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Norheim I, Pedersen R, Selle ML, Røssberg JI, Hestmark L, Heiervang KS, Ruud T, Åsholt VM, Hansson KM, Møller P, Fosse R, Romøren M. Implementation of guidelines on Family Involvement for persons with Psychotic disorders: a pragmatic cluster randomized trial. Effect on relatives' outcomes and family interventions received. Front Psychiatry 2024; 15:1381007. [PMID: 38855639 PMCID: PMC11157113 DOI: 10.3389/fpsyt.2024.1381007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/01/2024] [Indexed: 06/11/2024] Open
Abstract
Background Family interventions (FI) are recommended as part of the treatment for psychotic disorders, but the implementation in mental health services is generally poor. Recently, The Implementation of guidelines on Family Involvement for persons with Psychotic disorders (IFIP) trial, demonstrated significant improvements in implementation outcomes at cluster-level. This sub-study aims to examine the effectiveness of the IFIP intervention on relatives' outcomes and received FI. Methods A cluster randomized controlled trial, was conducted in 15 Norwegian Community Mental Health Center (CMHC) units that were randomized to either the IFIP intervention, including implementation interventions and clinical interventions, or treatment as usual (TAU). The clinical interventions consisted of FI: basic family involvement and support (BFIS) to all patients and family psychoeducation (FPE) to as many as possible. Patients with psychotic disorders and their closest relative were invited to fill in questionnaires at inclusion and 6 months and 12 months follow-up. Received FI was reported by both relatives and clinicians. The relatives' primary outcome was satisfaction with health service support, measured by the Carer well-being and support questionnaire part B (CWS-B). The relatives' secondary outcomes were caregiver experiences, expressed emotions and quality of life. Patients' outcomes will be reported elsewhere. Results In total 231 patient/relative pairs from the CMHC units were included (135 intervention; 96 control).The relatives in the intervention arm received an increased level of BFIS (p=.007) and FPE (p < 0.05) compared to the relatives in the control arm, including involvement in crisis planning. The primary outcome for relatives' satisfaction with health service support, showed a non-significant improvement (Cohen's d = 0.22, p = 0.08). Relatives experienced a significant reduced level of patient dependency (Cohen's d = -0.23, p = 0.03). Conclusion The increased support from clinicians throughout FI reduced the relatives' perceived level of patient dependency, and may have relieved the experience of responsibility and caregiver burden. The COVID-19 pandemic and the complex and pioneering study design have weakened the effectiveness of the IFIP intervention, underscoring possible potentials for further improvement in relatives' outcomes. Clinical Trial Registration ClinicalTrials.gov, identifier NCT03869177.
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Affiliation(s)
- Irene Norheim
- Department of Mental Health Research and Development, Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Maria Lie Selle
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Jan Ivar Røssberg
- Section for Treatment Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Hestmark
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Torleif Ruud
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Vilde Maria Åsholt
- Department of Mental Health Research and Development, Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway
| | | | - Paul Møller
- Department of Mental Health Research and Development, Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway
| | - Roar Fosse
- Department of Mental Health Research and Development, Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway
| | - Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Validation of the Longitudinal Interval Follow-Up Evaluation for the Long-Term Measurement of Mood Symptoms in Bipolar Disorder. Brain Sci 2022; 12:brainsci12121717. [PMID: 36552176 PMCID: PMC9776034 DOI: 10.3390/brainsci12121717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022] Open
Abstract
The long-term burden of symptoms is an important outcome in bipolar disorder (BD). A method which has minimal burden of assessment uses a retrospective interview, the Longitudinal Interval Follow-up Examination (LIFE), although this may be subject to problems with recall. This study examines the relationship between the retrospective LIFE scale and concurrently-rated mood rating scales in two clinical trials of 18 months of psychotherapy for patients with BD. The Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) were administered every eight to nine weeks and the LIFE was carried out every 6 months. Correlations between scores on mood rating scales and at equivalent times on the LIFE were examined, as well as of potential clinical moderators. There were significant correlations between LIFE depression ratings and concurrent MADRS score (r = 0.57) and between LIFE mania ratings and YMRS score (r = 0.40). In determining "mild depression" on the MADRS, a receiver operating characteristics (ROC) analysis showed an AUC of 0.78 for LIFE scores. Correlations, particularly for depression scores, were high even when the LIFE rating was several months before the interview, suggesting that the LIFE has validity in examining the burden of mood symptoms over time, with relatively little burden of assessment. Future research should examine the relationship between symptom burden and quality of life measured in this way.
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Kim S, Kim S, Choe AY, Kim E. Associations of Clozapine Use With Psychosocial Functioning and Quality of Life in Patients With Schizophrenia: A Community-Based Cross-Sectional Study. Psychiatry Investig 2021; 18:968-976. [PMID: 34619819 PMCID: PMC8542747 DOI: 10.30773/pi.2021.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/05/2021] [Accepted: 08/17/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE More attempts have been made recently to improve psychosocial functioning and quality of life in patients with schizophrenia, due to their crucial role in long-term outcomes. Previous studies on the effects of clozapine on psychosocial functioning have been limited in terms of generalizability and application to clinical practice. This study examined the relationship of clozapine use with psychosocial functioning and quality of life in patients with schizophrenia in a real-world setting. METHODS Data were obtained from a survey targeting community-dwelling patients with schizophrenia. The Behavior and Symptom Identification Scale (BASIS) and Satisfaction with Life Scale (SWLS) were administered to evaluate psychosocial functioning and quality of life, and patients were classified into Clozapine and Non-clozapine groups. Group differences were assessed using ANCOVA, with additional sensitivity analyses for participants on atypical antipsychotic medications only. RESULTS Of 292 patients, the Clozapine group (n=34) had significantly better psychosocial functioning and quality of life than the Nonclozapine group (n=258), as demonstrated by their low BASIS score (F=4.651, df=1, 290, p=0.032) and high SWLS score (F=14.637, df=1, 290, p<0.001). Similar findings for psychosocial outcomes were observed in the analyses of the atypical antipsychotic subgroup (n=195). CONCLUSION For optimal recovery in schizophrenia, restoration of impaired social functioning and enhanced satisfaction with life are essential. In this study, clozapine use was related to high levels of psychosocial functioning and quality of life in real-world settings. Further research on the causal relationship between clozapine use and psychosocial functioning is needed.
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Affiliation(s)
- Sujin Kim
- Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seoyoung Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ah Young Choe
- Seongnam Community Mental Health Welfare Center, Seongnam, Republic of Korea
| | - Euitae Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
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Inman J, Bannigan K, Akhurst J. Occupational therapy and psychosis: POINTER feasibility study for a pragmatic clinical trial. Br J Occup Ther 2021. [DOI: 10.1177/03080226211000257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The dearth of clinical trials of individualised occupational therapy with people with a diagnosis of psychosis limits the evidence base globally for occupational therapy practice. This study evaluated the feasibility of conducting a pragmatic clinical trial. Method Mixed methods design using a pragmatic perspective; two-centre, one-group pretest-posttest study, at six months. POINTER Occupational Intervention Specification captured routine individualised occupational therapy. Process evaluation included recruitment, retention, intervention delivery, fidelity, adherence and outcome measurement. The primary outcome was participation in activities of everyday life, measured by Time Use Survey, Participation Scale and Utrecht Scale for Evaluation of Rehabilitation-Participation. The Canadian Occupational Performance Measure measured self-reported experience of and satisfaction with occupational performance. The Short Form-36v2 Health Survey measured health-related quality of life, a secondary outcome. Participants’ experiences were explored using a questionnaire. Intervention providers’ perspectives were investigated via the POINTER occupational intervention log and focus groups. Results Recruitment was (20/36) and drop-out 20% (4/20). Fidelity was 77%, and adherence was good; POINTER had validity and utility. Outcome measurement was acceptable to participants, indicating increased participation in activities of everyday life. Conclusion A larger clinical trial is merited; recruitment processes need further exploration, and outcome measurement needs refining.
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Affiliation(s)
- Joanne Inman
- Faculty of Health & Social Care, Edge Hill University, Ormskirk, UK
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Ioannou M, Szabó Z, Widmark-Jensen M, Vyrinis G, Karlsson C, Steingrimsson S. Total Sleep Deprivation Followed by Bright Light Therapy as Rapid Relief for Depression: A Pragmatic Randomized Controlled Trial. Front Psychiatry 2021; 12:705090. [PMID: 34526921 PMCID: PMC8435586 DOI: 10.3389/fpsyt.2021.705090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Total sleep deprivation (TSD) combined with bright light therapy (BLT) has been suggested as a valuable add-on to standard treatment for rapid relief of depression. However, there is a lack of randomized controlled trials in real-life clinical settings. The aim of this pragmatic randomized clinical trial was to investigate the effectiveness, acceptance, and feasibility of TSD combined with BLT as add-on to standard treatment for depression in a real-life clinical setting. Methods: Thirty-three inpatients were randomly assigned to either: a) an intervention group receiving a single-night TSD followed by 6 days BLT (10.000 lux, 30 min/day) as add-on to standard treatment; or b) a control group receiving a short sleep-hygiene consultation in addition to standard treatment. The follow-up period was 1 week. Results: No statistical differences were found in response rates, reduction of depressive and insomnia symptoms, length of stay, readmission rate, and clinical improvement. Both groups reported positive experiences toward the received treatment with low drop-out rates. Conclusions: One-night TSD followed by BLT was not effective as a rapid relief for depression at 1-week follow-up; however, the treatment was feasible and well-tolerated.
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Affiliation(s)
- Michael Ioannou
- University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Zoltán Szabó
- Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Widmark-Jensen
- Region Halland, Varberg's Hospital, Anaesthesia and Intensive Care, Varberg, Sweden
| | - Georgios Vyrinis
- Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher Karlsson
- Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Steinn Steingrimsson
- University of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Gothenburg, Sweden.,Region Västra Götaland, Psykiatri Affektiva, Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
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What is the "best intro"-explanatory versus pragmatic antipsychotic drug trials. Lancet Psychiatry 2020; 7:1004-1006. [PMID: 33069272 DOI: 10.1016/s2215-0366(20)30436-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/21/2022]
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Fulford D, Mote J, Gard DE, Mueser KT, Gill K, Leung L, Dillaway K. Development of the Motivation and Skills Support (MASS) social goal attainment smartphone app for (and with) people with schizophrenia. ACTA ACUST UNITED AC 2020; 30:23-32. [PMID: 33437970 DOI: 10.1016/j.jbct.2020.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
People with schizophrenia and schizoaffective disorder (SZ) often struggle with social impairment, including small social networks and loneliness. Limitations in social skills and reduced social motivation-effort to engage in social connection-are key contributors to social impairment. While evidence-based approaches to improving social outcomes are available, including social skills training and cognitive behavioral therapy for psychosis, ongoing access to these interventions is often limited. Mobile technologies, including smartphone applications (apps), may address some of this need. In this paper, we describe the development of a smartphone app designed to address social skill and motivation deficits in SZ: the Motivation and Skills Support (MASS) app. We discuss the incorporation of stakeholder input into intervention design as well as results from usability pilot testing of the app in a sample of people with SZ. Finally, we describe next steps in the development and testing process of the MASS app.
