ABI – Cochrane – Music therapy for Acquired Brain Injury

Cochrane – Music therapy for Acquired Brain Injury, 2010

Reference:  Bradt J, Magee WL, Dileo C, Wheeler BL, McGilloway E. Music therapy for acquired brain injury. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD006787.

Abstract:

BACKGROUND: Acquired brain injury (ABI) can result in impairments in motor function, language, cognition, sensory processing and emotional disturbances. This may severely reduce a survivor’s quality of life. Music therapy has been used in rehabilitation to stimulate brain functions involved in movement, cognition, speech, emotions and sensory perceptions. A systematic review is needed to gauge the efficacy of music therapy as a rehabilitation intervention for people with ABI.

OBJECTIVES: To examine the effects of music therapy with standard care versus standard care alone or standard care combined with other therapies on gait, upper extremity function, communication, mood and emotions, social skills, pain, behavioral outcomes, activities of daily living and adverse events.

SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (February 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (July 2009), EMBASE (August 2009), CINAHL (March 2010), PsycINFO (July 2009), LILACS (August 2009), AMED (August 2009) and Science Citation Index (August 2009). We handsearched music therapy journals and conference proceedings, searched dissertation and specialist music databases, trials and research registers, reference lists, and contacted experts and music therapy associations. There was no language restriction.

SELECTION CRITERIA: Randomized and quasi-randomized controlled trials that compared music therapy interventions and standard care with standard care alone or combined with other therapies for people older than 16 years of age who had acquired brain damage of a non-degenerative nature and were participating in treatment programs offered in hospital, outpatient or community settings.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed methodological quality and extracted data. We present results using mean differences (using post-test scores) as all outcomes were measured with the same scale.

MAIN RESULTS: We included seven studies (184 participants). The results suggest that rhythmic auditory stimulation (RAS) may be beneficial for improving gait parameters in stroke patients, including gait velocity, cadence, stride length and gait symmetry. These results were based on two studies that received a low risk of bias score. There were insufficient data to examine the effect of music therapy on other outcomes.

AUTHORS’ CONCLUSIONS: RAS may be beneficial for gait improvement in people with stroke. These results are encouraging, but more RCTs are needed before recommendations can be made for clinical practice. More research is needed to examine the effects of music therapy on other outcomes in people with ABI.

Lancashire Care staff can either click on the links above or email: susan.jennings@lancashirecare.nhs.uk

Cochrane – Self-help and guided self-help for eating disorders

Self-help and guided self-help for eating disorders,    Cochrane,  2009

Sarah S J Perkins1, Rebecca RM Murphy2, Ulrike US Schmidt1, Chris Williams3

1Section of Eating Disorders, PO Box 59, Institute of Psychiatry, King’s College London, London, UK. 2Department of Psychiatry, Warneford Hospital, Oxford, UK. 3Psychological Medicine, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK

Perkins SSJ, Murphy RRM, Schmidt UUS, Williams C. Self-help and guided self-help for eating disorders. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004191. DOI: 10.1002/14651858.CD004191.pub2.

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Abstract:

Anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS) are common and disabling disorders. Many patients experience difficulties accessing specialist psychological treatments. Pure self-help (PSH: self-help material only) or guided self-help (GSH: self-help material with therapist guidance), may bridge this gap.

 

 

Objectives

Main objective:
Evaluate evidence from randomised controlled trials (RCTs) / controlled clinical trials (CCTs) for the efficacy of PSH/GSH with respect to eating disorder symptoms, compared with waiting list or placebo/attention control, other psychological or pharmacological treatments (or combinations/augmentations) in people with eating disorders.

Secondary objective:
Evaluate evidence for the efficacy of PSH/GSH regarding comorbid symptomatology and costs.

Search strategy

CCDANCTR-Studies and CCDANCTR-References were searched in November 2005, other electronic databases were searched, relevant journals and grey literature were checked, and personal approaches were made to authors.

Selection criteria

Published/unpublished RCTs/CCTs evaluating PSH/GSH for any eating disorder.

Data collection and analysis

Data was extracted using a customized spreadsheet. Relative Risks (RR) were calculated from dichotomous data and weighted/standardized mean differences (WMD/SMD) from continuous data, using a random effects model.

Main results

Twelve RCTs and three CCTs were identified, all focusing on BN, BED, EDNOS or combinations of these, in adults, using manual-based PSH/GSH across various settings.

Primary comparisons:
At end of treatment, PSH/GSH did not significantly differ from waiting list in abstinence from bingeing (RR 0.72, 95% CI 0.47 to 1.09), or purging (RR 0.86, 95% CI 0.68 to 1.08), although these treatments produced greater improvement on other eating disorder symptoms, psychiatric symptomatology and interpersonal functioning but not depression.

Compared to other formal psychological therapies, PSH/GSH did not differ significantly at end of treatment or follow-up in improvement on bingeing and purging (RR 0.99, 95% CI 0.75 to 1.31), other eating disorder symptoms, level of interpersonal functioning or depression. There were no significant differences in treatment dropout.

Secondary comparisons:
One small study in BED found that cognitive-behavioural GSH compared to a non-specific control treatment produced significantly greater improvements in abstinence from bingeing and other eating disorder symptoms. Studies comparing PSH with GSH found no significant differences between treatment groups at end of treatment or follow-up. Comparison between different types of PSH/GSH found significant differences on eating disorder symptoms but not on bingeing/purging abstinence rates.

Authors’ conclusions

PSH/GSH may have some utility as a first step in treatment and may have potential as an alternative to formal therapist-delivered psychological therapy. Future research should focus on producing large well-conducted studies of self-help treatments in eating disorders including health economic evaluations, different types and modes of delivering self-help (e.g. computerised versus manual-based) and different populations and settings.

 

Lancashire Care staff can either click on the link above or email: susan.jennings@lancashirecare.nhs.uk

Pharmacological interventions for borderline personality disorder – Cochrane

Pharmacological interventions for borderline personality disorder16 JUN 2010, DOI : 10.1002/14651858.CD005653

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The Cochrane Library

Jutta Stoffers, Birgit A Völlm, Gerta Rücker, Antje Timmer, Nick Huband and Klaus Lieb

Abstract:

Background

Drugs are widely used in borderline personality disorder (BPD) treatment, chosen because of properties known from other psychiatric disorders (“off-label use”), mostly targeting affective or impulsive symptom clusters.

