A research agenda to improve incidence and outcomes of assisted vaginal birth

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

System-on-chip upgrade of millimeter-wave imaging diagnostics for fusion plasma

Monolithic, millimeter wave "system-on-chip" technology has been employed in chip heterodyne radiometers in a newly developed Electron Cyclotron Emission Imaging (ECEI) system on the DIII-D tokamak for 2D electron temperature and fluctuation diagnostics. The system employs 20 horn-waveguide receiver modules each with customized W-band (75-110 GHz) monolithic microwave integrated circuit chips comprising a W-band low noise amplifier, a balanced mixer, a ×2 local oscillator (LO) frequency doubler, and two intermediate frequency amplifier stages in each module. Compared to previous quasi-optical ECEI arrays with Schottky mixer diodes mounted on planar antennas, the upgraded W-band array exhibits >30 dB additional gain and 20× improvement in noise temperature; an internal eight times multiplier chain is used to provide LO coupling, thereby eliminating the need for quasi-optical coupling. The horn-waveguide shielding housing avoids out-of-band noise interference on each module. The upgraded ECEI system plays an important role for absolute electron temperature and fluctuation measurements for edge and core region transport physics studies. An F-band receiver chip (up to 140 GHz) is under development for additional fusion facilities with a higher toroidal magnetic field. Visualization diagnostics provide multi-scale and multi-dimensional data in plasma profile evolution. A significant aspect of imaging measurement is focusing on artificial intelligence for science applications.

Learning before leaping: integration of an adaptive study design process prior to initiation of BetterBirth, a large-scale randomized controlled trial in Uttar Pradesh, India

Background

Pragmatic and adaptive trial designs are increasingly used in quality improvement (QI) interventions to provide the strongest evidence for effective implementation and impact prior to broader scale-up. We previously showed that an on-site coaching intervention focused on the World Health Organization Safe Childbirth Checklist (SCC) improved performance of essential birth practices (EBPs) in one facility in Karnataka, India. We report on the process and outcomes of adapting the intervention prior to larger-scale implementation in a randomized controlled trial in Uttar Pradesh (UP), India.

Methods

Initially, we trained a local team of physicians and nurses to coach birth attendants in SCC use at two public facilities for 4–6 weeks. Trained observers evaluated adherence to EBPs before and after coaching. Using mixed methods and a systematic adaptation process, we modified and strengthened the intervention. The modified intervention was implemented in three additional facilities. Pre/post-change in EBP prevalence aggregated across facilities was analyzed.

Results

In the first two facilities, limited improvement was seen in EBPs with the exception of post-partum oxytocin. Checklists were used <25 % of observations. We identified challenges in physicians coaching nurses, need to engage district and facility leadership to address system gaps, and inadequate strategy for motivating SCC uptake. Revisions included change to peer-to-peer coaching (nurse to nurse, physician to physician); strengthened coach training on behavior and system change; adapted strategy for effective leadership engagement; and an explicit motivation strategy to enhance professional pride and effectiveness. These modifications resulted in improvement in multiple EBPs from baseline including taking maternal blood pressure (0 to 16 %), post-partum oxytocin (36 to 97 %), early breastfeeding initiation (3 to 64 %), as well as checklist use (range 32 to 88 %), all p < 0.01. Further adaptations were implemented to increase the effectiveness prior to full trial launch.

Conclusions

The adaptive study design of implementation, evaluation, and feedback drove iterative redesign and successfully developed a SCC-focused coaching intervention that improved EBPs in UP facilities. This work was critical to develop a replicable BetterBirth package tailored to the local context. The multi-center pragmatic trial is underway measuring impact of the BetterBirth program on EBP and maternal-neonatal morbidity and mortality.

Trial registration

Clinical trials identifier: NCT02148952.

Waiting list may be a nocebo condition in psychotherapy trials: a contribution from network meta-analysis

OBJECTIVE

Various control conditions have been employed in psychotherapy trials, but there is growing suspicion that they may lead to different effect size estimates. The present study aims to examine the differences among control conditions including waiting list (WL), no treatment (NT) and psychological placebo (PP).

METHOD

We comprehensively searched for all randomized controlled trials (RCTs) comparing cognitive-behaviour therapies (CBT) against various control conditions in the acute phase treatment of depression, and applied network meta-analysis (NMA) to combine all direct and indirect comparisons among the treatment and control arms.