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Affiliation(s)
- Daniel Fulford
- Sargent College of Health & Rehabilitation Sciences, Boston University, Boston, USA.,Department of Psychological & Brain Sciences, Boston University, Boston, USA
| | - Jasmine Mote
- Sargent College of Health & Rehabilitation Sciences, Boston University, Boston, USA
| | - David E Gard
- Department of Psychology, San Francisco State University, San Francisco, USA
| | - Kim T Mueser
- Sargent College of Health & Rehabilitation Sciences, Boston University, Boston, USA.,Department of Psychological & Brain Sciences, Boston University, Boston, USA.,Department of Psychiatry, Boston University, Boston, USA
| | - Kathryn Gill
- Sargent College of Health & Rehabilitation Sciences, Boston University, Boston, USA
| | - Lawrence Leung
- Department of Psychology, San Francisco State University, San Francisco, USA
| | - Kara Dillaway
- Sargent College of Health & Rehabilitation Sciences, Boston University, Boston, USA
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Martin JLR, Pérez V, Sacristán M, Rodríguez-Artalejo F, Martínez C, Alvarez E. Meta-analysis of drop-out rates in randomised clinical trials, comparing typical and atypical antipsychotics in the treatment of schizophrenia. Eur Psychiatry 2020; 21:11-20. [PMID: 16380237 DOI: 10.1016/j.eurpsy.2005.09.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 09/13/2005] [Indexed: 10/25/2022] Open
Abstract
AbstractObjectiveTo assess antipsychotic medication in the treatment of schizophrenia, based on trial drop-out rates.MethodsThe studies included were randomised controlled trials that compared any of the four clinically best-established atypical antipsychotics (quetiapine, olanzapine, risperidone or clozapine) against either of two typical antipsychotics regarded as the gold standard (haloperidol or chlorpromazine).ResultsMeta-analysis indicated less risk of all-cause patient withdrawal from atypical medication trials where dosage was flexible, in both the short, relative risk (RR) 0.70 (95% CI 0.64–0.76), P < 0.00001, and long term, RR 0.72 (0.65–0.80), P < 0.00001. Similar results were observed for withdrawal due to adverse events, RR: 0.54 (0.41–0.72), P < 0.0001. Nevertheless, the favourable effects of atypical medication disappeared in trials relying on fixed dosage.ConclusionsWe detected a significant positive effect in terms of the outcome of treatment discontinuation for atypical versus typical medication, though only where the use of flexible rather than fixed doses (closer to an experimental control situation) was possible.
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Affiliation(s)
- José Luis R Martin
- Department of Clinical Research, Castilla-La Mancha Health Research Foundation (FISCAM), Edificio Bulevar, C/Berna, No. 2, Local 0-2, 45003 Toledo, Castilla-La Mancha, Spain.
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Lewis G, Duffy L, Ades A, Amos R, Araya R, Brabyn S, Button KS, Churchill R, Derrick C, Dowrick C, Gilbody S, Fawsitt C, Hollingworth W, Jones V, Kendrick T, Kessler D, Kounali D, Khan N, Lanham P, Pervin J, Peters TJ, Riozzie D, Salaminios G, Thomas L, Welton NJ, Wiles N, Woodhouse R, Lewis G. The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. Lancet Psychiatry 2019; 6:903-914. [PMID: 31543474 PMCID: PMC7029306 DOI: 10.1016/s2215-0366(19)30366-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/26/2019] [Accepted: 08/13/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Depression is usually managed in primary care, but most antidepressant trials are of patients from secondary care mental health services, with eligibility criteria based on diagnosis and severity of depressive symptoms. Antidepressants are now used in a much wider group of people than in previous regulatory trials. We investigated the clinical effectiveness of sertraline in patients in primary care with depressive symptoms ranging from mild to severe and tested the role of severity and duration in treatment response. METHODS The PANDA study was a pragmatic, multicentre, double-blind, placebo-controlled randomised trial of patients from 179 primary care surgeries in four UK cities (Bristol, Liverpool, London, and York). We included patients aged 18 to 74 years who had depressive symptoms of any severity or duration in the past 2 years, where there was clinical uncertainty about the benefit of an antidepressant. This strategy was designed to improve the generalisability of our sample to current use of antidepressants within primary care. Patients were randomly assigned (1:1) with a remote computer-generated code to sertraline or placebo, and were stratified by severity, duration, and site with random block length. Patients received one capsule (sertraline 50 mg or placebo orally) daily for one week then two capsules daily for up to 11 weeks, consistent with evidence on optimal dosages for efficacy and acceptability. The primary outcome was depressive symptoms 6 weeks after randomisation, measured by Patient Health Questionnaire, 9-item version (PHQ-9) scores. Secondary outcomes at 2, 6 and 12 weeks were depressive symptoms and remission (PHQ-9 and Beck Depression Inventory-II), generalised anxiety symptoms (Generalised Anxiety Disorder Assessment 7-item version), mental and physical health-related quality of life (12-item Short-Form Health Survey), and self-reported improvement. All analyses compared groups as randomised (intention-to-treat). The study is registered with EudraCT, 2013-003440-22 (protocol number 13/0413; version 6.1) and ISRCTN, ISRCTN84544741, and is closed to new participants. FINDINGS Between Jan 1, 2015, and Aug 31, 2017, we recruited and randomly assigned 655 patients-326 (50%) to sertraline and 329 (50%) to placebo. Two patients in the sertraline group did not complete a substantial proportion of the baseline assessment and were excluded, leaving 653 patients in total. Due to attrition, primary outcome analyses were of 550 patients (266 in the sertraline group and 284 in the placebo group; 85% follow-up that did not differ by treatment allocation). We found no evidence that sertraline led to a clinically meaningful reduction in depressive symptoms at 6 weeks. The mean 6-week PHQ-9 score was 7·98 (SD 5·63) in the sertraline group and 8·76 (5·86) in the placebo group (adjusted proportional difference 0·95, 95% CI 0·85-1·07; p=0·41). However, for secondary outcomes, we found evidence that sertraline led to reduced anxiety symptoms, better mental (but not physical) health-related quality of life, and self-reported improvements in mental health. We observed weak evidence that depressive symptoms were reduced by sertraline at 12 weeks. We recorded seven adverse events-four for sertraline and three for placebo, and adverse events did not differ by treatment allocation. Three adverse events were classified as serious-two in the sertraline group and one in the placebo group. One serious adverse event in the sertraline group was classified as possibly related to study medication. INTERPRETATION Sertraline is unlikely to reduce depressive symptoms within 6 weeks in primary care but we observed improvements in anxiety, quality of life, and self-rated mental health, which are likely to be clinically important. Our findings support the prescription of SSRI antidepressants in a wider group of participants than previously thought, including those with mild to moderate symptoms who do not meet diagnostic criteria for depression or generalised anxiety disorder. FUNDING National Institute for Health Research.
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Affiliation(s)
- Gemma Lewis
- Division of Psychiatry, University College London, London, UK.
| | - Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Anthony Ades
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Rebekah Amos
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Ricardo Araya
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Simon Gilbody
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | - Vivien Jones
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - David Kessler
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Daphne Kounali
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Naila Khan
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Paul Lanham
- School of Nursing and Health Studies, University of Dundee, Dundee, UK; Department of Liberal Arts, Durham University, Durham, UK
| | - Jodi Pervin
- Department of Health Sciences, University of York, York, UK
| | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Derek Riozzie
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Laura Thomas
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J Welton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Wiles
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
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Gastaldon C, Mosler F, Toner S, Tedeschi F, Bird VJ, Barbui C, Priebe S. Are trials of psychological and psychosocial interventions for schizophrenia and psychosis included in the NICE guidelines pragmatic? A systematic review. PLoS One 2019; 14:e0222891. [PMID: 31550279 PMCID: PMC6759154 DOI: 10.1371/journal.pone.0222891] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/08/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction The NICE clinical guidelines on psychosocial interventions for the treatment of schizophrenia and psychosis in adults are based on the results of randomized controlled trials (RCTs), which may not be studies with a pragmatic design, leading to uncertainty on applicability or recommendations to everyday clinical practice. Aim To assess the level of pragmatism of the evidence used to develop the NICE guideline for psychosocial interventions in psychoses. Material and methods We conducted a systematic and critical appraisal of RCTs used to develop the ‘psychological therapy and psychosocial interventions’ section of the NICE guideline on the treatment and management of psychosis and schizophrenia in adults, published in 2014. For each study we assessed pragmatism using the pragmatic–explanatory continuum indicator summary-2 (PRECIS-2) and the Cochrane risk of bias tool. The mean score of PRECIS-2, averaging across nine domains, was calculated to describe the level of pragmatism of each individual study. Results A total of 143 studies were included in the analysis. Based on the PRECIS-2 tool, 16.8% were explanatory, 33.6% pragmatic, and 49.7% were rated in an intermediate category. Compared to explanatory studies, pragmatic studies showed a lower risk of bias. Additionally, pragmatism did not significantly improve over time, and no associations were found between pragmatism and a number of trial characteristics. However, studies with a UK leading investigator had the highest mean score of pragmatism. Cognitive behavioural therapy (CBT), art therapy, family intervention, psychoeducation, and adherence therapy, showed the higher average pragmatism scores. Conclusions Two third of studies used to produce NICE recommendations on psychosocial interventions for the treatment of schizophrenia and psychosis in adults are based on studies that did not employ a pragmatic design.
