Gross Domestic Product (GDP) and productivity of schizophrenia trials: an ecological study

Rivers of evidence

There has been too much of a one-way flow drift down a river of evidence. Researchers from rich countries have produced the primary evidence which they proceed to summarise within reviews. These summaries have directed care worldwide. However, things are changing and the river of evidence can flow in the other direction. The care of women with eclampsia has been changed or refined throughout the world because of a large low and middle income country trial. The global care of people with heart disease has been greatly modified by studies originating in China. The care of people who are acutely aggressive because of psychosis has to be reconsidered in the light of the evidence coming from Brazil and India. Healthcare is an issue everywhere and evaluation of care is not the premise of any one culture-the evidence-river must run both ways.

Content and quality of 10,000 controlled trials in schizophrenia over 60 years

OBJECTIVE

To carry out an up-to-date comprehensive survey of the content and quality of intervention trials relevant to the treatment of people with schizophrenia.

DESIGN

Data were extracted and analyzed from 10,000 trials on the Cochrane Schizophrenia Group's Register.

MAIN OUTCOME MEASURES

Source, type and date of publication, country of origin, language, size of trial, interventions, and outcome measures.

RESULTS

In the last decade, there has been a great increase in the number of trials relevant to schizophrenia and an improvement in the accessibility to reports. The number of trials per year is rising (currently ∼600/year) with China now producing 25% of the annual total. The number of reports of trials is increasing at an even greater rate due to multiple publications. Drug trials still dominate (83%) although an increasing proportion of studies are now evaluating psychological therapies (21%). Trials remain small (median 60 people) and often employ new nonvalidated outcomes scales (2194 different scales were employed with every fifth trial introducing a new rating instrument).

CONCLUSIONS

A more collaborative, pragmatic, and patient-centered approach is necessary to produce larger schizophrenia trials. Wider consultation and careful consideration of all relevant perspectives would result in trials with greater clinical utility and direct value to people with the illness and their families or carers.

Forty-five years of schizophrenia trials in Italy: a survey

Background

Well-designed and properly executed randomized controlled trials (RCTs) provide the best evidence on the efficacy of healthcare interventions. Mental health has a strong tradition of using trial to evaluate treatments, but the translation of research to clinical practice is not always easy. Even well-conducted trials do not necessarily address the needs of every day care and trials can reflect local needs and the specific culture in which they are undertaken. Generalizing results to other contexts can become problematic but these trials may, nevertheless, be very helpful within their own context. Moreover, pathways for drug approval can be different depending on local regulatory agencies. Local trials are helpful for decision-making in the region from which they come, but should not be viewed in isolation. National quantity and quality of trials may vary across nations.

The aim of this study is to quantify trialing activity in Italy from 1948 until 2009 and to describe characteristics of these trials. In addition, we evaluated change over time in three keys aspects: sample size, follow-up duration, and number of outcomes.

Methods

We used the Cochrane Schizophrenia Group's register that contains 16,000 citations to 13,000 studies relating only to people with schizophrenia or schizophrenia-like illness. Randomized controlled trials and controlled clinical trials undertaken in Italy and involving pharmacological interventions were included.

Results

The original search identified 155 records of potentially eligible studies, 74 of which were excluded because do not meet inclusion criteria. A total of 81 studies were included in the analysis. The majority of trials were conducted in north Italy, and published in international journals between 1981 and 1995. The majority of studies (52 out of 81) used standardized diagnostic criteria for schizophrenia disorder. They were defined as randomized and used blind methods to administer treatment. However, most failed to report detail regarding methodological procedures and it is difficult to ascertain which studies are associated with a low risk of bias.

Conclusions

Trials should be designed to address the needs of everyday care with the aim of following large samples of typical patients in the long term. The Italian tradition in the area of trialing treatments for people with schizophrenia is not as strong as in many other similar countries and Italy should be producing more, better, independent, and clinically relevant trials.

Randomised trials relevant to mental health conducted in low and middle-income countries: a survey

BACKGROUND

A substantial proportion of the psychiatric burden of disease falls on the world's poorest nations, yet relatively little is known about randomised trials conducted in these countries. Our aim was to identify and describe a representative sample of mental health trials from low and middle-income countries.

METHODS

6107 electronic records, most with full text copies, were available following extensive searches for randomised or potentially randomised trials from low and middle-income countries published in 1991, 1995 and 2000. These records were searched to identify studies relevant to mental health. Data on study characteristics were extracted from the full text copies.

RESULTS

Trials relevant to mental health were reported in only 3% of the records. 176 records reporting 177 trials were identified: 25 were published in 1991, 45 in 1995, and 106 in 2000. Participants from China were represented in 46% of trials described. 68% of trials had <100 participants. The method of sequence generation was described in less than 20% of reports and adequate concealment of allocation was described in only 12% of reports. Participants were most frequently adults with unipolar depression (36/177) or schizophrenia (36/177). 80% of studies evaluated pharmacological interventions, a third of which were not listed by WHO as essential drugs. 41% of reports were indexed on PubMed; this proportion decreased from 68% in 1991 to 32% in 2000.