RESULTS

We identified 49 RCTs (2730 participants) comparing WL, NT, PP and CBT. This network of evidence was consistent, and the effect size estimates for CBT were substantively different depending on the control condition. The odds ratio of response for NT over WL was statistically significant at 2.9 (95% CI: 1.3-5.7). However, the quality of evidence, including publication bias, was less than ideal and none of the preplanned sensitivity analyses limiting to high-quality studies could be conducted, while findings of significant differences did not persist in post hoc sensitivity analyses trying to adjust for publication bias.

CONCLUSION

There may be important differences in control conditions currently used in psychotherapy trials.

Diagnosing and managing anorexia nervosa in UK primary care: a focus group study

BACKGROUND

Anorexia is a leading cause of adolescent hospital admission and death from psychiatric disorder. Despite the potential role of general practitioners in diagnosis, appropriate referral and coordinating treatment, few existing studies provide fine-grained accounts of GPs' beliefs about anorexia.

OBJECTIVES

To identify GPs' understandings and experiences of diagnosing and managing patients with anorexia in primary care.

METHODS

Case-based focus groups with co-working general practitioners in the East Midlands region of England were used to explore attitudes towards issues common to patients with eating disorders. Group discussions were transcribed and analysed using corpus linguistic and discourse analytic approaches.

RESULTS

Participants' discussion focused on related issues of making hesitant diagnoses, the utility of the body mass index, making referrals and overcoming patient resistance. Therapeutic relationships with patients with anorexia are considered highly complex, with participants using diagnostic tests as rhetorical strategies to help manage communicative obstacles.

CONCLUSIONS

Overcoming patient repudiation and securing referrals are particular challenges with this patient group. Successfully negotiating these problems appears to require advanced communication skills.

Efficacy, tolerability and side-effect profile of fluvoxamine for major depression: meta-analysis

Fluvoxamine, one of the oldest selective serotonin reuptaking inhibitors, is commonly prescribed to patients with major depression. Several studies have reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are outdated, have not been systematic and/or suffered from several methodological weaknesses. We conducted a systematic review to synthesize the best available evidence on the efficacy of fluvoxamine for adult patients suffering from major depression in comparison with other active antidepressive agents. Relevant randomized controlled trials were identified through a comprehensive search. The primary outcome was a relative risk of response, and the secondary outcome was a relative risk of remission. Tolerability and side-effect profile were also examined. Fifty-three trials were included. There were no large differences between fluvoxamine and any other antidepressants in terms of efficacy and tolerability. There is evidence of differing side effect profiles, especially when comparing gastrointestinal side effects between fluvoxamine and tricyclics. Clinicians should focus on practically or clinically relevant differences including those in side-effect profiles.

Psychotherapy for depression among children and adolescents: a systematic review

OBJECTIVE

To examine the clinical benefit, the harm and the cost-effectiveness of psychotherapies in comparison with no treatment, waiting-list controls, attention-placebos, and treatment as usual in depressed youths.

METHOD

Meta-analyses were undertaken by using data from all relevant randomized-controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response.

RESULTS

We identified 27 studies containing 35 comparisons and 1,744 participants. At post-treatment, psychotherapy was significantly superior (RR = 1.39, 95% CI 1.18-1.65, P = 0.0001, number-needed to treat 4.3). There was an evidence of the existence of small study effects, including a publication bias (P < 0.001). The superiority of psychotherapy was no longer statistically significant (1.18 [0.94-1.47], P = 0.15) at 6-month follow-up. None of the studies reported adverse effects or cost-effectiveness outcomes.

CONCLUSION

Although the findings were biased by some small positive trials, psychotherapies appear to help depressed youths for the short term, but are no longer significantly favourable at 6-month follow-up.

WITHDRAWN: Treatment discontinuation with selective serotonin reuptake inhibitors (SSRIs) versus tricyclic antidepressants (TCAs)

BACKGROUND

Selective serotonin reuptake inhibitors are thought to have better discontinuation rates (i.e. less people dropping out) than tricyclic and heterocyclic antidepressant drugs. It is important to quantify the drop-out rates of different antidepressant drugs in order to have a better understanding of the relative tolerability of these drugs.

OBJECTIVES

To assess the comparative tolerability of selective serotonin reuptake inhibitors and tricyclic/heterocyclic antidepressant drugs.