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Affiliation(s)
- Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- * E-mail:
| | - Franziska Mosler
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development Queen Mary University of London, London, England, United Kingdom
| | - Sarah Toner
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development Queen Mary University of London, London, England, United Kingdom
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Victoria Jane Bird
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development Queen Mary University of London, London, England, United Kingdom
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development Queen Mary University of London, London, England, United Kingdom
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Dixon LB, Goldman HH, Srihari VH, Kane JM. Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative. Annu Rev Clin Psychol 2018; 14:237-258. [PMID: 29328779 PMCID: PMC8990328 DOI: 10.1146/annurev-clinpsy-050817-084934] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
The schizophrenia spectrum disorders are neurodevelopmental illnesses with a lifetime prevalence near 1%, producing extensive functional impairment and low expectations for recovery. Until recently, treatment in the United States has largely attempted to stabilize individuals with chronic schizophrenia. The identification and promotion of evidence-based practices for schizophrenia via the Patient Outcomes Research Team, combined with international studies supporting the value of early intervention, provided the foundation for the Recovery After an Initial Schizophrenia Episode (RAISE) project. The RAISE studies further supported the value of reducing the duration of untreated psychosis and providing a multi-element treatment called coordinated specialty care (CSC) to improve outcomes for patients in usual treatment settings. Although CSC programs have proliferated rapidly in the United States, many challenges remain in the treatment and recovery of individuals with schizophrenia in the aftermath of RAISE.
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Affiliation(s)
- Lisa B Dixon
- New York State Psychiatric Institute, Columbia University Medical Center, New York, NY 10032, USA;
| | - Howard H Goldman
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Vinod H Srihari
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06511, USA
| | - John M Kane
- Zucker Hillside Hospital and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York 11549, USA
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Abstract
In recent years there has been much debate regarding the evaluation of treatments in medicine. The evidence-based medicine (EBM) movement has formed partly out of the realisation that clinical practice is often poorly informed by the best available evidence, and that many widely used treatments are either completely untested, or tested and proven to be ineffective or even harmful. EBM has been characterised as a stick by which policy-makers and academics beat clinicians (Williams & Garner, 2002). However, another side to EBM has been the realisation that research performed to test new treatments has often been of poor quality, or has asked the wrong questions (Hotopf et al, 1997; Thornley & Adams, 1998; Barbui & Hotopf, 2001). We have previously argued that clinicians could justifiably criticise the research establishment for failing to provide answers to relevant clinical problems of everyday practice (Hotopf et al, 1999).
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Clinical trial methodology to assess the efficacy/effectiveness of long-acting antipsychotics: Randomized controlled trials vs naturalistic studies. Psychiatry Res 2017; 247:257-264. [PMID: 27936437 DOI: 10.1016/j.psychres.2016.11.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 10/26/2016] [Accepted: 11/28/2016] [Indexed: 11/24/2022]
Abstract
Schizophrenia presents unique difficulties in clinical trial design associated with the condition's variable presentation and clinical course, and multiple features influencing affect, cognition, volition and perception. Randomized controlled trials (RCTs) are explanatory studies using a carefully selected patient population, predefined assessment intervals and, generally, symptom-focused endpoints. Naturalistic studies are pragmatic, with no active intervention, and outcomes that are generally those used in clinical practice (e.g. hospitalization, relapse rate). Both naturalistic studies and RCTs have pros and cons, making it difficult for physicians in clinical practice to apply research findings to their own treatment decisions. The choice of clinical trial design can have a significant impact on the comparative effectiveness or efficacy of drugs. This is particularly true for studies comparing long-acting injectable (LAI) antipsychotics with oral antipsychotics in schizophrenia, in which RCTs generally show no benefit for LAIs over oral drugs, whereas observational studies do. The more pragmatic the study design, the more likely it is to show a benefit for LAIs versus oral therapy. This article reviews the pros and cons of different study types, using published examples. Criteria are outlined to help physicians design appropriate prospective studies in schizophrenia including the relevant pragmatic and/or explanatory features, as required.
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Consequences of randomized clinical trial design decisions need to be clarified. J Clin Epidemiol 2016; 77:13-14. [PMID: 26957108 DOI: 10.1016/j.jclinepi.2016.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/29/2016] [Indexed: 01/07/2023]
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Reininghaus U, Depp CA, Myin-Germeys I. Ecological Interventionist Causal Models in Psychosis: Targeting Psychological Mechanisms in Daily Life. Schizophr Bull 2016; 42:264-9. [PMID: 26707864 PMCID: PMC4753613 DOI: 10.1093/schbul/sbv193] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Integrated models of psychotic disorders have posited a number of putative psychological mechanisms that may contribute to the development of psychotic symptoms, but it is only recently that a modest amount of experience sampling research has provided evidence on their role in daily life, outside the research laboratory. A number of methodological challenges remain in evaluating specificity of potential causal links between a given psychological mechanism and psychosis outcomes in a systematic fashion, capitalizing on longitudinal data to investigate temporal ordering. In this article, we argue for testing ecological interventionist causal models that draw on real world and real-time delivered, ecological momentary interventions for generating evidence on several causal criteria (association, time order, and direction/sole plausibility) under real-world conditions, while maximizing generalizability to social contexts and experiences in heterogeneous populations. Specifically, this approach tests whether ecological momentary interventions can (1) modify a putative mechanism and (2) produce changes in the mechanism that lead to sustainable changes in intended psychosis outcomes in individuals' daily lives. Future research using this approach will provide translational evidence on the active ingredients of mobile health and in-person interventions that promote sustained effectiveness of ecological momentary interventions and, thereby, contribute to ongoing efforts that seek to enhance effectiveness of psychological interventions under real-world conditions.
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Affiliation(s)
- Ulrich Reininghaus
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Centre for Epidemiology and Public Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK;
| | - Colin A Depp
- Department of Psychiatry, University of California, San Diego, CA; VA San Diego Healthcare System, San Diego, CA
| | - Inez Myin-Germeys
- Center for Contextual Psychiatry, Department of Neuroscience, KU Leuven, Belgium
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Montero M, Iraurgi I, Matellanes B, Montero JM. [Use of the reliable change index to evaluate the effectiveness of clinical interventions: Application of an asthma training program]. Aten Primaria 2015; 47:644-52. [PMID: 25700987 PMCID: PMC6983811 DOI: 10.1016/j.aprim.2014.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 12/02/2014] [Accepted: 12/03/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To compare two methods for the evaluation of outcomes to assess effectiveness of a therapeutic intervention of a professional education program on asthma control. DESIGN A naturalistic, intervention study in which asthmatic patients were attended by clinicians (IG group) who Had taken part in a special education program and a control group (CG) that received medical assistance from clinicians still waiting to be trained. LOCATION Five urban Primary Care Health Centres of the same region. PARTICIPANTS From an initial sample of 100 patients, 76 formed the final sample for analysis. The study included 37 males and 39 females, aged between 18 and 65 years (M=41.2 years). The two study groups were found to be homogeneous except for the sex variable. INTERVENTION Training program for clinical treatment adherence. MAIN MEASUREMENTS Peak flow as spirometric index, and structured interview. STATISTICAL ANALYSIS The results were initially analysed using classical techniques based on robust ANOVA models, and then by calculating the Reliable Change Index (RCI). RESULTS ANOVA models, conducted separately for each sex, showed no significant differences, due to sample size. RCI methodology showed significant differences in the percentage of patients improved in both groups, as well as clinically relevant changes being observed individually. CONCLUSIONS The RCI method is presented as an attractive alternative as regards the classical methods of analysis that can help in the clinical decision.
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Affiliation(s)
- Mikel Montero
- DeustoPsych, I+D+i en Psicología y Salud, Facultad de Psicología y Educación, Universidad de Deusto, Bilbao, Vizcaya, España.
| | - Ioseba Iraurgi
- DeustoPsych, I+D+i en Psicología y Salud, Facultad de Psicología y Educación, Universidad de Deusto, Bilbao, Vizcaya, España
| | - Begoña Matellanes
- DeustoPsych, I+D+i en Psicología y Salud, Facultad de Psicología y Educación, Universidad de Deusto, Bilbao, Vizcaya, España
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Corbetta D, Sirtori V, Castellini G, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev 2015; 2015:CD004433. [PMID: 26446577 PMCID: PMC6465192 DOI: 10.1002/14651858.cd004433.pub3] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities. OBJECTIVES To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke. SEARCH METHODS We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015). SELECTION CRITERIA Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none. DATA COLLECTION AND ANALYSIS One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability. MAIN RESULTS We included 42 studies involving 1453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment. AUTHORS' CONCLUSIONS CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.
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Affiliation(s)
- Davide Corbetta
- San Raffaele HospitalUnit of Functional RecoveryVia Olgettina, 48MilanItaly20132
| | - Valeria Sirtori
- San Raffaele HospitalUnit of Functional RecoveryVia Olgettina, 48MilanItaly20132
| | - Greta Castellini
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
| | - Lorenzo Moja
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanItaly20133
| | - Roberto Gatti
- University Vita‐Salute San RaffaeleSchool of PhysiotherapyVia Olgettina, 58MilanItaly20132
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Srihari VH, Tek C, Kucukgoncu S, Phutane VH, Breitborde NJK, Pollard J, Ozkan B, Saksa J, Walsh BC, Woods SW. First-Episode Services for Psychotic Disorders in the U.S. Public Sector: A Pragmatic Randomized Controlled Trial. Psychiatr Serv 2015; 66:705-12. [PMID: 25639994 PMCID: PMC4490067 DOI: 10.1176/appi.ps.201400236] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to determine the effectiveness of a comprehensive first-episode service, the clinic for Specialized Treatment Early in Psychosis (STEP), in an urban U.S. community mental health center by comparing it with usual treatment. METHODS This pragmatic randomized controlled trial enrolled 120 patients with first-episode psychosis within five years of illness onset and 12 weeks of antipsychotic exposure. Referrals were mostly from inpatient psychiatric units, and enrollees were randomly allocated to STEP or usual treatment. Main outcomes included hospital utilization (primary); the ability to work or attend age-appropriate schooling-or to actively seek these opportunities (vocational engagement); and general functioning. Analysis was by modified intent to treat (excluding only three who withdrew consent) for hospitalization; for other outcomes, only data for completers were analyzed. RESULTS After one year, STEP participants had less inpatient utilization compared with those in usual treatment: no psychiatric hospitalizations, 77% versus 56% (risk ratio [RR]=1.38, 95% confidence interval [CI]=1.08-1.58); mean hospitalizations, .33±.70 versus .68±.92 (p=.02); and mean bed-days, 5.34±13.53 versus 11.51±15.04 (p=.05). For every five patients allocated to STEP versus usual treatment, one additional patient avoided hospitalization over the first year (number needed to treat=5; CI=2.7-26.5). STEP participants also demonstrated better vocational engagement (91.7% versus 66.7%; RR=1.40, CI=1.18-1.48) and showed salutary trends in global functioning measures. CONCLUSIONS This trial demonstrated the feasibility and effectiveness of a U.S. public-sector model of early intervention for psychotic illnesses. Such services can also support translational research and are a relevant model for other serious mental illnesses.