Objectives

To assess the effects of drug treatment in BPD patients.

Search strategy

We searched bibliographic databases according to the Cochrane Developmental, Psychosocial and Learning Problems Group strategy up to September 2009, reference lists of articles, and contacted researchers in the field.

Selection criteria

Randomised studies comparing drug versus placebo, or drug versus drug(s) in BPD patients. Outcomes included total BPD severity, distinct BPD symptom facets according to DSM-IV criteria, associated psychopathology not specific to BPD, attrition and adverse effects.

Data collection and analysis

Two authors selected trials, assessed quality and extracted data, independently.

Main results

Twenty-eight trials involving a total of 1742 trial participants were included. First-generation antipsychotics (flupenthixol decanoate, haloperidol, thiothixene); second-generation antipsychotics (aripirazole, olanzapine, ziprasidone), mood stabilisers (carbamazepine, valproate semisodium, lamotrigine, topiramate), antidepressants (amitriptyline, fluoxetine, fluvoxamine, phenelzine sulfate, mianserin), and dietary supplementation (omega-3 fatty acid) were tested. First-generation antipsychotics were subject to older trials, whereas recent studies focussed on second-generation antipsychotics and mood stabilisers. Data were sparse for individual comparisons, indicating marginal effects for first-generation antipsychotics and antidepressants.

The findings were suggestive in supporting the use of second-generation antipsychotics, mood stabilisers, and omega-3 fatty acids, but require replication, since most effect estimates were based on single studies. The long-term use of these drugs has not been assessed.

Adverse event data were scarce, except for olanzapine. There was a possible increase in self-harming behaviour, significant weight gain, sedation and changes in haemogram parameters with olanzapine. A significant decrease in body weight was observed with topiramate treatment. All drugs were well tolerated in terms of attrition.

Direct drug comparisons comprised two first-generation antipsychotics (loxapine versus chlorpromazine), first-generation antipsychotic against antidepressant (haloperidol versus amitriptyline; haloperidol versus phenelzine sulfate), and second-generation antipsychotic against antidepressant (olanzapine versus fluoxetine). Data indicated better outcomes for phenelzine sulfate but no significant differences in the other comparisons, except olanzapine which showed more weight gain and sedation than fluoxetine. The only trial testing single versus combined drug treatment (olanzapine versus olanzapine plus fluoxetine; fluoxetine versus fluoxetine plus olanzapine) yielded no significant differences in outcomes.

Lancashire care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Cochrane – Combined pharmacotherapy and psychological therapies for post traumatic stress disorder

Combined pharmacotherapy and psychological therapies for post traumatic stress disorder, 7th July 2010, Cochrane Review

Hetrick Sarah E,Purcell Rosemary,Garner Belinda,Parslow Ruth

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Abstract:

Background

PTSD is an anxiety disorder related to exposure to a severe psychological trauma. Symptoms include re-experiencing the event, avoidance and arousal as well as distress and impairment resulting from these symptoms.

Guidelines suggest a combination of both psychological therapy and pharmacotherapy may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either intervention alone.

Objectives

To assess whether the combination of psychological therapy and pharmacotherapy provides a more efficacious treatment for PTSD than either of these interventions delivered separately.

Search strategy

Searches were conducted on the trial registers kept by the CCDAN group (CCDANCTR-Studies and CCDANCTR-References) to June 2010. The reference sections of included studies and several conference abstracts were also scanned.

Selection criteria

Patients of any age or gender, with chronic or recent onset PTSD arising from any type of event relevant to the diagnostic criteria were included. A combination of any psychological therapy and pharmacotherapy was included and compared to wait list, placebo, standard treatment or either intervention alone. The primary outcome was change in total PTSD symptom severity. Other outcomes included changes in functioning, depression and anxiety symptoms, suicide attempts, substance use, withdrawal and cost.

Data collection and analysis

Two or three review authors independently selected trials, assessed their ‘risk of bias’ and extracted trial and outcome data. We used a fixed-effect model for meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference and standardised mean difference were used to summarise continuous measures.

Main results

Four trials were eligible for inclusion, one of these trials (n =24) was on children and adolescents. All used an SSRI and prolonged exposure or a cognitive behavioural intervention. Two trials compared combination treatment with pharmacological treatment and two compared combination treatment with psychological treatment. Only two trials reported a total PTSD symptom score and these data could not be combined. There was no strong evidence to show if there were differences between the group receiving combined interventions compared to the group receiving psychological therapy (mean difference 2.44, 95% CI -2.87, 7.35 one study, n=65) or pharmacotherapy (mean difference -4.70, 95% CI -10.84 to 1.44; one study, n = 25). Trialists reported no significant differences between combination and single intervention groups in the other two studies. There were very little data reported for other outcomes, and in no case were significant differences reported.

Authors’ conclusions

There is not enough evidence available to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions alone. Further large randomised controlled trials are urgently required.

Lancashire Care staff can either click on the full-text link above or email: susan.jennings@lancashirecare.nhs.uk

Olanzapine versus other atypical antipsychotics for schizophrenia

Olanzapine versus other atypical antipsychotics for schizophrenia , Komossa K, Rummel-Kluge C, Hunger H, Schmid F, Schwarz S, Duggan L, Kissling W, Leucht S. Olanzapine versus other atypical antipsychotics for schizophrenia. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD006654

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Abstract:

Plain language summary

Olanzapine versus other atypical antipsychotics for schizophrenia
This review examined the effects of olanzapine compared to other second generation antipsychotic drugs for schizophrenia. We identified 50 relevant studies with 9476 participants, comparing olanzapine with amisulpride, aripiprazole, clozapine, quetiapine, risperidone and ziprasidone. Comparisons of olanzapine with the second generation antipsychotic drugs sertindole or zotepine are currently not available. Olanzapine was somewhat more efficacious than aripiprazole, quetiapine, risperidone and ziprasidone, whereas there was no efficacy difference compared to amisulpride and clozapine. The main disadvantage of olanzapine was its higher weight gain and associated metabolic problems compared to all other second generation antipsychotic drugs, except for clozapine.