SEARCH STRATEGY

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (1997 to 1999), MEDLINE (1966 to 1999), EMBASE (1974 to 1999) We also searched specialist journals, the reference lists of relevant papers and previous systematic reviews, conference abstracts and government documents. Representatives of the pharmaceutical industry were contacted.

SELECTION CRITERIA

Parallel group randomised controlled trials comparing selective serotonin reuptake inhibitors with tricyclic or heterocyclic antidepressants in people with depression.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and a third reviewer checked any cases of disagreement.

MAIN RESULTS

We included 136 trials. The selective serotonin reuptake inhibitors showed less participants dropping out compared to the tricyclic/heterocyclic group (odds ratio 1.21, 95% confidence interval 1.12 to 1.30). A statistically significant difference was found in total drop-outs between the selective serotonin reuptake inhibitors and the old tricyclics as well as the newer tricyclics. When the selective serotonin reuptake inhibitors were compared to the heterocyclic antidepressants, there was a non significant difference favouring the selective serotonin reuptake inhibitors. The poor tolerability profile of the old tricyclics was explained by differences in drop-outs for side-effects, but not for inefficacy.

AUTHORS' CONCLUSIONS

Whilst selective serotonin reuptake inhibitors do appear to show an advantage over tricyclic drugs in terms of total drop-outs, this advantage is relatively modest. This has implications for pharmaco-economic models, some of which may have overestimated the difference of drop-out rates between selective serotonin reuptake inhibitors and tricyclic antidepressants. These results are based on short-term randomised controlled trials, and may not generalise into clinical practice.

Family therapy for depression

BACKGROUND

People with depression often experience interpersonal problems. Family therapy for depression is a widely used intervention, but it is unclear whether this is an effective therapy for the treatment of depression.

OBJECTIVES

To assess the efficacy of family therapy for depression.

SEARCH STRATEGY

The following electronic databases were searched using a specific search strategy: CCDANCTR-Studies and CCDANCTR-References searched on 21/10/2005, The Cochrane Central Register of Controlled Trials, Medline (1966 to January 2005), EMBASE (1980 to January 2005), Psycinfo (1974 to January 2005). Reference lists of articles were also searched. Handsearches of relevant journals and bibliographies were conducted and first authors of included studies and experts in the field were contacted for further information.

SELECTION CRITERIA

Included studies were randomised controlled and controlled clinical trials comparing family therapy with no intervention or an alternative intervention in which depression symptomatology was a main outcome measure.

DATA COLLECTION AND ANALYSIS

Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of the selected trials were independently extracted by three review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. It was not possible to perform meta-analyses because of the heterogeneity of the selected studies.

MAIN RESULTS

Three high-quality and three low-quality studies, involving 519 people with depression, were identified. The studies were very heterogeneous in terms of interventions, participants, and measuring instruments. Despite fairly good methodological quality and positive findings of some studies, evidence for the effectiveness of family therapy for depression did not exceed level 3 (limited or conflicting evidence), except for moderate evidence (level 2), based on the non-combined findings from three studies, indicating that family therapy is more effective than no treatment or waiting list condition on decreasing depression, and on increasing family functioning.

AUTHORS' CONCLUSIONS

The current evidence base is too heterogeneous and sparse to draw conclusions on the overall effectiveness of family therapy in the treatment of depression. At this point, use of psychological interventions for the treatment of depression for which there is already an evidence-base would seem to be preferable to family therapy. Further high quality trials examining the effectiveness and comparative effectiveness of explicitly defined forms of family therapy are required.

Anterior cingulate volumes in schizophrenia: a systematic review and a meta-analysis of MRI studies

OBJECTIVES

Several MRI studies have investigated the anterior cingulate in schizophrenia, as this is a key region for emotional processing and higher executive performances. A systematic review of structural MRI studies and a meta-analysis were conducted to explore whether anterior cingulate volumes are abnormal in patients with schizophrenia.

METHOD

A systematic search strategy was used to identify eligible MRI studies. Thereafter, a meta-analysis was carried out by using a random effect model. Also, a meta-regression analysis was used to assess the influence of age, gender and slice thickness on effect sizes.

RESULTS

The meta-analysis was performed on seven studies. These results showed that the anterior cingulate volumes were significantly reduced in patients compared to healthy controls. Significant heterogeneity between these studies was observed. The meta-regression demonstrated that the effect size was significantly related only to slice thickness.