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Affiliation(s)
- Vinod H Srihari
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Cenk Tek
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Suat Kucukgoncu
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Vivek H Phutane
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Nicholas J K Breitborde
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Jessica Pollard
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Banu Ozkan
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - John Saksa
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Barbara C Walsh
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
| | - Scott W Woods
- Dr. Srihari, Dr. Tek, Dr. Kucukgoncu, Dr. Pollard, Dr Saksa, Dr. Walsh, and Dr. Woods are with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: ). Dr. Phutane is with Goulburn Valley Health, Shepparton, Victoria, Australia. Dr. Breitborde is with the Department of Psychiatry, University of Arizona, Tucson. Dr. Ozkan is with the Department of Psychiatry, Koc University, Istanbul, Turkey. Findings of this study were presented at the International Conference on Early Psychosis, San Francisco, October 11-13, 2012. This article is part of a special section on RAISE and other early intervention services. Marcela Horvitz-Lennon, M.D., M.P.H., served as guest editor of the special section
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Banzi R, Cusi C, Randazzo C, Sterzi R, Tedesco D, Moja L. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults. Cochrane Database Syst Rev 2015; 2015:CD011681. [PMID: 25931277 PMCID: PMC6864942 DOI: 10.1002/14651858.cd011681] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND This is an updated version of the Cochrane review published in 2005 on selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headache. The original review has been split in two parts and this review now only regards tension-type headache prevention. Another updated review covers migraine. Tension-type headache is the second most common disorder worldwide and has high social and economic relevance. As serotonin and other neurotransmitters may have a role in pain mechanisms, SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been evaluated for the prevention of tension-type headache. OBJECTIVES To determine the efficacy and tolerability of SSRIs and SNRIs compared to placebo and other active interventions in the prevention of episodic and chronic tension-type headache in adults. SEARCH METHODS For the original review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2003, Issue 4), MEDLINE (1966 to January 2004), EMBASE (1994 to May 2003), and Headache Quarterly (1990 to 2003). For this update, we revised the original search strategy to reflect the broader type of intervention (SSRIs and SNRIs). We searched CENTRAL (2014, Issue 10) on the Cochrane Library, MEDLINE (1946 to November 2014), EMBASE (1980 to November 2014), and PsycINFO (1987 to November 2014). We also checked the reference lists of retrieved articles and searched trial registries for ongoing trials. SELECTION CRITERIA We included randomised controlled trials comparing SSRIs or SNRIs with any type of control intervention in participants 18 years and older, of either sex, with tension-type headache. DATA COLLECTION AND ANALYSIS Two authors independently extracted data (headache frequency, index, intensity, and duration; use of symptomatic/analgesic medication; quality of life; and withdrawals) and assessed the risk of bias of trials. The primary outcome is tension-type headache frequency, measured by the number of headache attacks or the number of days with headache per evaluation period. MAIN RESULTS The original review included six studies on tension-type headache. We now include eight studies with a total of 412 participants with chronic forms of tension-type headache. These studies evaluated five SSRIs (citalopram, sertraline, fluoxetine, paroxetine, fluvoxamine) and one SNRI (venlafaxine). The two new studies included in this update are placebo controlled trials, one evaluated sertraline and one venlafaxine. Six studies, already included in the previous version of this review, compared SSRIs to other antidepressants (amitriptyline, desipramine, sulpiride, mianserin). Most of the included studies had methodological and/or reporting shortcomings and lacked adequate power. Follow-up ranged between two and four months.Six studies explored the effect of SSRIs or SNRIs on tension-type headache frequency, the primary endpoint. At eight weeks of follow-up, we found no difference when compared to placebo (two studies, N = 127; mean difference (MD) -0.96, 95% confidence interval (CI) -3.95 to 2.03; I(2)= 0%) or amitriptyline (two studies, N = 152; MD 0.76, 95% CI -2.05 to 3.57; I(2)= 44%).When considering secondary outcomes, SSRIs reduce the symptomatic/analgesic medication use for acute headache attacks compared to placebo (two studies, N = 118; MD -1.87, 95% CI -2.09 to -1.65; I(2)= 0%). However, amitriptyline appeared to reduce the intake of analgesic more efficiently than SSRIs (MD 4.98, 95% CI 1.12 to 8.84; I(2)= 0%). The studies supporting these findings were considered at unclear risk of bias. We found no differences compared to placebo or other antidepressants in headache duration and intensity.SSRIs or SNRI were generally more tolerable than tricyclics. However, the two groups did not differ in terms of number of participants who withdrew due to adverse events or for other reasons (four studies, N = 257; odds ratio (OR) 1.04; 95% CI 0.41 to 2.60; I(2)= 25% and OR 1.55, 95% CI 0.71 to 3.38; I(2)= 0%).We did not find any study comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. botulinum toxin) or non-drug therapies (e.g. psycho-behavioural treatments, manual therapy, acupuncture). AUTHORS' CONCLUSIONS Since the last version of this review, the new included studies have not added high quality evidence to support the use of SSRIs or venlafaxine (a SNRI) as preventive drugs for tension-type headache. Over two months of treatment, SSRIs or venlafaxine are no more effective than placebo or amitriptyline in reducing headache frequency in patients with chronic tension-type headache. SSRIs seem to be less effective than tricyclic antidepressants in terms of intake of analgesic medications. Tricyclic antidepressants are associated with more adverse events; however, this did not cause a greater number of withdrawals. No reliable information is available at longer follow-up. Our conclusion is that the use of SSRIs and venlafaxine for the prevention of chronic tension-type headache is not supported by evidence.
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Affiliation(s)
- Rita Banzi
- IRCCS ‐ Mario Negri Institute for Pharmacological ResearchLaboratory of Regulatory Policiesvia G La Masa 19MilanItaly20156
| | - Cristina Cusi
- Istituti Clinici di PerfezionamentoOut Patient Services ‐ NeurologyVia Castelvetro 22MilanoItaly20154
| | - Concetta Randazzo
- University of BolognaDepartment of Biomedical and Neuromotor SciencesVia San Giacomo, 12BolognaItaly40126
| | - Roberto Sterzi
- Azienda Ospedaliera NiguardaNeuroscience DepartmentPiazza Ospedale Maggiore, 3MilanoItaly20163
| | - Dario Tedesco
- University of BolognaDepartment of Biomedical and Neuromotor SciencesVia San Giacomo, 12BolognaItaly40126
| | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanMilanItaly20133
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
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Banzi R, Cusi C, Randazzo C, Sterzi R, Tedesco D, Moja L. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of migraine in adults. Cochrane Database Syst Rev 2015; 4:CD002919. [PMID: 25829028 PMCID: PMC6513227 DOI: 10.1002/14651858.cd002919.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in 2005 on selective serotonin reuptake inhibitors (SSRIs) for preventing migraine and tension-type headache. The original review has been split in two parts and this review now only regards migraine prevention. Another updated review is under development to cover tension-type headache.Migraine is a common disorder. The chronic forms are associated with disability and have a high economic impact. In view of discoveries about the role of serotonin and other neurotransmitters in pain mechanisms, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been evaluated for the prevention of migraine. OBJECTIVES To determine the efficacy and tolerability of SSRIs and SNRIs compared to placebo and other active interventions in the prevention of episodic and chronic migraine in adults. SEARCH METHODS For the original review, we searched MEDLINE (1966 to January 2004), EMBASE (1994 to May 2003), the Cochrane Central Register of Controlled Trials (CENTRAL 2003, Issue 4), and Headache Quarterly (1990 to 2003). For this update, we applied a revised search strategy to reflect the broader type of intervention (SSRIs and SNRIs). We searched CENTRAL (2014, Issue 10), MEDLINE (1946 to November 2014), EMBASE (1980 to November 2014), and PsycINFO (1987 to November 2014). We also checked the reference lists of retrieved articles and searched trial registries for ongoing trials. SELECTION CRITERIA We included randomised controlled trials comparing SSRIs or SNRIs with any type of control intervention in participants 18 years and older of either sex with migraine. DATA COLLECTION AND ANALYSIS Two authors independently extracted data (migraine frequency, index, intensity, and duration; use of symptomatic/analgesic medication; days off work; quality of life; mood improvement; cost-effectiveness; and adverse events) and assessed the risk of bias of trials. The primary outcome of this updated review is migraine frequency. MAIN RESULTS The original review included eight studies on migraine. Overall, we now include 11 studies on five SSRIs and one SNRI with a total of 585 participants. Six studies were placebo-controlled, four compared a SSRI or SNRI to amitriptyline, and one was a head-to-head comparison (escitalopram versus venlafaxine). Most studies had methodological or reporting shortcomings (or both): all studies were at unclear risk of selection and reporting bias. Follow-up rarely extended beyond three months. The lack of adequate power of most of the studies is also a major concern.Few studies explored the effect of SSRIs or SNRIs on migraine frequency, the primary endpoint. Two studies with unclear reporting compared SSRIs and SNRIs to placebo, suggesting a lack of evidence for a difference. Two studies compared SSRIs or SNRIs versus amitriptyline and found no evidence for a difference in terms of migraine frequency (standardised mean difference (SMD) 0.04, 95% confidence interval (CI) -0.72 to 0.80; I(2) = 72%), or other secondary outcomes such as migraine intensity and duration.SSRIs or SNRIs were generally more tolerable than tricyclics. However, the two groups did not differ in terms of the number of participants who withdrew due to adverse advents or for other reasons (one study, odds ratio (OR) 0.39, 95% CI 0.10 to 1.50 and OR 0.42, 95% CI 0.13 to 1.34).We did not find studies comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. antiepileptics and anti-hypertensives). AUTHORS' CONCLUSIONS Since the last version of this review, the new included studies have not added high quality evidence to support the use of SSRIs or venlafaxine as preventive drugs for migraine. There is no evidence to consider SSRIs or venlafaxine as more effective than placebo or amitriptyline in reducing migraine frequency, intensity, and duration over two to three months of treatment. No reliable information is available at longer-term follow-up. Our conclusion is that the use of SSRIs and SNRIs for migraine prophylaxis is not supported by evidence.
