Archive for the ‘help a drug user’ Category
Sunday, March 21st, 2010 |
Assertive community treatment for people with severe mental disorders, Marshall M, Lockwood A. Assertive community treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews 1998, Issue 2. Art. No.: CD001089
Click on the title above to access the full-text of this Cochrane Reviews
Abstract:
Background
Assertive Community Treatment (ACT) was developed in the early 1970s as a response to the closing down of psychiatric hospitals. ACT is a team-based approach aiming at keeping ill people in contact with services, reducing hospital admissions and improving outcome, especially social functioning and quality of life.
Objectives
To determine the effectiveness of Assertive Community Treatment (ACT) as an alternative to i. standard community care, ii. traditional hospital-based rehabilitation, and iii. case management. For each of the three comparisons the main outcome indices were i. remaining in contact with the psychiatric services, ii. extent of psychiatric hospital admissions, iii. clinical and social outcome and iv. costs.
Search strategy
Electronic searches of CINAHL (1982-1997), the Cochrane Schizophrenia Group’s Register of trials (1997), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations.
Selection criteria
The inclusion criteria were that studies should i. be randomised controlled trials, ii. have compared ACT to standard community care, hospital-based rehabilitation, or case management and iii. have been carried out on people with severe mental disorder the majority of whom were aged from 18 to 65. Studies of ACT were defined as those in which the investigators described the intervention as “Assertive Community Treatment” or one of its synonyms. Studies of ACT as an alternative to hospital admission, hospital diversion programmes, for those in crisis, were excluded. The reliability of the inclusion criteria were evaluated.
Data collection and analysis
Three types of outcome data were available: i. categorical data, ii. numerical data based on counts of real life events (count data) and iii. numerical data collected by standardised instruments (scale data). Categorical data were extracted twice and then cross-checked. Peto Odds Ratios and the number needed to treat (NNT) were calculated. Numerical count data were extracted twice and cross-checked. Count data could not be combined across studies for technical reasons (the data were skewed) but all relevant observations based on count data were reported in the review. Numerical scale data were subject to a quality assessment. The validity of the quality assessment was itself assessed. Numerical scale data of suitable quality were combined using the standardised mean difference statistic where possible, otherwise the data were reported in the text or ‘Other data tables’ of the review.
Main results
ACT versus standard community care
Those receiving ACT were more likely to remain in contact with services than people receiving standard community care (OR 0.51, 99%CI 0.37-0.70). People allocated to ACT were less likely to be admitted to hospital than those receiving standard community care (OR 0.59, 99%CI 0.41-0.85) and spent less time in hospital. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on i. accommodation status, ii. employment and iii. patient satisfaction. There were no differences between ACT and control treatments on mental state or social functioning. ACT invariably reduced the cost of hospital care, but did not have a clear cut advantage over standard care when other costs were taken into account.
ACT versus hospital-based rehabilitation services
Those receiving ACT were no more likely to remain in contact with services than those receiving hospital-based rehabilitation, but confidence intervals for the odds ratio were wide. People getting ACT were significantly less likely to be admitted to hospital than those receiving hospital-based rehabilitation (OR 0.2, 99%CI 0.09-0.46) and spent less time in hospital. Those allocated to ACT were significantly more likely to be living independently (OR (for not living independently) 0.19, 99%CI 0.06-0.54), but there were no other significant and robust differences in clinical or social outcome. There was insufficient data on costs to permit comparison.
ACT versus case management
There were no data on numbers remaining in contact with the psychiatric services or on numbers admitted to hospital. People allocated to ACT consistently spent fewer days in hospital than those given case management. There was insufficient data to permit robust comparisons of clinical or social outcome. The cost of hospital care was consistently less for those allocated to ACT, but ACT did not have a clear cut advantage over case management when other costs were taken into account.
Authors’ conclusions
ACT is a clinically effective approach to managing the care of severely mentally ill people in the community. ACT, if correctly targeted on high users of in-patient care, can substantially reduce the costs of hospital care whilst improving outcome and patient satisfaction. Policy makers, clinicians, and consumers should support the setting up of ACT teams.