CONCLUSIONS

Our work confirmed the presence of abnormally reduced anterior cingulate volumes in schizophrenia. However, several methodological issues limited the interpretation of these findings. Among these were different MR acquisition parameters and the small size of the sample, which was mostly composed of chronic patients. Future MRI studies should be planned to better understand the functional expression of anterior cingulate structural abnormalities.

Psychological treatments versus treatment as usual for obsessive compulsive disorder (OCD)

BACKGROUND

Obsessive compulsive disorder (OCD) is a chronic anxiety disorder associated with significant morbidity, social impairment and lower quality of life. Psychological treatments are a frequently used approach for OCD.

OBJECTIVES

To perform a systematic review of randomised trials of psychological treatments for obsessive compulsive disorder in comparison with treatment as usual.

SEARCH STRATEGY

We conducted an electronic search of CCDANCTR-Studies (31/10/2006), and other databases. We searched reference lists, and contacted experts in the field.

SELECTION CRITERIA

Published and unpublished randomised trials of psychological treatments versus treatment as usual for adults with a diagnosis of OCD DATA COLLECTION AND ANALYSIS: Two review authors worked independently throughout the selection of trials and data extraction. Findings were compared and disagreements were discussed with a third review author. Full data extraction, using a standardised data extraction sheet, was performed on all studies included in the review. Results were synthesised using Review Manager software. For dichotomous data, odds ratios were calculated. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated. Fixed and random effects models were used to pool the data. Reasons for heterogeneity in studies were explored and sensitivity analyses were performed by excluding trials of lower quality.

MAIN RESULTS

Eight studies (11 study comparisons) were identified, all of which compared cognitive and/or behavioural treatments versus treatment as usual control groups. Seven studies (ten comparisons) had usable data for meta-analyses. These studies demonstrated that patients receiving any variant of cognitive behavioural treatment exhibited significantly fewer symptoms post-treatment than those receiving treatment as usual (SMD -1.24, 95% CI -1.61 to -0.87, I(2) test for heterogeneity 33.4%). Different types of cognitive and/or behavioural treatments showed similar differences in effect when compared with treatment as usual. The overall treatment effect appeared to be influenced by differences in baseline severity.

AUTHORS' CONCLUSIONS

The findings of this review suggest that psychological treatments derived from cognitive behavioural models are an effective treatment for adult patients with obsessive compulsive disorder. Larger high quality randomised controlled trials involving longer follow up periods are needed, to further test cognitive behavioural treatments, and other psychological approaches, in comparison to each other and control conditions. Future trials should examine the predictors of response to each treatment, and also conduct cost-effectiveness evaluations.

Psychological therapies for generalised anxiety disorder

BACKGROUND

Generalised anxiety disorder (GAD) is a highly prevalent condition, characterised by excessive worry or anxiety about everyday events and problems. The effectiveness and effectiveness of psychological therapies as a group has not yet been evaluated in the treatment of GAD.

OBJECTIVES

To examine the efficacy and acceptability of psychological therapies, categorised as cognitive behavioural therapy (CBT), psychodynamic therapy and supportive therapy, compared with treatment as usual/waiting list (TAU/WL) and compared with one another, for patients with GAD.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, LILACS and controlledtrials.com in February 2006. We searched reference lists of retrieved articles, and contacted trial authors and experts in the field for information on ongoing/completed trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials conducted in non-inpatient settings, involving adults aged 18-75 years with a primary diagnosis of GAD, assigned to a psychological therapy condition compared with TAU/WL or another psychological therapy.

DATA COLLECTION AND ANALYSIS

Data on patients, interventions and outcomes were extracted by two review authors independently, and the methodological quality of each study was assessed. The primary outcome was anxiety reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of symptom reduction, using the standardised mean difference (SMD), with 95% confidence intervals.

MAIN RESULTS

Twenty five studies (1305 participants) were included in the review, of which 22 studies (1060 participants) contributed data to meta-analyses. Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at post-treatment (RR 0.63, 95%CI 0.55 to 0.73), and also in reducing anxiety, worry and depression symptoms. No studies conducted longer-term assessments of CBT against TAU/WL. Six studies compared CBT against supportive therapy (non-directive therapy and attention-placebo conditions). No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR 0.86, 95%CI 0.70 to 1.06), however significant heterogeneity was indicated, which was partly explained by the number of therapy sessions.