Lancashire Care staff can either click on the link above or email: susan.jennings@lancashirecare.nhs.uk

Music therapy for end-of-life care – Cochrane

Music therapy for end-of-life care , Bradt J, Dileo C. Music therapy for end-of-life care. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007169

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Abstract:

Background

Music therapy in end-of-life care aims to improve a person’s quality of life by helping relieve symptoms, addressing psychological needs, offering support, facilitating communication, and meeting spiritual needs. In addition, music therapists assist family and caregivers with coping, communication, and grief/bereavement.

Objectives

To examine effects of music therapy with standard care versus standard care alone or standard care combined with other therapies on psychological, physiological, and social responses in end-of-life care.

Search strategy

We searched CENTRAL, MEDLINE, CINAHL, EMBASE, PSYCINFO, LILACS, CancerLit, Science Citation Index, http://www.musictherapyworld.de, CAIRSS for Music, Proquest Digital Dissertations, ClinicalTrials.gov, Current Controlled Trials, and the National Research Register to September 2009. We handsearched music therapy journals and reference lists, and contacted experts to identify unpublished manuscripts. There was no language restriction.

Selection criteria

We included all randomized and quasi-randomized controlled trials that compared music interventions and standard care with standard care alone or combined with other therapies in any care setting with a diagnosis of advanced life-limiting illness being treated with palliative intent and with a life expectancy of less than two years.

Data collection and analysis

Data were extracted, and methodological quality was assessed, independently by review authors. Additional information was sought from study authors when necessary. Results are presented using weighted mean differences for outcomes measured by the same scale and standardized mean differences for outcomes measured by different scales. Posttest scores were used. In cases of statistically significant baseline difference, we used change scores.

Main results

Five studies (175 participants) were included. There is insufficient evidence of high quality to support the effect of music therapy on quality of life of people in end-of-life care. Given the limited number of studies and small sample sizes, more research is needed.

No strong evidence was found for the effect of music therapy on pain or anxiety.These results were based on two small studies. There were insufficient data to examine the effect of music therapy on other physical, psychological, or social outcomes.

Authors’ conclusions

A limited number of studies suggest there may be a benefit of music therapy on the quality of life of people in end-of-life care. However, the results stem from studies with a high risk of bias. More research is needed.

 

Lancashire care staff can click on the link above or email: susan.jennings@lancashirecare.nhs.uk

Music therapy for autistic spectrum disorder

Music therapy for autistic spectrum disorder, Gold C, Wigram T, Elefant C. Music therapy for autistic spectrum disorder. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004381

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Abstract:

Background

The central impairments of people with autistic spectrum disorder (ASD) include social interaction and communication. Music therapy uses music and its elements to enable communication and expression, thus attempting to address some of the core problems of people with ASD.

Objectives

To review the effects of music therapy for individuals with autistic spectrum disorders.

Search strategy

The following databases were searched: CENTRAL, 2005, (Issue 3); Medline, (1966 to July 2004); Embase, (1980 to July 2004); LILACS, (1982 to July 2004); PsycINFO, (1872 to July 2004); CINAHL, (1982 to July 2004); ERIC, (1966 to July 2004); ASSIA, (1987 to July 2004); Sociofile, (1963 to July 2004); Dissertation Abstracts International, (late 1960’s to July 2004). These searches were supplemented by searching specific sources for music therapy literature and manual searches of reference lists. Personal contacts to some investigators were made.

Selection criteria

All randomised controlled trials or controlled clinical trials comparing music therapy or music therapy added to standard care to “placebo” therapy, no treatment or standard care.

Data collection and analysis

Studies were independently selected, quality assessed and data extracted by two authors. Continuous outcomes were synthesised using a standardised mean difference (SMD) in order to enable a meta-analysis combining different scales, and to facilitate the interpretation of effect sizes. Heterogeneity was assessed using the I² statistic.

Main results

Three small studies were included (total n = 24). These examined the short-term effect of brief music therapy interventions (daily sessions over one week) for autistic children. Music therapy was superior to “placebo” therapy with respect to verbal and gestural communicative skills (verbal: 2 RCTs, n = 20, SMD 0.36 CI 0.15 to 0.57; gestural: 2 RCTs, n = 20, SMD 0.50 CI 0.22 to 0.79). Effects on behavioural problems were not significant.

Authors’ conclusions

The included studies were of limited applicability to clinical practice. However, the findings indicate that music therapy may help children with autistic spectrum disorder to improve their communicative skills. More research is needed to examine whether the effects of music therapy are enduring, and to investigate the effects of music therapy in typical clinical practice.

Lancashire care staff can either click on the link above, or email: susan.jennings@lancashirecare.nhs.uk

Cochrane – Psychosocial and pharmacological treatments for deliberate self harm

Psychosocial and pharmacological treatments for deliberate self harm,  Hawton KKE, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen K. Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD001764

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.

Keith KE Hawton, University Department of Psychiatry, Warneford Hospital, Oxford, OX3 7JX, UK

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Abstract:

Background

Deliberate self-harm is a major health problem associated with considerable risk of subsequent self-harm, including completed suicide.

Objectives

To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves.

Search strategy

Electronic databases screened: MEDLINE (from 1966-February 1999); PsycLit (from 1974-March 1999); Embase (from 1980-January 1999); The Cochrane Controlled Trials Register (CCTR) No.1 1999. Ten journals in the field of psychiatry and psychology were hand searched for the first version of this review. We have updated the hand search of three specialist journals in the field of suicidal research until the end of 1998. Reference lists of papers were checked and trialists contacted.

Selection criteria

All RCTs of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering a study engaged in any type of deliberately initiated self-poisoning or self-injury, both of which are generally subsumed under the term deliberate self-harm.

Data collection and analysis

Data were extracted from the original reports independently by two reviewers. Studies were categorized according to type of treatment. The outcome measure used to assess the efficacy of treatment interventions for deliberate self-harm was the rate of repeated suicidal behaviour. We have been unable to examine other outcome measures as originally planned (e.g. compliance with treatment, depression, hopelessness, suicidal ideation/thoughts, change in problems/problem resolution).