Lancashire Care staff can either click on the link above or email: susan.jennings@lancashirecare.nhs.uk
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Sunday, March 21st, 2010 |
Case management for people with severe mental disorders, Marshall M, Gray A, Lockwood A, Green R. Case management for people with severe mental disorders. Cochrane Database of Systematic Reviews 1998, Issue 2. Art. No.: CD000050.
1University of Manchester, The Lantern Centre, Preston., UK. 2Institute of Health Sciences, University of Oxford, Oxford, UK. 3School of Psychiatry and Behavioural Sciences, University of Manchester, Preston, UK. 4Fremont, USA
Click on the title above to access the full-text of this Cochrane Review
Abstract:
Background
Since the 1960s, in many parts of the world, large psychiatric were closed down and people were treated in outpatient clinics, day centres or community mental health centres. Rising readmission rates suggested that this type of community care may be less effective than anticipated. In the 1970s case management arose as a means of co-ordinating the care of severely mentally ill people in the community.
Objectives
To determine the effects of case management as an approach to caring for severely mentally ill people in the community. Case management was compared against standard care on four main indices: (i) numbers remaining in contact with the psychiatric services; (ii) extent of psychiatric hospital admissions; (iii) clinical and social outcome; and (iv) costs.
Search strategy
Electronic searches of CINAHL (1997), the Cochrane Schizophrenia Group’s Register of trials (1997), EMBASE (1980-1995), MEDLINE (1966-1995), PsycLIT (1974-1995) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations.
Selection criteria
The inclusion criteria were that studies should be randomised controlled trials that (i) had compared case management to standard community care; and (ii) had involved people with severe mental disorder mainly between the ages of 18-65. Studies of case management were defined as those in which the investigators described the intervention as ‘case’ or ‘care’ management rather than ‘Assertive Community Treatment’ or ‘ACT’.
Data collection and analysis
A study was carried out to test the reliability of the inclusion criteria. Categorical data were extracted twice and then cross-checked, any disagreements being resolved by discussion. Odds ratios and the number needed to treat were estimated. Continuous data collected by a measuring instrument was only included if the instrument (i) had been described in a peer-reviewed journal; (ii) was a self-report or had been completed by an independent rater; and (iii) provided a summary score for a broad area of functioning. Normally distributed continuous data were included if means and standard deviations were available. Non-normal data were included if analysed either after transformation or using non-parametric methods. Tests for heterogeneity were conducted.
Main results
Case management increased the numbers remaining in contact with services (for case management odds ratio = 0.70; 99%CI 0.50-0.98; n=1210). Case management approximately doubled the numbers admitted to psychiatric hospital (OR 1.84; 99% CI 1.33-2.57; n=1300). Except for a positive finding on compliance, from one study, case management showed no significant advantages over standard care on any psychiatric or social variable. Cost data did not favour case management but insufficient information was available to permit definitive conclusions.
Authors’ conclusions
Case management ensures that more people remain in contact with psychiatric services (one extra person remains in contact for every 15 people who receive case management), but it also increases hospital admission rates. Present evidence suggests that case management also increases duration of hospital admissions, but this is not certain. Whilst there is some evidence that case management improves compliance, it does not produce clinically significant improvement in mental state, social functioning, or quality of life. There is no evidence that case management improves outcome on any other clinical or social variables. Present evidence suggests that case management increases health care costs, perhaps substantially, although this is not certain. In summary, therefore, case management is an intervention of questionable value, to the extent that it is doubtful whether it should be offered by community psychiatric services. It is hard to see how policy makers who subscribe to an evidence-based approach can justify retaining case management as ‘the cornerstone’ of community mental health care. Case management is compared to the main alternative approach (ACT) in a forthcoming Cochrane review.
Lancashire Care staff can either click on the link above or email: susan.jennings@lancashirecare.nhs.uk
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Sunday, March 21st, 2010 |
Internet-based information-seeking behaviour amongst doctors and nurses: a short review of the literature , Health Information & Libraries Journal, 2010, Volume 27 Issue 1, Pages 2 - 10
Paula Younger – North Somerset Healthcare Library, Ground Floor, Weston Area Health Trust, Weston-super-Mare, BS23 4TQ, UK
Abstract:
Reviews of how doctors and nurses search for online information are relatively rare, particularly where research examines how they decide whether to use Internet-based resources. Original research into their online searching behaviour is also rare, particularly in real world clinical settings. as is original research into their online searching behaviour. This review collates some of the existing evidence, from 1995 to 2009.