AUTHORS' CONCLUSIONS

Psychological therapy based on CBT principles is effective in reducing anxiety symptoms for short-term treatment of GAD. The body of evidence comparing CBT with other psychological therapies is small and heterogeneous, which precludes drawing conclusions about which psychological therapy is more effective. Further studies examining non-CBT models are required to inform health care policy on the most appropriate forms of psychological therapy in treating GAD.

Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia

BACKGROUND

Panic disorder can be treated with pharmacotherapy, psychotherapy or in combination, but the relative merits of combined therapy have not been well established.

OBJECTIVES

To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia, in comparison with either therapy alone.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 11/10/2005, together with a complementary search of the Cochrane Central Register of Controlled Trials and MEDLINE, using the keywords antidepressant and panic. A reference search, SciSearch and personal contact with experts were carried out.

SELECTION CRITERIA

Two independent review authors identified randomised controlled trials comparing the combined therapy against either of the monotherapies among adult patients with panic disorder with or without agoraphobia.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data using predefined data formats, including study quality indicators. The primary outcome was relative risk (RR) of "response" i.e. substantial overall improvement from baseline as defined by the original investigators. Secondary outcomes included standardised weighted mean differences in global severity, panic attack frequency, phobic avoidance, general anxiety, depression and social functioning and relative risks of overall dropouts and dropouts due to side effects.

MAIN RESULTS

We identified 23 randomised comparisons (representing 21 trials, 1709 patients), 21 of which involved behaviour or cognitive-behaviour therapies. In the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR 1.24, 95% confidence interval (CI) 1.02 to 1.52) or psychotherapy (RR 1.17, 95% CI 1.05 to 1.31). The combined therapy produced more dropouts due to side effects than psychotherapy (number needed to harm (NNH) around 26). After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. After termination of the acute phase and continuation treatment, the combined therapy was more effective than pharmacotherapy alone (RR 1.61, 95% CI 1.23 to 2.11) and was as effective as psychotherapy (RR 0.96, 95% CI 0.79 to 1.16).

AUTHORS' CONCLUSIONS

Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.

Psychotherapeutic interventions for adults with asthma

BACKGROUND

Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease.

OBJECTIVES

To assess the effectiveness of psychological interventions for adults with asthma.

SEARCH STRATEGY

The Cochrane Airways Group specialised register and PsycINFO were searched with pre-defined terms until September 2003.

SELECTION CRITERIA

Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a form of control in adult participants were included in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted.

MAIN RESULTS

Twelve studies were included in the review, however study quality was poor and sample sizes were frequently small. No meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. Findings between studies were conflicting. This may have been due to the different types of interventions used and the deficiencies in trial design.

REVIEWER'S CONCLUSIONS

This review was unable to draw firm conclusions for the role of psychological interventions in asthma due to the absence of an adequate evidence base. Large, well-conducted and reported randomised trials are required in this area, in order to determine the effects of these techniques in the treatment of asthma in adults.

Improving referrals for glue ear from primary care: are multiple interventions better than one alone?

OBJECTIVES

To evaluate the effect of a risk factor checklist and training video for general practitioners in reducing inter-practice variation and improving the appropriateness of referrals (assessed by their positive predictive value or PPV) of patients with suspected otitis media with effusion (OME or 'glue ear') to secondary care.

METHODS

Fifty general practices (177 practitioners) from the NHS Trent region and the West of Scotland were cluster-randomised either to a control group (n = 12) or to one of three intervention groups (training video (n = 16), checklist (n = 11), or both (n = 11)). Data on all paediatric ear, nose and throat (ENT) referrals and diagnostic results at ENT clinics were collected for a one-year period pre- and post-intervention. Referral rates for OME and for closely related conditions were calculated for children aged 0-15 years, based on each practice's list size. PPV was defined as the proportion of referrals resulting in bilateral hearing loss > or = 20 dB at the ENT outpatient department.

RESULTS

There was a significant improvement in the PPV, adjusted for patients' waiting time between general practitioner (GP) referral and being seen at the ENT department. The improvement in PPV pre- and post-intervention was 15% (95% confidence interval, CI: -12.1% to 41.7%) for the practices receiving both interventions, compared with a degradation of 20% pre- and post-intervention (95% CI: -32.9% to -6.4%) for practices receiving only one intervention and a degradation of 34% for those receiving no intervention.