Main results

A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0.70; 0.45 to 1.11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0.45; 0.19 to 1.07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0.83 (0.61 to 1.14), and for antidepressant treatment compared with placebo was 0.83 (0.47 to 1.48). The remainder of the comparisons were in single small trials. Significantly reduced rates of further self-harm were observed for depot flupenthixol vs. placebo in multiple repeaters (0.09; 0.02 to 0.50), and for dialectical behaviour therapy vs. standard aftercare (0.24; 0.06 to 0.93).

Authors’ conclusions

There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.

Lancashire Care staff can either click on the link above or email: susan.jennings@lancashirecare.nhs.uk

Family therapy for anorexia nervosa – Cochrane

Family therapy for anorexia nervosa , Fisher CA, Hetrick SE, Rushford N. Family therapy for anorexia nervosa. Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD004780

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Abstract:

Background

Anorexia Nervosa (AN) is characterised by distorted body image and deliberately maintained low body weight. The long term prognosis is often poor, with severe medical, developmental and psychosocial complications, high rates of relapse and mortality. Different variants of family therapy have been commonly used for intervention.

Objectives

To evaluate the efficacy of family therapy compared with standard treatment and other treatments.

Search strategy

The Cochrane Collaboration Depression, Anxiety and Neuroses Controlled Trials Register (CCDANCTR) was searched until August 2008; MEDLINE, PsycInfo and EMBASE and ClinicalTrials.gov were searched up to January 2008. A conference abstract book and included studies reference lists were searched. All lead authors of included studies were also contacted.

Selection criteria

Randomised controlled trials (RCTS) of interventions described as ‘family therapy’ compared to any other intervention or other types of family therapy were eligible for inclusion. 

Patients of any age or gender with a primary clinical diagnosis of anorexia nervosa (AN) were included.

Data collection and analysis

Two review authors selected the studies, assessed quality and extracted data. We used a random effects meta-analysis. Relative risk was used to summarise dichotomous outcomes and both the standardised mean difference and mean difference to summarise continuous measures.

Main results

13 trials were included, the majority investigating family based therapy, or variants. Reporting of trial conduct was generally inadequate. The full extent of the risk of bias is unclear. 

There was some evidence (from two studies, 81 participants) to suggest that family therapy may be more effective than treatment as usual on rates of remission, in the short term (RR 3.83 95% CI 1.60 to 9.13). Based on one study (30 participants) there was no significant advantage for family therapy over educational interventions (RR 9.00 95% CI 0.53, 153.79) or over other psychological interventions (RR 1.13 95% CI 0.72 to 1.76) based on four studies (N=149).

All other reported comparisons for relapse rates, cognitive distortion, weight measures and dropouts yielded non-significant results.

Authors’ conclusions

There is some evidence to suggest that family therapy may be effective compared to treatment as usual in the short term. However, this is based on few trials that included only a small number of participants, all of which had issues regarding potential bias. There appears to be little advantage of family therapy over other psychological interventions. The field would benefit from a large, well-conducted trial.

Lancashire Care staff can either click on the link above or email: susan.jennings@lancashirecare.nhs.uk

Physical health care monitoring for people with serious mental illness – Cochrane

Physical health care monitoring for people with serious mental illness , Tosh G, Clifton A, Mala S, Bachner M. Physical health care monitoring for people with serious mental illness. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD008298

East Midlands Workforce Deanery, Nottingham, UK.

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Abstract:

BACKGROUND: Current guidance suggests that we should monitor the physical health of people with serious mental illness and there has been a significant financial investment over recent years to provide this. OBJECTIVES: To assess the effectiveness of physical health monitoring as a means of reducing morbidity, mortality and reduction in quality of life in people with serious mental illness. SEARCH STRATEGY: We searched the Cochrane Schizophrenia Group Trials Register (October 2009) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO. SELECTION CRITERIA: All randomised or quasi-randomised clinical trials focusing on physical health monitoring versus standard care or comparing i) self monitoring vs monitoring by health care professional; ii) simple vs complex monitoring; iii) specific vs non-specific checks iv) once only vs regular checks or v) comparison of different guidance. DATA COLLECTION AND ANALYSIS: The authors (GT, AC, SM) independently screened search results and identified three studies as possibly fulfilling the review’s criteria. On examination, however, all three were subsequently excluded. MAIN RESULTS: We did not identify any randomised trials which assessed the effectiveness of physical health monitoring in people with serious mental illness. AUTHORS’ CONCLUSIONS: There is no evidence from randomised trials to support current guidance and practice. Guidance and practice are based on expert consensus, clinical experience and good intentions rather than high quality evidence.

Lancashire Care staff can either click on the title above or email: susan.jennings@lancashirecare.nhs.uk

Max Marshall, Medical Director, Lancashire Care NHS Foundation Trust – Assertive community treatment for people with severe mental disorders

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

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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

Cochrane – Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

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

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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

Cochrane – Antidepressants for depression in physically ill people

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.

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The Cochrane library and the treatment of major depression in children and youth: an overview of reviews

The Cochrane library and the treatment of major depression in children and youth: an overview of reviewsEvidence-Based Child Health: A Cochrane Review Journal, Volume 4, Issue 4, Date: December 2009, Pages: 1336-1350

 Suzanne Zinck, Alexa Bagnell, Kenneth Bond, Amanda S. Newton

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Abstract:

