaedic healthcare.

METHODS AND ANALYSIS

In this multicentre randomised controlled trial of parallel design, the groups eSano BackCare-D versus treatment as usual will be compared. 210 participants with CBP and diagnosed depression will be recruited subsequent to orthopaedic rehabilitation care. Assessments will be conducted prior to randomisation and 9 weeks (post-treatment) and 6 months after randomisation. The primary outcome is depression severity (Hamilton Rating Scale for Depression-17). Secondary outcomes are depression remission and response, health-related quality of life, pain intensity, pain-related disability, self-efficacy and work capacity. Demographic and medical variables as well as internet affinity, intervention adherence, intervention satisfaction and negative effects will also be assessed. Data will be analysed on an intention-to-treat basis with additional per-protocol analyses. Moreover, a cost-effectiveness and cost-utility analysis will be conducted from a societal perspective after 6 months.

ETHICS AND DISSEMINATION

All procedures are approved by the ethics committee of the Albert-Ludwigs-University of Freiburg and the data security committee of the German Pension Insurance (Deutsche Rentenversicherung). The results will be published in peer-reviewed journals and presented on international conferences.

TRIAL REGISTRATION NUMBER

DRKS00009272; Pre-results.

Culturally Relevant Family Therapy Practice with Parents of Children and Adolescents

BACKGROUND

India is diverse in culture, with multiple aspects that may not match with the Western societal picture. Hence, it has often been seen that therapists encounter unique aspects of therapy that is faced during actual practice, which is never written in any textbook or research papers. Substantial information is present through both outcome (efficacy and effectiveness) studies and process research, but it has very little impact of actual Marital and Family Therapy (MFT) practice. This paper throws light into "how" and "what" of family therapy with parents of children/adolescents having psychiatric disorders.

MATERIALS AND METHODS

Focused group discussion was conducted with practicing family therapists and mental health professionals working in Psychiatric Tertiary Hospital (National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India). Qualitative analysis was done to disseminate process issues in therapy.

RESULTS

Aspects that are vital for families having children and adolescent with psychiatric disorders include: Academic decline and loss of parental control as main reasons for seeking help, integration of models is noted to be beneficial, therapeutic alliance, intake sessions, conjoint sessions and individual sessions are important, cultural issues like gender of therapist, their cultural belief model, therapist's cultural competence need to be taken into consideration.

CONCLUSIONS

Challenges and way-outs to overcome these has been mentioned and implications discussed.

Mortality Rates Among Substance Use Disorder Participants in Clinical Trials: Pooled Analysis of Twenty-Two Clinical Trials Within the National Drug Abuse Treatment Clinical Trials Network

BACKGROUND

Most substance use disorders (SUD) treatment clinical trials are too short and small to reliably estimate the incidence of rare events like death.

OBJECTIVE

The aim of this study is to estimate the overall mortality rates among a SUD treatment-seeking population by pooling participants from multiple clinical trials conducted through the National Institute on Drug Abuse (NIDA)-sponsored National Drug Abuse Treatment Clinical Trials Network (CTN).

PARTICIPANTS

Drug and or alcohol users (N=9866) who sought treatment and participated in one of the twenty-two CTN trials.

MEASUREMENTS

Data were collected through randomized clinical trials in national community treatment programs for SUD. Pooled analysis was performed to assess age- and gender-standardized mortality rate(s) (SM rate(s)), and mortality ratio(s) (SM ratio(s)) of CTN trial participants compared to the U.S. general population.

RESULTS

The age- and gender-SM rate among CTN trials participants was 1403 (95% CI: 862-2074) per 100,000 person years (PY) compared to 542 (95% CI: 541-543) per 100,000 PY among the U.S. general population in 2005. By gender, age-adjusted SM ratio for female CTN trial participants was over five times (SM ratio=5.35, 95% CI: 3.31-8.19)), and for male CTN trial participants, it was over three times (SM ratio=3.39, 95% CI: 2.25-4.90) higher than their gender comparable peers in the U.S. general population.

CONCLUSIONS

Age and gender-standardized mortality rates and ratios among NIDA CTN SUD treatment-seeking clinical trial participants are higher than the age and gender comparable U.S. general population. The overall mortality rates of CTN trial participants are similar to in-treatment mortality reported in large U.S. and non-U.S. cohorts of opioid users. Future analysis with additional CTN trial participants and risk times will improve the stability of estimates, especially within subgroups based on primary substance of abuse. These SUD mortality rates can be used to facilitate safety monitoring within SUD clinical trials.

Unintended effects in settings-based health promotion

The settings-based approach to health promotion (HP) employs a social ecological (SE) framework to integrate HP into the usual activities of the setting and to increase the setting’s support for healthy choices. The SE approach calls for systems thinking to account for the inextricable relationship between people, their behaviour and their environment. Knowledge about a setting can be used to mobilise people to participate in HP, to optimise success by taking into account the local context, and to anticipate and avoid barriers to success. In other words, the SE approach aims to help HP reach its goals for better health, established in concert with community needs and wishes. Yet, the focus on HP goals may detract attention from how intervention may have unanticipated, and even untoward effects on the setting. There is much evidence from classical ecological research that well-meaning interventions have unintended effects. Biology is so tuned to the possibility that the study of unintended effects is integral to the field. There is some evidence – but much less - that HP also has unexpected, deleterious effects. The evidence is limited because of neglect; the subject of unintended effects is only of peripheral interest in HP. This is a call for a more robust SE approach, in which frameworks used to guide settings-based HP are augmented so as to be concerned with planned effects, and also unplanned effects. What can be done to more responsibly monitor, document and report the full panoply of our effects, including detecting and preventing untoward effects?