CONCLUSIONS

Disseminating a risk factor checklist and training video on glue ear to GPs using a multi-channel approach can improve the quality of referrals to ENT.

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

OBJECTIVES

To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference.

DESIGN

Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes.

SETTING

31 general practices in Trent region.

PARTICIPANTS

Patients aged 18-70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms.

MAIN OUTCOME MEASURES

Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria.

RESULTS

At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval -2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist's overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse.

CONCLUSIONS

Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment.

Do the attitudes and beliefs of young teenagers towards general practice influence actual consultation behaviour?

BACKGROUND

Teenagers are believed to have health concerns that are not adequately addressed in primary care because of perceived barriers that inhibit them from consulting a general practitioner (GP). We report the results of a study examining links between potential attitudinal barriers and actual help-seeking behaviour.

AIM

To determine whether the attitudes of teenagers towards general practice are associated with differences in consultation patterns.

METHOD

Results of a postal questionnaire survey of attitudes to general practice, performed among teenage patients aged 13 to 15 years registered with five general practices in the East Midlands, were analysed in relation to consultation data from retrospective casenote analysis for the preceding 12 months.

RESULTS

Matched questionnaire and consultation data were available for 678 teenagers. We found few significant differences in overall consultation rates between teenagers expressing differing attitudes about aspects of general practice. Differences did exist in relation to perceived difficulty in getting an appointment, feeling able to confide in a GP, and perception of adequate time being given in the consultation. Fear of embarrassment was associated with lower consultation rates for gynaecological problems and contraception.

CONCLUSIONS

Negative perceptions of general practice by teenagers may have less of an influence on actual consultation behaviour than previously believed. However, there are some aspects of care that merit further attention if teenagers are to feel able to consult their GP more easily.

Treating depression in general practice: factors affecting patients' treatment preferences

We performed a cross-sectional survey of general practice attenders to determine their preferences regarding treatment for depression and characteristics associated with such preferences. Counselling was more popular than drug therapy (antidepressants), particularly among women, those who believed antidepressants are addictive, and those who had received such treatment in the past.

Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial

BACKGROUND

There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor.

AIMS

To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response.

METHOD

A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms.

RESULTS

There were 103 randomised and 220 preference patients in the trial. We found: no differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome.

CONCLUSIONS

These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting.

Changing patterns in the use of the Mental Health Act 1983 in England, 1984-1996

BACKGROUND

The Mental Health Act 1983 (MHA) is due to be revised by Parliament in the near future.

AIMS

To explore changes in the use of the Act since its introduction.

METHOD

The Department of Health and the Home Office routinely collect data on the numbers of patients admitted to psychiatric hospitals under the MHA. We present absolute figures, by year, for the total numbers admitted under each section of the Act. We used the total psychiatric hospital admissions and total prison populations as denominator data.

RESULTS

Formal admissions rose from 16,044 in 1984 to 26,308 in 1996, a 63% increase. Admissions under the MHA have increased as a proportion of all admissions. The increase is mainly accounted for by changes in the use of Part II of the Act, in particular sections 2 and 3. The use of forensic sections (Part III) has also increased, with a marked increase of sections 47 and 48. Use of Part X of the Act (sections 135 and 136) declined in the late 1980s but rose again in the 1990s.

CONCLUSIONS

Formal admissions are more common than they were in 1984, despite there being fewer psychiatric beds. This is probably due to changes in the provision of psychiatric services, and changing societal pressures on psychiatrists away from libertarianism and towards coercion.

Selective serotonin reuptake inhibitors versus tricyclic and heterocyclic antidepressants: comparison of drug adherence

BACKGROUND

Selective serotonin reuptake inhibitors are thought to have better discontinuation rates (i.e. less people dropping out) than tricyclic and heterocyclic antidepressant drugs. It is important to quantify the drop-out rates of different antidepressant drugs in order to have a better understanding of the relative tolerability of these drugs.

OBJECTIVES

To assess the comparative tolerability of selective serotonin reuptake inhibitors and tricyclic/heterocyclic antidepressant drugs.