Background
Major depression (MDD) in children and adolescents is a mood disorder that has up to 25% lifetime prevalence by the end of adolescence. Pharmacological and nonpharmacological treatments are recommended to reduce symptoms, increase psychosocial functioning, and prevent relapse. Traditionally, decisions for these treatments were made based on reported effects for adults, but a body of pediatric-based evidence is now emerging to inform treatment decisions.
Objectives
To synthesize the evidence currently in the Cochrane Library Database of Systematic Reviews (CDSR) related to the question: In children and youth with diagnosed major depression, do pharmacologic or nonpharmacologic treatments improve symptom response, response rates, functional capacity, adherence and persistence, and decrease cost and adverse events?.
Methods
CDSR was searched using the term depression in the title for all systematic reviews examining pharmacologic and nonpharmacologic interventions for the treatment of depression in children 18 years. Data were extracted and entered into tables; data were synthesized using qualitative and quantitative methods.
Main Results
Of the studies included in the CDSR, there was no significant improvement in treatment outcomes in depressed children and adolescents treated with pharmacological (tricyclic antidepressant [TCA] or selective serotonin reuptake inhibitor [SSRI]) or nonpharmacological (exercise) interventions.
Author’s Conclusions
Although this overview indicates no clear evidence for pharmacological and nonpharmacological interventions for treatment of depression in this age group, the CDSR does not include several recent research publications in this area that demonstrate beneficial effects of treatment. In context of existing research there may be a moderate effect of SSRI in moderate to severe depression in children and youth. Best practice recommendations are consideration of treatment with SSRI (fluoxetine first line) in moderate to severe depression with close monitoring and weighing risk/benefit profile based on individual assessment. Psychotherapeutic interventions not in this overview, including Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT), have some evidence of effectiveness in mild to moderate depression. Although exercise remains an important part of healthy living, there is no evidence to support its use in treatment of depression in children and adolescents. This overview in the context of recent research indicates the need for ongoing study in this important area of child and youth mental health.

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Omega-3 Supplementation Delays Transition to Psychotic Disorder in Ultra-High Risk Adolescents and Young Adults

Long-chain omega-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo-controlled trial, Archives of General Psychiatry. 2010;67(2):146-154

Amminger, Paul et al.

Abstract:

Context  The use of antipsychotic medication for the prevention of psychotic disorders is controversial. Long-chain {omega}-3 (omega-3) polyunsaturated fatty acids (PUFAs) may be beneficial in a range of psychiatric conditions, including schizophrenia. Given that {omega}-3 PUFAs are generally beneficial to health and without clinically relevant adverse effects, their preventive use in psychosis merits investigation. Objective  To determine whether {omega}-3 PUFAs reduce the rate of progression to first-episode psychotic disorder in adolescents and young adults aged 13 to 25 years with subthreshold psychosis.

Design  Randomized, double-blind, placebo-controlled trial conducted between 2004 and 2007.

Setting  Psychosis detection unit of a large public hospital in Vienna, Austria.

Participants  Eighty-one individuals at ultra-high risk of psychotic disorder.

Interventions  A 12-week intervention period of 1.2-g/d {omega}-3 PUFA or placebo was followed by a 40-week monitoring period; the total study period was 12 months.

Main Outcome Measures  The primary outcome measure was transition to psychotic disorder. Secondary outcomes included symptomatic and functional changes. The ratio of {omega}-6 to {omega}-3 fatty acids in erythrocytes was used to index pretreatment vs posttreatment fatty acid composition.

Results  Seventy-six of 81 participants (93.8%) completed the intervention. By study’s end (12 months), 2 of 41 individuals (4.9%) in the {omega}-3 group and 11 of 40 (27.5%) in the placebo group had transitioned to psychotic disorder (P = .007). The difference between the groups in the cumulative risk of progression to full-threshold psychosis was 22.6% (95% confidence interval, 4.8-40.4). {omega}-3 Polyunsaturated fatty acids also significantly reduced positive symptoms (P = .01), negative symptoms (P = .02), and general symptoms (P = .01) and improved functioning (P = .002) compared with placebo. The incidence of adverse effects did not differ between the treatment groups.

Conclusions  Long-chain {omega}-3 PUFAs reduce the risk of progression to psychotic disorder and may offer a safe and efficacious strategy for indicated prevention in young people with subthreshold psychotic states.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

 

Polyunsaturated fatty acid supplementation for schizophrenia, Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001257. DOI: 10.1002/14651858.CD001257

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Polyunsaturated fatty acid (PUFA) supplementation has been studied for treatment of schizophrenia although theevidence to date has been inconclusive (Cochrane Database Syst Rev 2009 Jul 8;(3):CD001257). In a recent randomized trial evaluating PUFAs as a preventive intervention, omega-3 polyunsaturated fatty acid supplementation decreased the transition to a psychotic disorder in ultra-high risk adolescents and young adults (level 1 [likely reliable] evidence). Eighty-one patients aged 13-25 years at ultra-high risk of psychotic disorder were randomized to omega-3 (1.2 g/day) vs. placebo for 12 weeks and then followed for 1 year. All participants had subthreshold psychosis and either attenuated positive psychotic symptoms, transient psychosis, or genetic risk with decreasing functioning. After 1 year, transition to a psychotic disorder requiring antipsychotic medication had occurred in 4.9% of patients receiving supplements compared to 27.5% in those receiving placebo (p = 0.007, NNT 5). Omega-3 supplementation was also associated with a significant reduction in symptoms and improvement in global assessment of functioning (Arch Gen Psychiatry 2010 Feb;67(2):146.

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Cochrane – Interventions for helping people recognise early signs of recurrence in bipolar disorder

Interventions for helping people recognise early signs of recurrence in bipolar disorder , Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD004854. DOI: 10.1002/14651858.CD004854.pub2.

Richard Morriss1, Mohammad Amir Faizal2, Ashley P Jones3, Paula R Williamson4, Catherine A Bolton5, James P McCarthy6

1Psychiatry, University of Nottingham , Nottingham, UK. 2Psychiatry, Mersey Care NHS Trust, Liverpool, UK. 3Institute of Child Health, University of Liverpool, Liverpool, UK. 4Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, UK. 5Child and Adolescent Mental Health Service, Royal Bolton Hospital Trust, Bolton, UK. 6Ferndale Unit, Merseycare NHS Trust, Liverpool, UK

Click on the title above to access the Cochrane intervention report

Abstract:

Background

Recurrence rates for bipolar disorder are high despite effective treatments with mood stabiliser drugs. Self-help treatments and psychological treatments that teach patients to recognise and manage early warning symptoms and signs (EWS) of impending manic or depressive episodes are popular with patients. The main aim of such interventions is to intervene early and prevent bipolar episodes, thereby increasing the time to the next recurrence and preventing hospitalisation.