Objectives: To establish whether there are any significant differences in the ways and reasons why doctors and nurses seek out online information; to establish how nurses and doctors locate information online; to establish whether any conclusions can be drawn from the existing evidence that might assist health and medical libraries in supporting users.
Methods: An initial scoping literature search was carried out on PubMed and CINAHL to identify existing reviews of the subject area and relevant original research between 1995 and 2009. Following refinement, further searches were carried out on Embase (Ovid), LISA and LISTA. Following the initial scoping search, two journals were identified as particularly relevant for further table of contents searching. Articles were exclused where the main focus was on patients searching for information or where the focus was the evaluation of online-based educational software or tutorials. Articles were included if they were review or meta-analysis articles, where they reported original research, and where the primary focus of the online search was for participants’ ongoing Continuing Professional Development (CPD). The relevant articles are outlined, with details of numbers of participants, response rates, and the user groups.
Results: There appear to be no significant differences between the reasons why doctors and nurses seek online Internet-based evidence, or the ways in which they locate that evidence. Reasons for searching for information online are broadly the same: primarily patient care and CPD (Continuing Professional Development). The perceived barriers to accessing online information are the same in both groups. There is a lack of awareness of the library as a potential online information enabler.
Conclusions: Libraries need to examine their policy and practice to ensure that they facilitate access to online evidence-based information, particularly where users are geographically remote or based in the community rather than in a hospital setting. Librarians also need to take into account the fact that medical professionals on duty may not be able to take advantage of the academic model of online information research. Further research is recommended into the difference between the idealised academic model of searching and real world practicalities; and how other user groups search, for example patients.
Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk
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Sunday, March 21st, 2010 |
Clinical characteristics of depressed outpatients previously overdiagnosed with bipolar disorder
Abstract
The diagnosis of bipolar disorder in depressed patients requires the ascertainment of prior episodes of mania and hypomania. Several research reports and commentaries have suggested that bipolar disorder is underrecognized and that many patients with nonbipolar major depressive disorder have, in fact, bipolar disorder. In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported the opposite phenomenon—that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question that has not been previously examined is whether there is a particular clinical or demographic profile associated with bipolar disorder overdiagnosis among depressed patients. Forty psychiatric outpatients with current major depressive disorder reported having been previously diagnosed with bipolar disorder, which was not confirmed when interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). Psychiatric diagnoses, clinical and demographic variables were compared in these 40 patients and 233 depressed patients who were not diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered the SCID for DSM-IV Axis I disorders, the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders, and the Schedule for Affective Disorders and Schizophrenia for clinical features of depression. The depressed patients who were overdiagnosed with bipolar disorder were diagnosed with a significantly higher number of Axis I disorders and were more likely to be diagnosed with specific phobia, posttraumatic stress disorder, and drug abuse/dependence. The patients overdiagnosed with bipolar disorder were also significantly more likely to be diagnosed with a current personality disorder and were more chronically ill with greater psychosocial impairment. Thus, the results suggest that depressed outpatients who had previously been overdiagnosed with bipolar disorder were more chronically and severely ill than depressed outpatients who had not been overdiagnosed.
Mark Zimmerman
, a, 
, Camilo J. Ruggeroa, Iwona Chelminskia and Diane Younga
a Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI 02905, USA
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Sunday, March 21st, 2010 |
Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality , Malone D, Marriott S, Newton-Howes G, Simmonds S, Tyrer P. Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000270
1Mental Health Services for Older People, Rotorua Hospital, Roturua, New Zealand. 2Paterson Centre for Mental Health, St Mary’s Hospital, London, UK. 3Hawkes Bay District Health Board, Napier, New Zealand. 4Academic Unit of Psychiatry, St Charles Hospital, London, UK. 5Department of Psychological, Imperial College, London, UK
Click on the title above to access the full-text of this Cochrane review
Abstract:
Background
Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings, underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).