SEARCH STRATEGY

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (1997 to 1999), MEDLINE (1966 to 1999), EMBASE (1974 to 1999) We also searched specialist journals, the reference lists of relevant papers and previous systematic reviews, conference abstracts and government documents. Representatives of the pharmaceutical industry were contacted.

SELECTION CRITERIA

Parallel group randomised controlled trials comparing selective serotonin reuptake inhibitors with tricyclic or heterocyclic antidepressants in people with depression.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and a third reviewer checked any cases of disagreement.

MAIN RESULTS

We included 136 trials. The selective serotonin reuptake inhibitors showed less participants dropping out compared to the tricyclic/heterocyclic group (odds ratio 1.21, 95% confidence interval 1.12 to 1.30). A statistically significant difference was found in total drop-outs between the selective serotonin reuptake inhibitors and the old tricyclics as well as the newer tricyclics. When the selective serotonin reuptake inhibitors were compared to the heterocyclic antidepressants, there was a non significant difference favouring the selective serotonin reuptake inhibitors. The poor tolerability profile of the old tricyclics was explained by differences in drop-outs for side-effects, but not for inefficacy.

REVIEWER'S CONCLUSIONS

Whilst selective serotonin reuptake inhibitors do appear to show an advantage over tricyclic drugs in terms of total drop-outs, this advantage is relatively modest. This has implications for pharmaco-economic models, some of which may have overestimated the difference of drop-out rates between selective serotonin reuptake inhibitors and tricyclic antdepressants. These results are based on short-term randomised controlled trials, and may not generalise into clinical practice.

Pragmatic randomised controlled trials in psychiatry

BACKGROUND

Randomised controlled trials (RCTs) are the most important method of evaluating new treatments and treatment policies. Despite this, there are relatively few large pragmatic RCTs in psychiatry.

AIMS

To explore the main advantages of large pragmatic RCTs and the obstacles to performing them in psychiatry.

METHOD

A narrative review of literature on pragmatic RCTs with examples drawn from psychiatry and other medical specialities.

RESULTS

Obstacles to performing pragmatic RCTs in psychiatry include the complexity of psychiatric interventions, the complexity of outcomes used in psychiatry and the difficulties of blinding subjects and investigators to some psychiatric interventions.

CONCLUSIONS

Researchers need to frame questions in a form that is relevant to clinicians and to convince clinicians to cooperate in simple large pragmatic trials.

Should general practitioners refer patients with major depression to counsellors? A review of current published evidence. Nottingham Counselling and Antidepressants in Primary Care (CAPC) Study Group

Major depression can be treated effectively with antidepressants. However, in the United Kingdom, patients with depression are often referred to counsellors, and surveys indicate that public opinion favours this approach. We carried out a literature review to determine the evidence for the effectiveness of counselling for depression in primary care. Because no studies were identified in which counselling had been evaluated specifically in relation to treating depression, we examined indirect evidence from studies evaluating the overall effectiveness of generic counselling in primary care, and studies evaluating the effectiveness of psychological treatments, other than counselling, for depression. Methodological problems influencing the interpretation of such studies are discussed. We conclude that, while specific psychological treatments have been shown to have equivalent effectiveness as antidepressants, there is currently insufficient evidence to recommend that generic counselling should be used alone in the treatment of patients with major depression.

Strategies for the prevention of psychiatric disorder in primary care in south London

STUDY OBJECTIVE

To compare the potential impact of high risk and population based approaches to the prevention of psychiatric disorder, using a representative sample of general practice attenders as the target population.

DESIGN

This was a prospective cohort study.

SETTING

A health centre in south London.

PARTICIPANTS

Three hundred and seven consecutive attenders aged 16-65, recruited at randomly selected general practice surgeries.

MAIN RESULTS

A linear association was found between the number of different types of socioeconomic adversity reported at recruitment (T1) and the prevalence of psychiatric disorder one year later (T2). The population attributable fraction (PAF) for socioeconomic adversity at T1 was 37.4%. In theory, social interventions for high risk individuals at T1 would reduce the prevalence of psychiatric disorder at T2 by 9% at most, compared with a reduction of 18% if just one item of socioeconomic adversity were eliminated among those with any socioeconomic risk factors.

CONCLUSIONS

Social interventions targeted at individuals at highest risk of the most common mental disorders are likely to be extremely limited in their capacity to reduce the prevalence of these conditions. A population based risk reduction strategy, modified according to individual risk, represents a potentially feasible and effective alternative.