Objectives

To compare the effectiveness of an EWS intervention plus treatment as usual (TAU ) versus TAU (involving and not involving a psychological therapy) on time to manic, depressive and all bipolar episodes (the primary outcome), hospitalisation, functioning, depressive and manic symptoms.

Search strategy

Relevant studies identified by searching Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References – searched on 20/10/2005), supplemented with hand searching the journal Bipolar Disorders, searching the UK National Research Register, checking reference lists of included studies and contacting authors.

Selection criteria

Only randomised controlled trials (RCTs) were included. Participants were adults with a diagnosis of bipolar disorder based on standardised psychiatric criteria.

Data collection and analysis

Two reviewers independently rated trials for inclusion. Data were extracted from included trials by reviewers using a data extraction sheet. Authors of all the included studies were contacted for any additional information required. Time to recurrence data was summarised as log hazard ratios, dichotomous data as relative risk and continuous data as weighted mean difference, using random effects models to calculate effect size only when there was heterogeneity in the data.

Main results

Eleven RCTs were identified, but only six provided primary outcome data. All six RCTs were of high quality. Time to first recurrence of any type (RE, hazards ratio 0.57, 95% CI 0.39 to 0.82), time to manic/hypomanic episode, time to depressive episode, and percentage of people hospitalised and functioning favoured the intervention group. Neither depressive nor hypomanic symptoms differed between intervention and control groups.

Authors’ conclusions

This review shows a beneficial effect of EWS in time to recurrence, percentage of people hospitalised and functioning in people with bipolar disorder. However, the absence of data on the primary outcome measure in so many included studies is a source of concern and a potential source of bias. Mental health services should consider routinely providing EWS interventions to adults with bipolar disorder, as they appear to reduce hospitalisation and therefore may be cost-effective.

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Cochrane – Behavioural and CBT for OCD in children and adolescents

Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents, Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004856. DOI: 10.1002/14651858.CD004856.pub2.

Click on the title above to access the full-text of this review

Abstract:

Background

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2006.

Obsessive-compulsive disorder (OCD) in children and adolescents is characterised by persistent intrusive thoughts, inappropriate impulses or images which cause marked anxiety, and/or by persistent repetitive behaviours such as hand washing, checking and ordering. Along with antidepressant medication, behavioural or cognitive-behavioural therapy (BT/CBT) is recommended as the treatment of choice for paediatric obsessive-compulsive disorder (OCD).

Objectives

This review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against medication and whether there are benefits in using BT/CBT combined with medication.

Search strategy

We searched CCDANCTR-Studies,CCDANCTR-References (16/3/2009), MEDLINE, EMBASE, PsycINFO, national trials registers, reference lists of all selected studies and handsearched journals related to cognitive behavioural treatment of OCD.

Selection criteria

Included studies were randomised or quasi-randomised controlled trials trials with participants 18 years of age or younger with a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included standard behavioural or cognitive-behavioural techniques, either alone or in combination, compared with wait-list, attention placebo, pill placebo or medication.

Data collection and analysis

The quality of selected studies was assessed independently by two review authors. Using Review Manager software, weighted mean differences were calculated for the total severity of OCD symptoms at post treatment and relative risks for having OCD at post treatment.

Main results

Eight studies with 343 participants were included. The review found evidence for lower post-treatment OCD severity and reduced risk of continuing with OCD for the BT/CBT group compared to pill placebo or wait-list comparisons. There was no evidence found that the efficacy of BT/CBT alone and medication alone differ in terms of post treatment symptom severity or in the risk of having OCD. There was some evidence of a benefit for combined BT/CBT and medication compared to medication alone but not relative to BT/CBT alone. The low rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families.

Authors’ conclusions

Although only based on a small number of studies which vary in quality, behavioural or cognitive-behaviour therapy alone appears to be an effective treatment for OCD in children and adolescents. It is as effective as medication alone and may lead to better outcomes when combined with medication compared to medication alone. Additional higher quality trials are needed to confirm these findings.

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Cochrane – Interventions for promoting physical activity

Interventions for promoting physical activity  Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD003180. DOI: 10.1002/14651858.CD003180.pub2.

Charles Foster1, Melvyn Hillsdon2, Margaret Thorogood3

1BHF Health Promotion Reserach Group, University of Oxford, Headington, Oxford, UK. 2Department of Excercise and Health Sciences, University of Bristol , Bristol , UK. 3Public Health and Epidemiology, University of Warwick, Coventry, UK

Abstract:

Background

Little is known about the effectiveness of strategies to enable people to achieve and maintain recommended levels of physical activity.

Objectives

To assess the effectiveness of interventions designed to promote physical activity in adults aged 16 years and older, not living in an institution.

Search strategy

We searched The Cochrane Library (issue 1 2005), MEDLINE, EMBASE, CINAHL, PsycLIT, BIDS ISI, SPORTDISCUS, SIGLE, SCISEARCH (from earliest dates available to December 2004). Reference lists of relevant articles were checked. No language restrictions were applied.

Selection criteria

Randomised controlled trials that compared different interventions to encourage sedentary adults not living in an institution to become physically active. Studies required a minimum of six months follow up from the start of the intervention to the collection of final data and either used an intention-to-treat analysis or, failing that, had no more than 20% loss to follow up.

Data collection and analysis

At least two reviewers independently assessed each study quality and extracted data. Study authors were contacted for additional information where necessary. Standardised mean differences and 95% confidence intervals were calculated for continuous measures of self-reported physical activity and cardio-respiratory fitness. For studies with dichotomous outcomes, odds ratios and 95% confidence intervals were calculated.

Main results

The effect of interventions on self-reported physical activity (19 studies; 7598 participants) was positive and moderate (pooled SMD random effects model 0.28 95% CI 0.15 to 0.41) as was the effect of interventions (11 studies; 2195 participants) on cardio-respiratory fitness (pooled SMD random effects model 0.52 95% CI 0.14 to 0.90). There was significant heterogeneity in the reported effects as well as heterogeneity in characteristics of the interventions. The heterogeneity in reported effects was reduced in higher quality studies, when physical activity was self-directed with some professional guidance and when there was on-going professional support.