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Affiliation(s)
- Rita Banzi
- IRCCS ‐ Mario Negri Institute for Pharmacological ResearchLaboratory of Regulatory Policiesvia G La Masa 19MilanItaly20156
| | - Cristina Cusi
- Istituti Clinici di PerfezionamentoOut Patient Services ‐ NeurologyVia Castelvetro 22MilanoItaly20154
| | - Concetta Randazzo
- University of BolognaDepartment of Biomedical and Neuromotor SciencesVia San Giacomo, 12BolognaItaly40126
| | - Roberto Sterzi
- Azienda Ospedaliera NiguardaNeuroscience DepartmentPiazza Ospedale Maggiore, 3MilanoItaly20163
| | - Dario Tedesco
- University of BolognaDepartment of Biomedical and Neuromotor SciencesVia San Giacomo, 12BolognaItaly40126
| | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanMilanItaly20133
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
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Abstract
Practical clinical trials (PCTs) are randomized experiments under typical practice conditions with the aim of testing the "real-life" benefits and risks of therapeutic interventions. Influential PCTs have been conducted in cardiology, oncology, and internal medicine. Psychotropic medications are widely and increasingly used in medical practice. This review examines recent progress in conducting PCTs in psychopharmacology. The January 2000 to October 2014 MEDLINE, Scopus, and ClinicalTrials.gov databases were searched for peer-reviewed publications of PCTs with at least 100 subjects per treatment arm. Most PCTs in psychiatry evaluated mental health services or psychosocial interventions rather than specific pharmacotherapies. Of 157 PCTs in psychiatry, 30 (19%) were in psychopharmacology, with a median of 2 publications per year and no increase during the period of observation. Sample size ranged from 200 to 18,154; only 11 studies randomized 500 patients or more. Psychopharmacology PCTs were equally likely to be funded by industry as by public agencies. There were 10 PCTs of antidepressants, for a total of 4206 patients (in comparison with at least 46 PCTs of antihypertensive medications, for a total of 208,014 patients). Some psychopharmacology PCTs used suicidal behavior, treatment discontinuation, or mortality as primary outcome and produced effectiveness and safety data that have influenced both practice guidelines and regulatory decisions. Practical clinical trials can constitute an important source of information for clinicians, patients, regulators, and policy makers but have been relatively underused in psychopharmacology. Electronic medical records and integrated practice research networks offer promising platforms for a more efficient conduct of PCTs.
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Abstract
At more than 10 years after the paper by Hotopf and colleagues regarding pragmatic trials in psychiatry, the field has evolved and is evolving further. There have been many developments in our understanding of what pragmatism really means, and excellent examples of truly pragmatic trials in psychiatry are currently available. Funders have helped encourage more emphasis on the need for such studies, but 'local' and trans-national regulations could help more. Consumers of the evidence should have a greater voice in generating the research agenda and, as this happens, the questions generated are more likely to be answered by a pragmatic approach to trials.
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Affiliation(s)
- M Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Public Health and Community Medicine, Section of Psychiatry,University of Verona,Verona,Italy
| | - C Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Public Health and Community Medicine, Section of Psychiatry,University of Verona,Verona,Italy
| | - S Stroup
- Psychiatric Institute,Columbia University,New York, NY,USA
| | - C Adams
- Division of Psychiatry,University of Nottingham,Nottingham,UK
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Marwaha S, He Z, Broome M, Singh SP, Scott J, Eyden J, Wolke D. How is affective instability defined and measured? A systematic review. Psychol Med 2014; 44:1793-1808. [PMID: 24074230 DOI: 10.1017/s0033291713002407] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Affective instability (AI) is poorly defined but considered clinically important. The aim of this study was to examine definitions and measures of AI employed in clinical populations. METHOD This study was a systematic review using the PRISMA guidelines. MEDLINE, Embase, PsycINFO, PsycArticles and Web of Science databases were searched. Also five journals were hand searched. Primary empirical studies involving randomized controlled trials (RCTs), non-RCTs, controlled before and after, and observational investigations were included. Studies were selected, data extracted and quality appraised. A narrative synthesis was completed. RESULTS A total of 11 443 abstracts were screened and 37 studies selected for final analysis on the basis that they provided a definition and measure of AI. Numbers of definitions for each of the terms employed in included studies were: AI (n = 7), affective lability (n = 6), affective dysregulation (n = 1), emotional dysregulation (n = 4), emotion regulation (n = 2), emotional lability (n = 1), mood instability (n = 2), mood lability (n = 1) and mood swings (n = 1); however, these concepts showed considerable overlap in features. A total of 24 distinct measures were identified that could be categorized as primarily measuring one of four facets of AI (oscillation, intensity, ability to regulate and affect change triggered by environment) or as measuring general emotional regulation. CONCLUSIONS A clearer definition of AI is required. We propose AI be defined as 'rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences'. No single measure comprehensively assesses AI and a combination of current measures is required for assessment. A new short measure of AI that is reliable and validated against external criteria is needed.
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Affiliation(s)
- S Marwaha
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - Z He
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - M Broome
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - S P Singh
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
| | - J Scott
- Academic Psychiatry, Institute of Neuroscience,Newcastle University,Newcastle upon Tyne,UK
| | - J Eyden
- Department of Psychology,University of Warwick,Coventry,UK
| | - D Wolke
- Division of Mental Health and Wellbeing, Warwick Medical School,University of Warwick,Coventry,UK
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Cogo-Moreira H, Brandão de Ávila CR, Ploubidis GB, de Jesus Mari J. Pathway evidence of how musical perception predicts word-level reading ability in children with reading difficulties. PLoS One 2013; 8:e84375. [PMID: 24358358 PMCID: PMC3866178 DOI: 10.1371/journal.pone.0084375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/22/2013] [Indexed: 11/20/2022] Open
Abstract
Objective To investigate whether specific domains of musical perception (temporal and melodic domains) predict the word-level reading skills of eight- to ten-year-old children (n = 235) with reading difficulties, normal quotient of intelligence, and no previous exposure to music education classes. Method A general-specific solution of the Montreal Battery of Evaluation of Amusia (MBEA), which underlies a musical perception construct and is constituted by three latent factors (the general, temporal, and the melodic domain), was regressed on word-level reading skills (rate of correct isolated words/non-words read per minute). Results General and melodic latent domains predicted word-level reading skills.
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Affiliation(s)
- Hugo Cogo-Moreira
- Department of Psychiatry and Medical Psychology, Federal University of São Paulo, Sao Paulo, Sao Paulo, Brazil
- * E-mail:
| | | | - George B. Ploubidis
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jair de Jesus Mari
- Department of Psychiatry and Medical Psychology, Federal University of São Paulo, Sao Paulo, Sao Paulo, Brazil
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Drug treatments for schizophrenia: pragmatism in trial design shows lack of progress in drug design. Epidemiol Psychiatr Sci 2013; 22:223-33. [PMID: 23388168 PMCID: PMC8367335 DOI: 10.1017/s204579601200073x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Aims. The introduction of second generation antipsychotic (SGA) medication over a decade ago led to changes in prescribing practices; these drugs have eclipsed their predecessors as treatments for schizophrenia. However, the metabolic side effects of these newer antipsychotics have been marked and there are increasing concerns as to whether these novel drugs really are superior to their predecessors in terms of the balance between risks and benefits. In this article, we review the literature regarding comparisons between first generation antipsychotic (FGA) and SGA in terms of clinical effectiveness. Methods. Large (n > 150) randomized-controlled trials (RCTs) comparing the effectiveness (efficacy and side effects) of FGA and SGA medications other than clozapine were reviewed, as were meta-analyses that included smaller studies. Results. The superiority in efficacy and reduced extrapyramidal side effects (EPSE) of SGAs is modest, especially when compared with low-dose FGAs. However, the high risk of weight gain and other metabolic disturbances associated with certain SGAs such as olanzapine is markedly higher than the risk with FGAs at the doses used in the trials. Conclusions. The efficacy profiles of various FGAs and SGAs are relatively similar, but their side effects vary between and within classes. Overall, large pragmatic trials of clinical effectiveness indicate that the care used in prescribing and managing drug treatments to ensure tolerability may be more important than the class of drug used.
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Abstract
This Editorial addresses the crucial issue of which research methodology is most suited for capturing the complexity of psychosocial interventions conducted in 'real world' mental health settings. It first examines conventional randomized controlled trial (RCT) methodology and critically appraises its strengths and weaknesses. It then considers the specificity of mental health care treatments and defines the term 'complex' intervention and its implications for RCT design. The salient features of pragmatic RCTs aimed at generating evidence of psychosocial intervention effectiveness are then described. Subsequently, the conceptualization of pragmatic RCTs, and of their further developments - which we propose to call 'new generation' pragmatic trials - in the broader routine mental health service context, is explored. Helpful tools for planning pragmatic RCTs, such as the CONSORT extension for pragmatic trials, and the PRECIS tool are also examined. We then discuss some practical challenges that are involved in the design and implementation of pragmatic trials based on our own experience in conducting the GET UP PIANO Trial. Lastly, we speculate on the ways in which current ideas on the purpose, scope and ethics of mental health care research may determine further challenges for clinical research and evidence-based practice.
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Armstrong BM, Hall M, Crawfurd E, Smith TO. A feasibility study for a pragmatic randomised controlled trial comparing cast immobilisation versus no immobilisation for patients following first-time patellar dislocation. Knee 2012; 19:696-702. [PMID: 21962458 DOI: 10.1016/j.knee.2011.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/22/2011] [Accepted: 08/23/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this feasibility study was to begin to determine the efficacy of cylinder cast immobilisation compared to no form of immobilisation for patients following first-time patellar dislocation (FTPD). MATERIALS AND METHODS Participants were patients who attended a National Health Service Accident and Emergency department following a FTPD. Patients were randomised to receive immobilisation for four weeks in a cylinder cast followed by rehabilitation, versus no immobilisation and early rehabilitation. All patients were followed-up over a three month period, assessed using the Visual analogue scale for pain, Short Form-36, the Lysholm knee score and the Modified Functional Index. RESULTS Forty-one patients were approached to participate. Eight satisfied the pre-defined eligibility criteria and were randomised between the two groups. Whilst the results indicated a trend for superior short-term functional outcomes for those patients not immobilised compared to those immobilised following a FTPD, the small sample and baseline imbalances between the groups may have had a substantial influence on the results. CONCLUSION This feasibility study has indicated that the outcome measurements adopted were appropriate to answer this research question, but the assessment of return to normal activity, recurrent instability and dislocation and cost-effectiveness over a longer follow-up period is recommended. Similarly, defining a more pragmatic eligibility criteria and recruiting from multiple centres would be recommended for the definitive trial requiring a sample of 348 patients to demonstrate a statistical significant treatment effect.