CONCLUSION

In terms of overall health burden, trial research activity from low and middle-income countries in mental health appears to be low, and in no area adequately reflects need.

Searching the Polish Medical Bibliography (Polska Bibliografia Lekarska) for trials

BACKGROUND

The Polish Medical Bibliography (Polska Bibliografia Lekarska) contains 350 000 records dating from 1979. These records from the fields of medicine, nursing, dentistry, health care systems and preclinical sciences are from nearly 300 biomedical journals published in Poland.

METHODS

We systematically searched the Polish Medical Bibliography Part II (1996-2006) CD-ROM (July 2006) using both English and Polish phrases for randomized trials, manually checked results and, for the trials identified in this way, sought these on medline and embase.

RESULTS

Systematic searching identified records of 680 randomized trials from all areas of health care. Nearly 40% of these were not found on either medline or embase.

CONCLUSIONS

The Polish Medical Bibliography should be of interest to health care information specialists concerned with comprehensive searches for trials.

Searching a biomedical bibliographic database from Bulgaria: the ABS database

BACKGROUND

The University of Sofia, Bulgaria, disseminates local biomedical literature (1994 to present) through a free online database, ABS.

OBJECTIVES

Our objectives were to systematically search ABS, identify citations to controlled trials and discover what proportion of these studies are to be found on medline.

METHODS

We searched using Bulgarian and English phrases; manually selected citations of controlled trials and sought these citations on medline.

RESULTS

Using the two languages, we found a total of 628 unique citations, 47 of which seem to be relevant controlled trials (precision 7.48%, 13% of ABS citations were found on medline). The trials in ABS commonly focused on evaluation of care for people with cardiovascular or urological problems.

DISCUSSION

ABS is another source of easily accessed trials not readily available elsewhere.

The schizophrenia drug-treatment paradox: pharmacological treatment based on best possible evidence may be hardest to practise in high-income countries

Most people with schizophrenia live in low- and middle-income countries in which clinicians/policy makers are not the first targets of marketing. Because it is years after a drug is first launched that the full effects become known with confidence, the evidence upon which to base practice in low- and middle-income countries may be less biased than that in richer nations.

Randomised trials relevant to mental health conducted in low and middle-income countries: protocol for a survey of studies published in 1991, 1995 and 2000 and assessment of their relevance

BACKGROUND

A substantial proportion of the psychiatric burden of disease falls on the world's poorest nations. Despite this, relatively little is known about the quality and content of clinical research undertaken in these countries, or the relevance of the interventions evaluated and specifically that of randomised trials. This project aims to survey the content, quality and accessibility of a sample of trials relevant to mental health conducted within low and middle-income countries; to compare these with studies conducted in high-income countries; and to assess their relevance for the needs of low and middle-income countries.

METHODS

An extensive search for all trials, or possible trials, published in 1991, 1995 and 2000 with participants in low and middle-income countries has already been conducted. Studies evaluating prevention or treatment of a mental health problem within these three years will be identified and further searches conducted to assess completeness of the initial search. Data on study quality and characteristics will be extracted from each report. Accessibility will be estimated based on whether each citation is available on MEDLINE. Trials relevant to schizophrenia will be compared with a random sample of schizophrenia trials from high-income countries in the same years. Topics covered by the trials will be compared with the estimated burden of disease.

CONCLUSION

Trials and systematic reviews of trials are the gold standard of evaluation of care and increasingly provide the basis for recommendations to clinicians, to providers of care and to policy makers. Results from this study will present the first assessment of the scope, quality and accessibility of mental health trials in low and middle-income countries.

Internet-based search of randomised trials relevant to mental health originating in the Arab world

BACKGROUND

The internet is becoming a widely used source of accessing medical research through various on-line databases. This instant access to information is of benefit to busy clinicians and service users around the world. The population of the Arab World is comparable to that of the United States, yet it is widely believed to have a greatly contrasting output of randomised controlled trials related to mental health. This study was designed to investigate the existence of such research in the Arab World and also to investigate the availability of this research on-line.

METHODS

Survey of findings from three internet-based potential sources of randomised trials originating from the Arab world and relevant to mental health care.

RESULTS

A manual search of an Arabic online current contents service identified 3 studies, MEDLINE, EMBASE, and PsycINFO searches identified only 1 study, and a manual search of a specifically indexed, study-based mental health database, PsiTri, revealed 27 trials.

CONCLUSION

There genuinely seem to be few trials from the Arab world and accessing these on-line was problematic. Replication of some studies that guide psychiatric/psychological practice in the Arab world would seem prudent.