Authors’ conclusions

Our review suggests that physical activity interventions have a moderate effect on self-reported physical activity, on achieving a predetermined level of physical activity and cardio-respiratory fitness. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of the interventions. Future studies should provide greater detail of the components of interventions.

 

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Cochrane – Psychological treatments for bulimia nervosa and binging

Psychological treatments for bulimia nervosa and binging  Hay PPJ, Bacaltchuk J, Stefano S, Kashyap P. Psychological treatments for bulimia nervosa and binging. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD000562

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Abstract:

Background

A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used.

Objectives

To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating.

Search strategy

Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007.

Selection criteria

Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate.

Data collection and analysis

Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied.

Main results

48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.

Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.

Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders.

Authors’ conclusions

There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.

Lancashire Care staff only, can email for full-text of this Cochrane document: susan.jennings@lancashirecare.nhs.uk

Alternatives to inpatient mental health care for children and young people – Cochrane

Alternatives to inpatient mental health care for children and young people, Cochrane Database of  Systematic Reviews,  2009 Apr 15;(2):CD006410

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Shepperd S, Doll H, Gowers S,  James A, Fazel M, Fitzpatrick R, Pollock J.

Department of Public Health, University of Oxford, Rosemary Rue Building, Headington, Oxford, Oxfordshire, UK, OX3 7LF. Sasha.Shepperd@dphpc.ox.ac.uk

Abstract:

Background

Current policy in the UK and elsewhere places emphasis on the provision of mental health services in the least restrictive setting, whilst also recognising that some children will require inpatient care. As a result, there are a range of mental health services to manage young people with serious mental health problems who are at risk of being admitted to an inpatient unit in community or outpatient settings.

Objectives

1. To assess the effectiveness, acceptability and cost of mental health services that provide an alternative to inpatient care for children and young people.
2. To identify the range and prevalence of different models of service that seek to avoid inpatient care for children and young people.

Search strategy

Our search included the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 4), MEDLINE (1966 to 2007), EMBASE (1982 to 2006), the British Nursing Index (1994 to 2006), RCN database (1985 to 1996), CINAHL (1982 to 2006) and PsycInfo (1972 to 2007).

Selection criteria

Randomised controlled trials of mental health services providing specialist care, beyond the scope of generic outpatient provision, as an alternative to inpatient mental health care, for children or adolescents aged from five to 18 years who have a serious mental health condition requiring specialist services beyond the capacity of generic outpatient provision. The control group received mental health services in an inpatient or equivalent setting.

Data collection and analysis

Two authors independently extracted data and assessed study quality. We grouped studies according to the intervention type but did not pool data because of differences in the interventions and measures of outcome. Where data were available we calculated confidence intervals (CIs) for differences between groups at follow up. We also calculated standardised mean differences (SMDs) and 95% CIs for each outcome in terms of mean change from baseline to follow up using the follow-up SDs. We calculated SMDs (taking into account the direction of change and the scoring of each instrument) so that negative SMDs indicate results that favour treatment and positive SMDs favour the control group.

Main results

We included seven randomised controlled trials (recruiting a total of 799 participants) evaluating four distinct models of care: multi-systemic therapy (MST) at home, specialist outpatient service, intensive home treatment and intensive home-based crisis intervention (‘Homebuilders’ model for crisis intervention). Young people receiving home-based MST experienced some improved functioning in terms of externalising symptoms and they spent fewer days out of school and out-of-home placement. At short term follow up the control group had a greater improvement in terms of adaptability and cohesion; this was not sustained at four months follow up. There were small, significant patient improvements reported in both groups in the trial evaluating the intensive home-based crisis intervention using the ‘Homebuilders’ model. No differences at follow up were reported in the two trials evaluating intensive home treatment, or in the trials evaluating specialist outpatient services.

Authors’ conclusions

The quality of the evidence base currently provides very little guidance for the development of services. If randomised controlled trials are not feasible then consideration should be given to alternative study designs, such as prospective systems of audit conducted across several centres, as this has the potential to improve the current level of evidence. These studies should include baseline measurement at admission along with demographic data, and outcomes measured using a few standardised robust instruments.

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Strength training for older people – Cochrane

Progressive resistance strength training for improving physical function in older adults, Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD002759

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Abstract:

 

Background

Muscle weakness in old age is associated with physical function decline. Progressive resistance strength training (PRT) exercises are designed to increase strength.

Objectives

To assess the effects of PRT on older people and identify adverse events.

Search strategy

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register (to March 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to May 01, 2008), EMBASE (1980 to February 06 2007), CINAHL (1982 to July 01 2007) and two other electronic databases. We also searched reference lists of articles, reviewed conference abstracts and contacted authors.

Selection criteria

Randomised controlled trials reporting physical outcomes of PRT for older people were included.

Data collection and analysis

Two review authors independently selected trials, assessed trial quality and extracted data. Data were pooled where appropriate.

Main results

One hundred and twenty one trials with 6700 participants were included. In most trials, PRT was performed two to three times per week and at a high intensity. PRT resulted in a small but significant improvement in physical ability (33 trials, 2172 participants; SMD 0.14, 95% CI 0.05 to 0.22). Functional limitation measures also showed improvements: e.g. there was a modest improvement in gait speed (24 trials, 1179 participants, MD 0.08 m/s, 95% CI 0.04 to 0.12); and a moderate to large effect for getting out of a chair (11 trials, 384 participants, SMD -0.94, 95% CI -1.49 to -0.38). PRT had a large positive effect on muscle strength (73 trials, 3059 participants, SMD 0.84, 95% CI 0.67 to 1.00). Participants with osteoarthritis reported a reduction in pain following PRT(6 trials, 503 participants, SMD -0.30, 95% CI -0.48 to -0.13). There was no evidence from 10 other trials (587 participants) that PRT had an effect on bodily pain. Adverse events were poorly recorded but adverse events related to musculoskeletal complaints, such as joint pain and muscle soreness, were reported in many of the studies that prospectively defined and monitored these events. Serious adverse events were rare, and no serious events were reported to be directly related to the exercise programme.

Authors’ conclusions

This review provides evidence that PRT is an effective intervention for improving physical functioning in older people, including improving strength and the performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported.