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Balfour A, Lanman M. An evaluation of time-limited psychodynamic psychotherapy for couples: a pilot study. Psychol Psychother 2012; 85:292-309. [PMID: 22903920 DOI: 10.1111/j.2044-8341.2011.02030.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Psychodynamic Couple Psychotherapy has developed as a modality in only a few organizations in the public and voluntary sectors in this country. Varieties of couple therapy have evolved due to economic or other constraints, some more open-ended, others involving differing time limits or behavioural techniques. In this study, a time limit of 40 sessions was imposed on the Psychodynamic therapy to improve comparability with other therapeutic approaches. We examined work with 18 couples, employing various measures which, while not in the context of a full controlled trial, produced some interesting and indicative results. We aimed to investigate (1) the effects of time-limited psychodynamic couple psychotherapy, and (2) whether the measures used produce interesting results after 40 weeks. DESIGN Within a normal clinical setting, measurements of individual and couple functioning would be taken at fixed points in the course of 40-week couple therapies, and analysed for evidence of significant change. Due to funding and clinical limitations within the setting, a baseline period before therapy started was used instead of a control group. METHOD Couples were invited to opt in to the study when applying to the agency for therapy. They were provided with 40 weekly sessions of couple therapy. Videotapes of sessions at beginning, middle, and end of the therapies were rated by independent observer, using the Personal Relatedness Profile (PRP) (Hobson, Patrick, & Valentine, 1998) adapted for couples (Lanman, Grier, & Evans, 2003), alongside two individual self-report measures, Clinical Outcomes in Routine Evaluation (CORE) (Evans et al., 2000), and the Golombok Rust Inventory of Marital Satisfaction (GRIMS) (Rust, Bennun, Crow, & Golumbok, 1990). RESULTS The couples showed improvement as rated both by therapists and observers (rating the videotaped sessions) on the PRP after 40 sessions. On the CORE measure, participants showed improvement at both 20 and 40 sessions. On the GRIMS measure of marital satisfaction, results were non-significant. CONCLUSIONS The results provide indicative evidence for the effectiveness of 40-session couple psychotherapy and provide some convergent validation for the utility of the PRP (as adapted for couples) as a measure of change.
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Abstract
Services that provide comprehensive, early intervention (EI) have shown promise in improving long-term outcomes in schizophrenia. This article reviews the rationale and salient concepts relevant to understanding the growing EI literature. A selective review of studies evaluating the effectiveness of integrated EI is followed by a discussion of feasibility, especially in the US context. Finally, the authors present a framework that seeks to integrate activities traditionally categorized and separated as discovery and implementation. This framework is offered as a way to advance both goals.
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Affiliation(s)
- Vinod H Srihari
- Department of Psychiatry, Yale University,and Clinic for Specialized Treatment Early in Psychosis (STEP), 34 Park Street, Connecticut Mental Health Center, Room 273A, New Haven, CT 06519, USA.
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Wells M, Williams B, Treweek S, Coyle J, Taylor J. Intervention description is not enough: evidence from an in-depth multiple case study on the untold role and impact of context in randomised controlled trials of seven complex interventions. Trials 2012; 13:95. [PMID: 22742939 PMCID: PMC3475073 DOI: 10.1186/1745-6215-13-95] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 05/21/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A number of single case reports have suggested that the context within which intervention studies take place may challenge the assumptions that underpin randomised controlled trials (RCTs). However, the diverse ways in which context may challenge the central tenets of the RCT, and the degree to which this information is known to researchers or subsequently reported, has received much less attention. In this paper, we explore these issues by focusing on seven RCTs of interventions varying in type and degree of complexity, and across diverse contexts. METHODS This in-depth multiple case study using interviews, focus groups and documentary analysis was conducted in two phases. In phase one, a RCT of a nurse-led intervention provided a single exploratory case and informed the design, sampling and data collection within the main study. Phase two consisted of a multiple explanatory case study covering a spectrum of trials of different types of complex intervention. A total of eighty-four data sources across the seven trials were accessed. RESULTS We present consistent empirical evidence across all trials to indicate that four key elements of context (personal, organisational, trial and problem context) are crucial to understanding how a complex intervention works and to enable both assessments of internal validity and likely generalisability to other settings. The ways in which context challenged trial operation was often complex, idiosyncratic, and subtle; often falling outside of current trial reporting formats. However, information on such issues appeared to be available via first hand 'insider accounts' of each trial suggesting that improved reporting on the role of context is possible. CONCLUSIONS Sufficient detail about context needs to be understood and reported in RCTs of complex interventions, in order for the transferability of complex interventions to be assessed. Improved reporting formats that require and encourage the clarification of both general and project-specific threats to the likely internal and external validity need to be developed. In addition, a cultural change is required in which the open and honest reporting of such issues is seen as an indicator of study strength and researcher integrity, rather than a symbol of a poor quality study or investigator ability.
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Affiliation(s)
- Mary Wells
- School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
| | - Brian Williams
- Nursing, Midwifery and Allied Health Professions Research Unit, Iris Murdoch Building, University of Stirling, Stirling, FK9 4LA, UK
| | - Shaun Treweek
- Population Health Sciences, School of Medicine, University of Dundee, The Mackenzie building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Joanne Coyle
- Social Dimensions of Health Institute, University of St Andrews and University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
| | - Julie Taylor
- School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
- National Society for the Prevention of Child Abuse and Neglect (NSPCC), Weston House, 42 Curtain Rd, London, EC2A 3NH, UK
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Dell'osso B, Camuri G, Castellano F, Vecchi V, Benedetti M, Bortolussi S, Altamura AC. Meta-Review of Metanalytic Studies with Repetitive Transcranial Magnetic Stimulation (rTMS) for the Treatment of Major Depression. Clin Pract Epidemiol Ment Health 2011; 7:167-77. [PMID: 22135698 PMCID: PMC3227860 DOI: 10.2174/1745017901107010167] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 08/25/2011] [Accepted: 08/25/2011] [Indexed: 01/06/2023]
Abstract
Background: Major Depression (MD) and treatment-resistant depression (TRD) are worldwide leading causes of disability and therapeutic strategies for these impairing and prevalent conditions include pharmacological augmentation strategies and brain stimulation techniques. In this perspective, repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation technique with a favorable profile of tolerability which, despite being recently approved by the Food and Drug Administration (FDA) for the treatment of patients with medication-refractory unipolar depression, still raises some doubts about most effective parameters of stimulation. Methods: A literature search was performed using PubMed for the years 2001 through February 2011 in order to review meta-analytic studies assessing efficacy and safety issues for rTMS in depressive disorders. Fifteen meta-analyses were identified and critically discussed in order to provide an updated and comprehensive overview of the topic with specific emphasis on potentially optimal parameters of stimulation. Results: First meta-analyses on the efficacy of rTMS for the treatment of MD and TRD have shown mixed results. On the other hand, more recent meta-analytic studies seem to support the antidepressant efficacy of the technique to a greater extent, also in light of longer periods of stimulation (e.g. > 2 weeks). Conclusion: rTMS seems to be an effective and safe brain stimulation technique for the treatment of medication refractory depression. Nevertheless, further studies are needed to better define specific stimulation-related issues, such as duration of treatment as well as durability of effects and predictors of response.
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Affiliation(s)
- Bernardo Dell'osso
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
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Parabiaghi A, D'Avanzo B, Tettamanti M, Barbato A. The GiSAS study: Rationale and design of a pragmatic randomized controlled trial on aripiprazole, olanzapine and haloperidol in the long-term treatment of schizophrenia. Contemp Clin Trials 2011; 32:675-84. [DOI: 10.1016/j.cct.2011.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 03/29/2011] [Accepted: 04/21/2011] [Indexed: 11/24/2022]
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Werneck AP, Hallak JC, Nakano E, Elkis H. Time to rehospitalization in patients with schizophrenia discharged on first generation antipsychotics, non-clozapine second generation antipsychotics, or clozapine. Psychiatry Res 2011; 188:315-9. [PMID: 21596442 DOI: 10.1016/j.psychres.2011.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 04/10/2011] [Accepted: 04/12/2011] [Indexed: 10/18/2022]
Abstract
Rehospitalization is an important outcome of drug effectiveness in schizophrenia. In this study, the hypothesis that clozapine and some second generation antipsychotics (SGA) were superior to first generation antipsychotics (FGA) in preventing rehospitalization of patients with schizophrenia discharged from a university hospital in Brazil was tested. A retrospective observational study was conducted designed to evaluate time to rehospitalization of patients with schizophrenia discharged on a regimen of oral FGA, depot FGA, risperidone, olanzapine and amisulpride, other SGA, or clozapine, during a three-year follow-up period. Risk factors associated with rehospitalization were examined. Of the 464 patients with schizophrenia discharged from hospital, 242 met criteria for study entry. Higher rehospitalization rates were observed in patients treated with depot FGA (30%), risperidone (30%) and other SGA groups (28.5%), respectively. Clozapine was significantly associated with lower rehospitalization risk compared with risperidone. The risk of rehospitalization in patients on olanzapine and amisulpride, and oral FGA, was similar to that of patients in use of clozapine. These results however, are limited by the heterogeneity of illness severity across the groups.
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Affiliation(s)
- Ana Paula Werneck
- Department and Institute of Psychiatry, University of Sao Paulo Medical School, Rua Dr. Ovidio Pires de Campos 785, Sao Paulo, 05403-010, Brazil.
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Abstract
The great majority of randomised controlled trials (RCTs) that compare antiepileptic drugs are industry sponsored and have the objective of obtaining a monotherapy license for a drug. Such trials do not inform everyday clinical practice as they tend to be too short and to depart from clinical practice by restricting clinicians in their choice of actions. The data that exists provides evidence that drugs with actions on voltage-gated sodium channels provide best seizure control for localised onset seizures and epilepsy syndromes, while valproate provides best seizure control for generalised epilepsy and unclassified syndromes. Drugs do, however, vary in their tolerability over the short term and in their risk for rare serious idiosyncratic adverse events, chronic toxicity and teratogenicity; issues that cannot be examined within the scope of RCTs.