Objectives
To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management.
Search strategy
We searched The Cochrane Schizophrenia Group Trials Register (March 2006). We manually searched the Journal of Personality Disorders, and contacted colleagues at ENMESH, ISSPD and in forensic psychiatry.
Selection criteria
We included all randomised controlled trials of CMHT management versus non-team standard care.
Data collection and analysis
We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model.
Main results
CMHT management did not reveal any statistically significant difference in death by suicide and in suspicious circumstances (n=587, 3 RCTs, RR 0.49 CI 0.1 to 2.2) although overall, fewer deaths occurred in the CMHT group. We found no significant differences in the number of people leaving the studies early (n=253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). Significantly fewer people in the CMHT group were not satisfied with services compared with those receiving standard care (n=87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11). Also, hospital admission rates were significantly lower in the CMHT group (n=587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to accident and emergency services, contact with primary care, and contact with social services did not reveal any statistical difference between comparison groups.
Authors’ conclusions
Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide. The evidence for CMHT based care is insubstantial considering the massive impact the drive toward community care has on patients, carers, clinicians and the community at large.
Lancashire Care staff can either click on the link above , or email: susan.jennings@lancashirecare.nhs.uk
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Sunday, March 21st, 2010 |
Antidepressants for depression in physically ill people , Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M. Antidepressants for depression in physically ill people. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD007503
Click on the title above to access the full-text of this Cochrane Review
Abstract:
Background
There is an increased risk of depression in people with a physical illness. Depression is associated with reduced treatment adherence, poor prognosis, increased disability and higher mortality in many physical illnesses. Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients. This review updates Gill’s Cochrane review (2000), which found that antidepressants were effective for depression in physical illness. Since Gill there have been a number of larger trials assessing the efficacy of antidepressants in this context.
Objectives
To determine the efficacy of antidepressants in the treatment of depression in patients with a physical illness.
Search strategy
Electronic searches of the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) trial registers were conducted together with supplementary searches of The Cochrane Central Register of Controlled Trials (CENTRAL) and the standard bibliographic databases, MEDLINE, EMBASE and PsycINFO. Reference lists of included studies were scanned and trials registers were searched to identify additional unpublished data. Last searches were run in December 2009.
Selection criteria
Randomised controlled trials comparing the efficacy of antidepressants and placebo in the treatment of depression in adults with a physical illness. Depression included diagnoses of Major Depression, Adjustment Disorder and Dysthymia based on standardised criteria.
Data collection and analysis
The primary outcome was efficacy 6-8 weeks after randomisation. Data were also extracted at three additional time-points (4-5 weeks, 9-18 weeks, >18 weeks). Acceptability and tolerability were assessed by comparing the number of drop-outs and adverse events. Odds ratios with 95% confidence intervals were calculated for dichotomous data (response to treatment). Standardised mean differences with 95% CI were calculated for continuous data (mean depression score). Data were pooled using a random effects model.
Main results
Fifty-one studies including 3603 participants were included in the review. Forty-four studies including 3372 participants contributed data towards the efficacy analyses. Pooled efficacy data for the primary outcome provided an OR of 2.33, CI 1.80-3.00, p<0.00001 (25 studies, 1674 patients) favouring antidepressants. Antidepressants were also more efficacious than placebo at the other time-points. At 6-8 weeks, fewer patients receiving placebo dropped out compared to patients treated with an antidepressant. Dry mouth and sexual dysfunction were more common in patients treated with an antidepressant.
Authors’ conclusions
This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.
Lancashire Care staff can either click on the link above or email: susan.jennings@lancashirecare.nhs.uk
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Saturday, March 20th, 2010 |
Prevention programs in the 21st century: what we do not discuss in public , Addiction, 2010, Volume 105 Issue 4, Pages 578 - 581
Harold Holder
Abstract:
Prevention research concerning alcohol, tobacco and other drugs faces a number of challenges as the scientific foundation is strengthened for the future. Seven issues which the prevention research field should address are discussed: lack of transparency in analyses of prevention program outcomes, lack of disclosure of copyright and potential for profit/income during publication, post-hoc outcome variable selection and reporting only outcomes which show positive and statistical significance at any follow-up point, tendency to evaluate statistical significance only rather than practical significance as well, problem of selection bias in terms of selecting subjects and limited generalizability, the need for confirmation of outcomes in which only self-report data are used and selection of appropriate statistical distributions in conducting significance testing. In order to establish a solid scientific base for alcohol, tobacco and drug prevention, this paper calls for discussions, disclosures and debates about the above issues (and others) as essential. In summary, the best approach is always transparency.
Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk
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Saturday, March 20th, 2010 |
Prevention programs in the 21st century: what we do not discuss in public , Addiction, 2010, Volume 105 Issue 4, Pages 578 - 581
Harold Holder
Abstract:
Prevention research concerning alcohol, tobacco and other drugs faces a number of challenges as the scientific foundation is strengthened for the future. Seven issues which the prevention research field should address are discussed: lack of transparency in analyses of prevention program outcomes, lack of disclosure of copyright and potential for profit/income during publication, post-hoc outcome variable selection and reporting only outcomes which show positive and statistical significance at any follow-up point, tendency to evaluate statistical significance only rather than practical significance as well, problem of selection bias in terms of selecting subjects and limited generalizability, the need for confirmation of outcomes in which only self-report data are used and selection of appropriate statistical distributions in conducting significance testing. In order to establish a solid scientific base for alcohol, tobacco and drug prevention, this paper calls for discussions, disclosures and debates about the above issues (and others) as essential. In summary, the best approach is always transparency.
Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk
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Saturday, March 20th, 2010 |
Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine , Acta Psychiatrica Scandinavica, March 2010, Volume 121 Issue 3, Pages 190 - 200
J. Wijkstra
Abstract:
It remains unclear whether unipolar psychotic depression should be treated with an antidepressant and an antipsychotic or with an antidepressant alone.
Method: In a multi-center RCT, 122 patients (18–65 years) with DSM-IV-TR psychotic major depression and HAM-D-17 ? 18 were randomized to 7 weeks imipramine (plasma-levels 200–300 ?g/l), venlafaxine (375 mg/day) or venlafaxine–quetiapine (375 mg/day, 600 mg/day). Primary outcome was response on HAM-D-17. Secondary outcomes were response on CGI and remission (HAM-D-17).
Results: Venlafaxine–quetiapine was more effective than venlafaxine with no significant differences between venlafaxine–quetiapine and imipramine, or between imipramine and venlafaxine. Secondary outcomes followed the same pattern.
Conclusion: That unipolar psychotic depression should be treated with a combination of an antidepressant and an antipsychotic and not with an antidepressant alone, can be considered evidence based with regard to venlafaxine–quetiapine vs. venlafaxine monotherapy. Whether this is also the case for imipramine monotherapy is likely, but cannot be concluded from the data.
Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk
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Saturday, March 20th, 2010 |
Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine , Acta Psychiatrica Scandinavica, March 2010, Volume 121 Issue 3, Pages 190 - 200
J. Wijkstra
Abstract:
It remains unclear whether unipolar psychotic depression should be treated with an antidepressant and an antipsychotic or with an antidepressant alone.
Method: In a multi-center RCT, 122 patients (18–65 years) with DSM-IV-TR psychotic major depression and HAM-D-17 ? 18 were randomized to 7 weeks imipramine (plasma-levels 200–300 ?g/l), venlafaxine (375 mg/day) or venlafaxine–quetiapine (375 mg/day, 600 mg/day). Primary outcome was response on HAM-D-17. Secondary outcomes were response on CGI and remission (HAM-D-17).
Results: Venlafaxine–quetiapine was more effective than venlafaxine with no significant differences between venlafaxine–quetiapine and imipramine, or between imipramine and venlafaxine. Secondary outcomes followed the same pattern.
Conclusion: That unipolar psychotic depression should be treated with a combination of an antidepressant and an antipsychotic and not with an antidepressant alone, can be considered evidence based with regard to venlafaxine–quetiapine vs. venlafaxine monotherapy. Whether this is also the case for imipramine monotherapy is likely, but cannot be concluded from the data.
Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk
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