Human subjects protection: an event monitoring committee for research studies of girls from breast cancer families

PURPOSE

Researchers must monitor the safety of research participants, particularly in studies involving children and adolescents. Yet, there is limited guidance for the development and implementation of oversight committees for psychosocial, behavioral intervention, and observational studies.

METHODS

We implemented a model for an Event Monitoring Committee (EMC) in three related studies recruiting 6- to 19-year-old girls from families with and without breast cancer.

RESULTS

The EMC model can be valuable for investigators and local institutional review boards when additional oversight is desired. Recommendations are provided and intended to be broadly applicable to a wide range of research activities designed to improve the health of children, adolescents, and families. EMC goals, membership, and procedures for monitoring and assessing risks and benefits should be defined but should also be flexible and tailored to the study design and population. The EMC model also provides an independent comprehensive, study-wide oversight mechanism for multicenter psychosocial, behavioral intervention, and observational studies.

CONCLUSIONS

An EMC provides an alternative oversight approach where additional independent assessment and oversight of study-related risks are desired, particularly in the setting of vulnerable populations, children and adolescents, or where risks nontraditional to the medical field (i.e., social, emotional, or cultural) are possible.

The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials

Background

There is a concern in the literature that harm from interventions is insufficiently documented in clinical trials in general, and in those assessing psychological treatments in particular. A recent decision by a trial steering committee to stop recruitment into a randomized controlled trial (RCT) of a psychological intervention for personality disorder led to an investigation of the recording of harm in trials funded by the National Institute for Health Research (NIHR).

Methods

The protocols and final reports of all 82 NIHR trials funded between 1995 and 2013 were examined for the reporting of adverse events. These were subdivided by category of intervention.

Results

None of the psychological intervention trials mentioned the occurrence of an adverse event in their final report. Trials of drug treatments were more likely to mention adverse events in their protocols compared with those using psychological treatments. When adverse events were mentioned, the protocols of psychological interventions relied heavily on severe adverse events guidelines from the National Research Ethics Service (NRES), which were developed for drug rather than psychological interventions and so may not be appropriate for the latter.

Conclusions

This survey supported the belief that the reporting of adverse events in psychological treatments is weak and the criteria used may not be appropriate. Recommendations are made as to how current practice might be improved.

Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioral disorders: a review of current practice

BACKGROUND

Data suggest that certain psychological interventions can induce harm in a significant number of patients. While the need for adequate reporting of harms in clinical trials has repeatedly been emphasized, it is uncertain whether such information is routinely collected and reported in trials within this research field.

METHOD

We used the two major databases in clinical psychology and medicine (PsycINFO and PubMed) to identify original publications from 2010 reporting randomized controlled trials of psychological interventions for patients with mental and behavioral disorders. Two reviewers searched the full-text reports for information about monitoring of adverse events, side effects, and deterioration.

RESULTS

A total of 132 eligible trials were identified. Only 28 trials (21%) included information that indicated any monitoring of harms on patient level. Four (3%) of these trials provided a description of adverse events as well as the methods used for collecting these data. Five of the trials (4%) reported adverse events but did not give complete information about the method. An additional four reports (3%) briefly stated that no adverse events occurred, whereas 15 trials (11%) only provided information on deterioration or indicated monitoring of deterioration. The probability of including harm-related information was related to the journal impact factor.

CONCLUSION

Important information about harms is not reported systematically within this research field, suggesting that the risk of reporting bias is nontrivial in conclusions about the risk-benefit ratio of psychological treatments. Guidelines on how to define, detect, and report harms related to psychological interventions could facilitate better reporting.

Strategies for safety reporting in substance abuse trials

BACKGROUND

Reporting all adverse events (AEs) and serious adverse events (SAEs) in substance use disorder (SUD) clinical trials has yielded limited relevant safety information and has been burdensome to research sites.

OBJECTIVE

This article describes a new strategy utilizing standard data elements for AE and SAEs that defines a threshold to reduce unnecessary safety reporting burden in SUD clinical trials and describes retrospective review and prospective preliminary data on the strategy's safety reporting impact.

METHODS

We developed a new strategy to standardize safety reporting and tailor reporting to the trial intervention risk. Protocols and safety data from 17 SUD clinical trials were reviewed. Retrospective analysis of five of these studies and prospective application to new studies is described.

RESULTS

Across the 17 previously completed trials, a total of 11,220 AEs and 1330 SAEs were reported in the 6737 participants. Wide variability in AE and SAE reporting rates were noted based on trial type and inconsistent reporting strategies. Application of the new, tailored safety strategy retrospectively and prospectively reduces reporting burden of irrelevant safety events.

CONCLUSION

Comparison of the previous reporting strategies used in SUD trials to the new strategy demonstrates a more consistent safety system with a reduction in safety reporting burden while maintaining appropriate safety monitoring.

SCIENTIFIC SIGNIFICANCE

Safety assessments should be tailored to the participant risks based on the trial intervention. The current strategies could be applied to safety assessments across all clinical trials in SUDs.