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Cook WL, Khan KM, Bech MH, Brasher PM, Brown RA, Bryan S, Donaldson MG, Guy P, Hanson HM, Leia C, Macri EM, Sims-Gould J, McKay HA, Ashe MC. Post-discharge management following hip fracture--get you back to B4: a parallel group, randomized controlled trial study protocol. BMC Geriatr 2011; 11:30. [PMID: 21651819 PMCID: PMC3132160 DOI: 10.1186/1471-2318-11-30] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 06/09/2011] [Indexed: 11/10/2022] Open
Abstract
Background Fall-related hip fractures result in significant personal and societal consequences; importantly, up to half of older adults with hip fracture never regain their previous level of mobility. Strategies of follow-up care for older adults after fracture have improved investigation for osteoporosis; but managing bone health alone is not enough. Prevention of fractures requires management of both bone health and falls risk factors (including the contributing role of cognition, balance and continence) to improve outcomes. Methods/Design This is a parallel group, pragmatic randomized controlled trial to test the effectiveness of a post-fracture clinic compared with usual care on mobility for older adults following their hospitalization for hip fracture. Participants randomized to the intervention will attend a fracture follow-up clinic where a geriatrician and physiotherapist will assess and manage their mobility and other health issues. Depending on needs identified at the clinical assessment, participants may receive individualized and group-based outpatient physiotherapy, and a home exercise program. Our primary objective is to assess the effectiveness of a novel post-discharge fracture management strategy on the mobility of older adults after hip fracture. We will enrol 130 older adults (65 years+) who have sustained a hip fracture in the previous three months, and were admitted to hospital from home and are expected to be discharged home. We will exclude older adults who prior to the fracture were: unable to walk 10 meters; diagnosed with dementia and/or significant comorbidities that would preclude their participation in the clinical service. Eligible participants will be randomly assigned to the Intervention or Usual Care groups by remote allocation. Treatment allocation will be concealed; investigators, measurement team and primary data analysts will be blinded to group allocation. Our primary outcome is mobility, operationalized as the Short Physical Performance Battery at 12 months. Secondary outcomes include frailty, rehospitalizations, falls risk factors, quality of life, as well as physical activity and sedentary behaviour. We will conduct an economic evaluation to determine health related costs in the first year, and a process evaluation to ascertain the acceptance of the program by older adults, as well as clinicians and staff within the clinic. Trial registration number ClinicalTrials.gov: NCT01254942
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Affiliation(s)
- Wendy L Cook
- Centre for Hip Health and Mobility, Vancouver, Canada
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Do findings from new trials for schizophrenia fit with existing evidence: not duped … just beguiled? ACTA ACUST UNITED AC 2011. [DOI: 10.1017/s1121189x00002281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractNo treatment has caused a greater revolution in the treatment of people with schizophrenia than chlorpromazine. The new generation of drugs has been embraced by psychiatry with an enthusiasm fostered by the unmet needs of both patients and industry. Recent, independently funded trials have highlighted already existing data illustrating how the new antipsychotics drugs are an additional advance but not a revolution. In this story there are lessons for psychiatry to opt for science rather than seduction.
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Kisely SR, Campbell LA, Preston NJ. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2011:CD004408. [PMID: 21328267 PMCID: PMC4164937 DOI: 10.1002/14651858.cd004408.pub3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation. OBJECTIVES To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness. SEARCH STRATEGY We undertook searches of the Cochrane Schizophrenia Group Register 2003, 2008, and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study. SELECTION CRITERIA All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness. DATA COLLECTION AND ANALYSIS We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H). MAIN RESULTS We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8). In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review. AUTHORS' CONCLUSIONS Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.
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Affiliation(s)
- Steve R Kisely
- School of Population Health, The University of Queensland, Brisbane, Australia
| | | | - Neil J Preston
- Mental Health Directorate, Fremantle Hospital and Health Service, Fremantle, Australia
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Patterson S, Kramo K, Soteriou T, Crawford MJ. The great divide: A qualitative investigation of factors influencing researcher access to potential randomised controlled trial participants in mental health settings. J Ment Health 2010; 19:532-41. [DOI: 10.3109/09638237.2010.520367] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVE Response to specific depression treatments varies widely among individuals. Understanding and predicting that variation could have great benefits for people living with depression. METHOD The authors describe a conceptual model for identifying and evaluating evidence relevant to personalizing treatment for depression. They review evidence related to three specific treatment decisions: choice between antidepressant medication and psychotherapy, selection of a specific antidepressant medication, and selection of a specific psychotherapy. They then discuss potential explanations for negative findings as well as implications for research and clinical practice. RESULTS Many previous studies have examined general predictors of outcome, but few have examined true moderators (predictors of differential response to alternative treatments). The limited evidence indicates that some specific clinical characteristics may inform the choice between antidepressant medication and psychotherapy and the choice of specific antidepressant medication. Research to date does not identify any biologic or genetic predictors of sufficient clinical utility to inform the choice between medication and psychotherapy, the selection of specific medication, or the selection of a specific psychotherapy. CONCLUSIONS While individuals vary widely in response to specific depression treatments, the variability remains largely unpredictable. Future research should focus on identifying true moderator effects and should consider how response to treatments varies across episodes. At this time, our inability to match patients with treatments implies that systematic follow-up assessment and adjustment of treatment are more important than initial treatment selection.
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Affiliation(s)
| | - Roy H. Perlis
- Laboratory of Psychiatric Pharmacogenomics, Massachusetts General Hospital, Boston, MA
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Danaher BG, Seeley JR. Methodological issues in research on web-based behavioral interventions. Ann Behav Med 2010; 38:28-39. [PMID: 19806416 DOI: 10.1007/s12160-009-9129-0] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Web-based behavioral intervention research is rapidly growing. PURPOSE We review methodological issues shared across Web-based intervention research to help inform future research in this area. METHODS We examine measures and their interpretation using exemplar studies and our research. RESULTS We report on research designs used to evaluate Web-based interventions and recommend newer, blended designs. We review and critique methodological issues associated with recruitment, engagement, and social validity. CONCLUSIONS We suggest that there is value to viewing this burgeoning realm of research from the broader context of behavior change research. We conclude that many studies use blended research designs, that innovative mantling designs such as the Multiphase Optimization Strategy and Sequential Multiple Assignment Randomized Trial methods hold considerable promise and should be used more widely, and that Web-based controls should be used instead of usual care or no-treatment controls in public health research. We recommend topics for future research that address participant recruitment, engagement, and social validity.
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Affiliation(s)
- Brian G Danaher
- Oregon Research Institute, 1715 Franklin Boulevard, Eugene, OR 97403, USA.
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Catts SV, O'Toole BI, Carr VJ, Lewin T, Neil A, Harris MG, Frost ADJ, Crissman BR, Eadie K, Evans RW. Appraising evidence for intervention effectiveness in early psychosis: conceptual framework and review of evaluation approaches. Aust N Z J Psychiatry 2010; 44:195-219. [PMID: 20180724 DOI: 10.3109/00048670903487167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The literature that is relevant to evaluation of treatment effectiveness is large, scattered and difficult to assemble for appraisal. This scoping review first develops a conceptual framework to help organize the field, and second, uses the framework to appraise early psychosis intervention (EPI) studies. Literature searches were used to identify representative study designs, which were then sorted according to evaluation approach. The groupings provided a conceptual framework upon which a map of the field could be drawn. Key words were cross-checked against definitions in dictionaries of scientific terms and the National Library of Medicine Medical Subject Headings (MeSH) browser. Using the final list of key words as search terms, the EPI evaluation literature was appraised. Experimental studies could be grouped into two classes: efficacy and effectiveness randomized controlled trials. Non-experimental studies could be subgrouped into at least four overlapping categories: clinical epidemiological; health service evaluations; quality assurance studies; and, quasi-experimental assessments of treatment effects. Applying this framework to appraise EPI studies indicated promising evidence for the effectiveness of EPI irrespective of study design type, and a clearer picture of where future evaluation efforts should be focused. Reliance on clinical trials alone will restrict the type of information that can inform clinical practice. There is convergent evidence for the benefits of specialized EPI service functions across a range of study designs. Greater investment in health services research and quality assurance approaches in evaluating EPI effectiveness should be made, which will involve scaling up of study sizes and development of an EPI programme fidelity rating template. The degree of complexity of the evaluation field suggests that greater focus on research methodology in the training of Australasian psychiatrists is urgently needed.
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Affiliation(s)
- Stanley V Catts
- School of Medicine, University of Queensland, K Floor, Mental Health Centre, Royal Brisbane and Women's Hospital, Herston, Qld 4029, Australia.
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Srihari VH, Breitborde NJK, Pollard J, Tek C, Hyman L, Frisman LK, McGlashan TH, Jacobs S, Woods SW. Public-academic partnerships: early intervention for psychotic disorders in a community mental health center. Psychiatr Serv 2009; 60:1426-8. [PMID: 19880454 PMCID: PMC4469899 DOI: 10.1176/appi.ps.60.11.1426] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early intervention may improve long-term outcomes for psychotic illnesses. Early-intervention services in other countries have focused on reducing the duration of untreated illness and adapting interventions for younger patients. This column describes the process of building such a service, called specialized treatment early in psychosis (STEP), at the Connecticut Mental Health Center. This effort is rooted in a long-standing collaborative relationship between the Connecticut Department of Mental Health and Addiction Services and Yale. The authors describe the critical contribution of such partnerships in evaluating the cost-effectiveness of early intervention in a "real-world" U.S. setting.
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Affiliation(s)
- Vinod H Srihari
- Connecticut Mental Health Center, Yale University School of Medicine, New Haven, CT 06519, USA.
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Sirtori V, Corbetta D, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in stroke patients. Cochrane Database Syst Rev 2009:CD004433. [PMID: 19821326 DOI: 10.1002/14651858.cd004433.pub2] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND In stroke patients, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitation programmes for hemiparetic patients. Constraint-induced movement therapy (CIMT) is a current approach to stroke rehabilitation that implies the forced use and the massed practice of the affected arm by restraining the unaffected arm. OBJECTIVES To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in hemiparetic patients. SEARCH STRATEGY We searched the Cochrane Stroke Group trials register (last searched June 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2008), MEDLINE (1966 to June 2008), EMBASE (1980 to June 2008), CINAHL (1982 to June 2008), and the Physiotherapy Evidence Database (PEDro) (June 2008). SELECTION CRITERIA Randomised control trials (RCTs) and quasi-RCTs (qRCTs) comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none. DATA COLLECTION AND ANALYSIS Two review authors independently classified the identified trials according to the inclusion and exclusion criteria, assessed methodological quality and extracted data. The primary outcome was disability. MAIN RESULTS We included 19 studies involving 619 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little if at all. Only five studies had adequate allocation concealment. The majority of studies were underpowered (median number of included patients was 15) and we cannot rule out small-trial bias. Six trials (184 patients) assessed disability immediately after the intervention, indicating a significant standard mean difference (SMD) of 0.36, 95% confidence interval (CI) 0.06 to 0.65. For the most frequently reported outcome, arm motor function (11 studies involving 373 patients), the SMD was 0.72 (95% CI 0.32 to 1.12). There were only two studies that explored disability improvement after a few months of follow up and found no significant difference, SMD -0.07 (95% CI -0.53 to 0.40). AUTHORS' CONCLUSIONS CIMT is a multifaceted intervention: the restriction to the normal limb is accompanied by a certain amount of exercise of the appropriate quality. It is associated with a moderate reduction in disability assessed at the end of the treatment period. However, for disability measured some months after the end of treatment, there was no evidence of persisting benefit. Further randomised trials, with larger sample sizes and longer follow up, are justified.
