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Psychiatrists, like all doctors, are obliged to offer our patients treatments based on the highest level of evidence that is available. For some of our interventions the evidence may be patchy while for others it may be more firm. Distilling all the findings from the variety of trials that are available is often impossible. To assist us, systematic reviews/meta-analyses are a very useful resource and they represent the highest level of evidence. The Cochrane Collaboration is the most prestigious source of systematic reviews yet many doctors have difficulty understanding the methodology and findings of these very lengthy papers. For this reason, I felt that an educational journal like BJPsych Advances was the ideal vehicle to promote evidence-based practice through the publication of summaries of recent Cochrane reviews. Elaboration on the content and on the methodology of these by means of an accompanying commentary was felt to be the most concise and informative way of disseminating this knowledge and of demystifying systematic review terminology such as heterogeneity, effect size, Forrest and Funnel plots, among others. I greatly welcome the publication of all the Systematic Review summaries published in BJPsych Advances and their associated commentaries (entitled Cochrane Corner and Round the Corner respectively) in a collection and am confident that it will enrich your knowledge to a new level.
Self-harm (intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for self-harm, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self-harm.
Maintenance drug treatment in bipolar disorder is a key component of management. There is clinical uncertainty about the relative efficacy of valproate, either alone or in combination, particularly in comparison to lithium. This month's Cochrane corner review aimed to summarise the best evidence available. This commentary puts the findings into their clinical context and updates them in the light of subsequent analyses and the recent revision of the NICE guidelines on bipolar disorder.
The pharmacological treatment of depression is often hampered by side-effects and unsatisfactory response to treatment. Vortioxetine is one of the newest antidepressants on the market, purportedly with a different mechanism of action compared with other antidepressants. This month's Cochrane Corner review examines the evidence available for the use of vortioxetine as a first-line treatment for depression in adults. This commentary puts the Cochrane review's findings into their clinical context and revises them in view of earlier and later studies.
Self-harm is a significant social and healthcare problem, with substantial morbidity and healthcare costs. It has strong links to further self-harm and to suicide. The current review is one of three that investigate interventions in preventing recurrence of self-harm, and it focuses on pharmacological treatment. The conclusions are limited by the small number and size of trials identified, and the low quality of evidence. No benefit on recurrence of self-harm was detected in three small trials of antidepressants, but the types studied are ones that are now less commonly used. A small trial of flupentixol suggested a possible benefit on repetition, but this has not been replicated. One small trial of lithium showed no benefit, but this was in contrast to a recent large meta-analysis showing a significant anti-suicidal effect of lithium when used to treat mood disorder. The review highlights important areas for further research.
Network meta-analysis (NMA) is a statistical method that allows comparison of multiple treatments against each other. The use of NMA, and its advantages and potential limitations, is discussed here in the context of this issue's Cochrane review of psychological treatments for panic disorder. The review showed benefits for psychological treatment when compared to a waiting list, particularly for cognitive behavioural therapy in both the short and longer term. The findings were limited by the primary studies available, but despite these, this analysis using NMA presents the best evidence to date of the relative benefits of different types of psychological treatments in panic disorder.
Psychotic depression is a severe condition. Drug treatment (antipsychotics, antidepressants or the combination) or electroconvulsive therapy (ECT) are both effective. However, a 2005 Cochrane review of drug treatments could not find a clear benefit for combination treatment with antidepressant and antipsychotic medication over antidepressants alone. The current updated Cochrane review (2015) incorporated two larger studies and found evidence of superiority for combination treatment. The review was constrained by the small number of available studies and could not address key questions such as the relative merits of antipsychotics and/or antidepressants compared with ECT or ketamine in acute treatment, and which treatments are best for long-term maintenance and prevention of recurrence. However, the methodology used was rigorous and the review gives the best summary to date of the evidence, as well as providing a platform for informing future research.
Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary healthcare has been identified as essential to improving the delivery of mental healthcare. Consultation liaison is a model of mental healthcare where the primary care provider maintains the central role in the delivery of mental healthcare, with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental healthcare in the primary care setting and, in turn, improve outcomes for people with a mental disorder.
‘Collaborative care’ (involving a case manager) and ‘primary care liaison’ or ‘consultation liaison’ (with no case manager) are models of liaison psychiatry in primary care. Here, I briefly consider the evidence for collaborative care, discuss Gillies et al 's Cochrane review on consultation liaison, and suggest avenues for future study and development of liaison psychiatry in primary care.
Individuals with severe mental illness have increased rates of physical health problems and reduced life expectancy. As a vulnerable population, they have been identified as needing increased physical health monitoring and treatment. The first of two Cochrane reviews considered here assessed the evidence for the benefit of monitoring but found no studies that could be included. The second reviewed the evidence for provision of general physical healthcare advice. Although the results were suggestive of benefit, the evidence, where available, was of poor quality. These reviews highlight an important area for future research to evaluate the relative health and cost benefits of different types of intervention.
Major depressive disorder in children and adolescents is common and associated with significant morbidity and mortality. This 2012 meta-analysis by Hetrick et al shows statistically significant, but small, improvements in depressive symptom scores and probability of remission with second-generation antidepressants (SGAs) compared with placebo. SGAs lead to a small, but significant, increase in risk of suicidal thoughts/attempts compared with placebo. Patients included in the primary studies had milder depression, less psychiatric comorbidity and less suicidality than those normally seen in clinical practice in the UK's National Health Service. However, primary studies had significant methodological shortcomings. Therefore, caution is needed when trying to generalise results to clinical practice.
Chronic fatigue syndrome (CFS) is syndrome of unremitting fatigue of at least 6 months' duration that causes significant disability. Exercise therapy has a proven track record in medicine and could be effective for some patients with CFS. An updated Cochrane review of eight studies appeared to suggest that exercise helps fatigue symptoms, but with only a small probability of recovery and/or improvement in daily function. Provisional data on acceptability suggest that most patients are willing to participate. However, one key study (PACE), which was well powered and influential in the Cochrane review, has been met with considerable controversy owing to lack of clarity on outcomes. Following release of the PACE study primary data, re-analysis suggested smaller effect sizes than initially reported.
Young children with autism spectrum disorders (ASD) have impairments in the areas of communication and social interaction and often display repetitive or non-compliant behaviour. This early pattern of difficulties is a challenge for parents. Therefore, approaches that help parents develop strategies for interaction and management of behaviour are an obvious route for early intervention in ASD. This review updates a Cochrane review first published in 2002 but is based on a new protocol.