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Affiliation(s)
- Valeria Sirtori
- Unita Operativa di Recupero e Rieducazione Funzionale, Fondazione Centro San Raffaele del Monte Tabor, via Olgettina, 58, Milan, Lombardia, Italy, 20132
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Cooley K, Szczurko O, Perri D, Mills EJ, Bernhardt B, Zhou Q, Seely D. Naturopathic care for anxiety: a randomized controlled trial ISRCTN78958974. PLoS One 2009; 4:e6628. [PMID: 19718255 PMCID: PMC2729375 DOI: 10.1371/journal.pone.0006628] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 05/10/2009] [Indexed: 01/09/2023] Open
Abstract
Background Anxiety is a serious personal health condition and represents a substantial burden to overall quality of life. Additionally anxiety disorders represent a significant cost to the health care system as well as employers through benefits coverage and days missed due to incapacity. This study sought to explore the effectiveness of naturopathic care on anxiety symptoms using a randomized trial. Methods Employees with moderate to severe anxiety of longer than 6 weeks duration were randomized based on age and gender to receive naturopathic care (NC) (n = 41) or standardized psychotherapy intervention (PT) (n = 40) over a period of 12 weeks. Blinding of investigators and participants during randomization and allocation was maintained. Participants in the NC group received dietary counseling, deep breathing relaxation techniques, a standard multi-vitamin, and the herbal medicine, ashwagandha (Withania somnifera) (300 mg b.i.d. standardized to 1.5% withanolides, prepared from root). The PT intervention received psychotherapy, and matched deep breathing relaxation techniques, and placebo. The primary outcome measure was the Beck Anxiety Inventory (BAI) and secondary outcome measures included the Short Form 36 (SF-36), Fatigue Symptom Inventory (FSI), and Measure Yourself Medical Outcomes Profile (MY-MOP) to measure anxiety, mental health, and quality of life respectively. Participants were blinded to the placebo-controlled intervention. Results Seventy-five participants (93%) were followed for 8 or more weeks on the trial. Final BAI scores decreased by 56.5% (p<0.0001) in the NC group and 30.5% (p<0.0001) in the PT group. BAI group scores were significantly decreased in the NC group compared to PT group (p = 0.003). Significant differences between groups were also observed in mental health, concentration, fatigue, social functioning, vitality, and overall quality of life with the NC group exhibiting greater clinical benefit. No serious adverse reactions were observed in either group. Relevance Many patients seek alternatives and/or complementary care to conventional anxiety treatments. To date, no study has evaluated the potential of a naturopathic treatment protocol to effectively treat anxiety. Knowledge of the efficacy, safety or risk of natural health products, and naturopathic treatments is important for physicians and the public in order to make informed decisions. Interpretation Both NC and PT led to significant improvements in patients' anxiety. Group comparison demonstrated a significant decrease in anxiety levels in the NC group over the PT group. Significant improvements in secondary quality of life measures were also observed in the NC group as compared to PT. The whole system of naturopathic care for anxiety needs to be investigated further including a closer examination of the individual components within the context of their additive effect. Trial Registration Controlled-Trials.com ISRCTN78958974
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Affiliation(s)
- Kieran Cooley
- Department of Research and Clinical Epidemiology, The Canadian College of Naturopathic Medicine, Toronto, Canada.
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Treweek S, Zwarenstein M. Making trials matter: pragmatic and explanatory trials and the problem of applicability. Trials 2009; 10:37. [PMID: 19493350 PMCID: PMC2700087 DOI: 10.1186/1745-6215-10-37] [Citation(s) in RCA: 299] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 06/03/2009] [Indexed: 12/20/2022] Open
Abstract
Randomised controlled trials are the best research design for decisions about the effect of different interventions but randomisation does not, of itself, promote the applicability of a trial's results to situations other than the precise one in which the trial was done. While methodologists and trialists have rightly paid great attention to internal validity, much less has been given to applicability. This narrative review is aimed at those planning to conduct trials, and those aiming to use the information in them. It is intended to help the former group make their trials more widely useful and to help the latter group make more informed decisions about the wider use of existing trials. We review the differences between the design of most randomised trials (which have an explanatory attitude) and the design of trials more able to inform decision making (which have a pragmatic attitude) and discuss approaches used to assert applicability of trial results. If we want evidence from trials to be used in clinical practice and policy, trialists should make every effort to make their trial widely applicable, which means that more trials should be pragmatic in attitude.
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Affiliation(s)
- Shaun Treweek
- Division of Clinical and Population Sciences and Education, University of Dundee, Dundee, UK
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Merrick Zwarenstein
- Centre for Health Services Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Chen DT, Shepherd LL. When, why, and how to conduct research in child and adolescent psychiatry: practical and ethical considerations. Psychiatr Clin North Am 2009; 32:361-80. [PMID: 19486819 DOI: 10.1016/j.psc.2009.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Changes in the clinical research enterprise to involve practicing psychiatrists in gathering evidence in real-world settings are truly exciting. The CAPTN breaks important ground as a PBRN in psychiatry. The authors anticipate that more practical clinical trials will come. These changes challenge psychiatrists to reach an entirely new level of understanding and appreciation of the ethical and practical challenges of commingling clinical practice and research. It is time that all practicing psychiatrists prepare to meet these challenges.
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Affiliation(s)
- Donna T Chen
- Center for Biomedical Ethics and Humanities, University of Virginia School of Medicine, Box 800758, Hospital Drive, Barringer 5th Floor, Charlottesville, VA 22908, USA.
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Grossman I. ADME pharmacogenetics: current practices and future outlook. Expert Opin Drug Metab Toxicol 2009; 5:449-62. [DOI: 10.1517/17425250902902322] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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O'Brien AJ, McKenna BG, Kydd RR. Compulsory community mental health treatment: literature review. Int J Nurs Stud 2009; 46:1245-55. [PMID: 19296950 DOI: 10.1016/j.ijnurstu.2009.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 01/15/2009] [Accepted: 02/09/2009] [Indexed: 10/21/2022]
Abstract
Following their introduction in the United States in the 1970s various forms of compulsory treatment in the community have been introduced internationally. Compulsory treatment in the community involves a statutory framework that mandates enforceable treatment in a community setting. Such frameworks can be categorized as preventative, least restrictive, or as having both preventative and least restrictive features. Research falls into two categories; descriptive, naturalistic studies and controlled and uncontrolled comparative studies. The research has produced equivocal results, and presents numerous methodological challenges. Where programmes have demonstrated improved outcomes debate continues as to whether these outcomes are associated with legal compulsion or enhanced service provision. Service user, family and clinician perspectives demonstrate a divergence of views within and across groups, with clinicians more strongly in support than service users. The issue of compulsory community treatment is an important one for nurses, who are often at the forefront of clinical service provision, in some cases in statutory roles. Critical reflection on the issue of compulsory community treatment requires understanding of the limitations of empirical investigations and of the various ethical and social policy issues involved. There is a need for further research into compulsory community treatment and possible alternatives.
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Affiliation(s)
- Anthony J O'Brien
- School of Nursing, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Zwarenstein M, Treweek S, Gagnier JJ, Altman DG, Tunis S, Haynes B, Oxman AD, Moher D. Improving the reporting of pragmatic trials: an extension of the CONSORT statement. BMJ 2008; 337:a2390. [PMID: 19001484 PMCID: PMC3266844 DOI: 10.1136/bmj.a2390] [Citation(s) in RCA: 1172] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND The CONSORT statement is intended to improve reporting of randomised controlled trials and focuses on minimising the risk of bias (internal validity). The applicability of a trial's results (generalisability or external validity) is also important, particularly for pragmatic trials. A pragmatic trial (a term first used in 1967 by Schwartz and Lellouch) can be broadly defined as a randomised controlled trial whose purpose is to inform decisions about practice. This extension of the CONSORT statement is intended to improve the reporting of such trials and focuses on applicability. Methods At two, two-day meetings held in Toronto in 2005 and 2008, we reviewed the CONSORT statement and its extensions, the literature on pragmatic trials and applicability, and our experiences in conducting pragmatic trials. Recommendations We recommend extending eight CONSORT checklist items for reporting of pragmatic trials: the background, participants, interventions, outcomes, sample size, blinding, participant flow, and generalisability of the findings. These extensions are presented, along with illustrative examples of reporting, and an explanation of each extension. Adherence to these reporting criteria will make it easier for decision makers to judge how applicable the results of randomised controlled trials are to their own conditions. Empirical studies are needed to ascertain the usefulness and comprehensiveness of these CONSORT checklist item extensions. In the meantime we recommend that those who support, conduct, and report pragmatic trials should use this extension of the CONSORT statement to facilitate the use of trial results in decisions about health care.
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The effect of methylphenidate on auditory information processing in healthy volunteers: a combined EEG/MEG study. Psychopharmacology (Berl) 2008; 197:475-86. [PMID: 18264697 DOI: 10.1007/s00213-007-1065-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Accepted: 12/19/2007] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The psychomotor stimulant methylphenidate (MPH) has been shown to improve attentional processes, reflected in behavioural measures such as vigilance, reaction time and visual attention tasks. The neural mechanisms of MPH action on sensory information processing, however, remain poorly understood. To the authors' knowledge, this present study is the first to investigate whether a single dose of MPH affects neural substrates of passive attention in healthy adults studied with simultaneous whole-head magnetoencephalography (MEG) and electroencephalography (EEG). METHODS Monaural left-ear auditory stimuli were presented in an oddball paradigm with infrequent deviant tones differing in frequency and duration. Neuronal activity was recorded with simultaneous whole-head MEG and EEG in 13 healthy subjects (five females; aged 27 +/- 5 years) after oral administration of 40 mg MPH or placebo in a randomised, double-blind, cross-over design. We analysed both electric and magnetic N100, P200 and mismatch negativity (MMN) components. RESULTS MPH increased arousal levels in visual analogue scales. MPH had no effect on the dipole strength of MMN or MMNm in either frequency or duration deviations. MPH did, however, reduce P200 amplitudes in EEG. CONCLUSIONS The lack of effect of MPH on either MMN or MMNm suggests no association between catecholaminergic activities and MMN generation. However, our findings imply that MPH may change the neural bases of auditory information processing such as the early stimulus evaluation reflected in the P200 component. Dopamine and noradrenaline neurotransmitter systems could be responsible for the modulation of these processes. The exclusive effect of MPH on the P200 component could have a clinical application.
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