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Cochrane – Psychological Interventions for the Prevention of PTSD

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD006869

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Neil P Roberts1, Neil J Kitchiner1, Justin Kenardy2, Jonathan Bisson3

1Traumatic Stress Service, Cardiff and Vale NHS Trust, Cardiff, UK. 2Department of Psychology, University of Queensland, Brisbane, Australia. 3Department of Psychological Medicine, Cardiff University, Cardiff, UK

Abstract:

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual Psychological Debriefing is not an effective intervention at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of preventing PTSD.

Objectives

To examine the efficacy of multiple session early psychological interventions commenced within three months of a traumatic event aimed at preventing PTSD. Single session individual/group psychological interventions were excluded.

Search strategy

Computerised databases were searched systematically, the most recent search was conducted in August 2008. The Journal of Traumatic Stress and the Journal of Consulting and Clinical Psychology were handsearched for the last two years. Personal communication was undertaken with key experts in the field.

Selection criteria

Randomised controlled trials of any multiple session early psychological intervention or treatment (two or more sessions) designed to prevent symptoms of PTSD.

Data collection and analysis

Data were entered using Review Manager software. The methodological quality of included studies was assessed individually by two review authors. Data were analysed for summary effects using Review Manager 4.2. Mean difference was used for meta-analysis of continuous outcomes and relative risk for dichotomous outcomes.

Main results

Eleven studies with a total of 941 participants were found to have evaluated brief psychological interventions aimed at preventing PTSD in individuals exposed to a specific traumatic event, examining a heterogeneous range of interventions. Eight studies were entered into meta-analysis. There was no observable difference between treatment and control conditions on primary outcome measures for these interventions at initial outcome (k=5, n=479; RR 0.84; 95% CI 0.60 to 1.17). There was a trend for increased self-report of PTSD symptoms at 3 to 6 month follow-up in those who received an intervention (k=4, n=292; SMD 0.23; 95% CI 0.00 to 0.46). Two studies compared a memory structuring intervention against supportive listening. There was no evidence supporting the efficacy of this intervention.

Authors’ conclusions

The results suggest that no psychological intervention can be recommended for routine use following traumatic events and that multiple session interventions, like single session interventions, may have an adverse effect on some individuals. The clear practice implication of this is that, at present, multiple session interventions aimed at all individuals exposed to traumatic events should not be used. Further, better designed studies that explore new approaches to early intervention are now required.

 

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Cochrane – Statins for the prevention of dementia

Statins for the prevention of dementia

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McGuinness B, Craig D, Bullock R, Passmore P. Statins for the prevention of dementia. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003160

Abstract:

There good evidence that statins given in late life to individuals at risk of vascular disease have no effect in preventing dementia
Evidence accumulating from biological and epidemiological studies suggest that high levels of serum cholesterol may promote the pathological processes that lead to Alzheimer’s disease. Lowering cholesterol in experimental animal models slows the expression of Alzheimer’s pathology. These findings raise the possibility that treating humans with cholesterol lowering medications might reduce the risk of developing Alzheimer’s disease. The statin family of medications (lovastatin, pravastatin,simvastatin, and others) are powerful cholesterol lowering agents of proven benefit in vascular disease. Several clinical studies comparing the occurrence of Alzheimer’s disease between users of statins and non-users of statins suggest that risk of Alzheimer’s disease is substantially reduced among the users. However, because these studies are not randomized trials, they provide insufficient evidence to recommend statin therapy. Two randomized trials have since been carried out and neither showed any reduction in occurrence of AD or dementia in patients treated with statins compared to those given placebo. Statins cannot therefore be recommended for the prevention of AD or dementia.

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Cochrane – Interventions for preventing falls in older people living in the community

Interventions for preventing falls in older people living in the community,

Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007146

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Abstract:

 

Background

Approximately 30% of people over 65 years of age living in the community fall each year.

Objectives

To assess the effects of interventions to reduce the incidence of falls in older people living in the community.

Search strategy

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials (all to May 2008).

Selection criteria

Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.

Main results

We included 111 trials (55,303 participants).

Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97), as did Tai Chi (RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97).

Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95%CI 0.65 to 0.86), but not risk of falling.

Overall, vitamin D did not reduce falls (RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. 

Overall, home safety interventions did not reduce falls (RaR 0.90, 95%CI 0.79 to 1.03); RR 0.89, 95%CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95%CI 0.22 to 0.78).

Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95%CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95%CI 0.41 to 0.91).

Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.42, 95%CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls (RaR 0.66, 95%CI 0.45 to 0.95).

There is some evidence that falls prevention strategies can be cost saving.

Authors’ conclusions

Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

 

 

Lancashire Care staff can request the full-text of this paper, email: susan.jennings@lancashirecare.nhs.uk

Cochrane – Psychosocial Well-being of Children affected by HIV and AIDS

Interventions for improving the psychosocial well-being of children affected by HIV and AIDS. Cochrane, April 2009

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Abstract:

As a result of HIV-related mortalities more than 13 million children under the age of 15 have lost a parent due to HIV and AIDS. There are also many children who have HIV-positive parents or primary caregivers; these children are affected by HIV and AIDS and are potentially vulnerable to HIV transmission. Children affected by HIV and AIDS are more vulnerable and face greater challenges to their psychosocial well-being compared to other children of the same age. Interventions have been adopted with the aim of improving the psychosocial well-being of children affected by HIV and AIDS.

Objectives

The primary objective of this review was to assess the effectiveness of interventions that aim to improve the psychosocial well-being of children directly affected by HIV and AIDS.

Search strategy

Electronic databases were systematically searched using pre-defined search terms. Internet searches of relevant organizations involved in HIV and AIDS work were conducted and experts in the field and were contacted directly. Searches were conducted between January and September 2008.

Selection criteria

Randomised controlled trials, crossover trials, cluster-randomised trials and factorial trials were eligible for inclusion. If no controlled trials were found, data from well-designed non-randomised intervention studies (such as before and after studies), cohort, and case-control observational studies were considered for inclusion. Studies which included male and female children under the age of 18 years of age, either orphaned due to AIDS (one or more parents died of HIV related-illness or AIDS), or vulnerable children (one or more parents living with HIV or AIDS) were eligible for review.

Interventions that aim to improve the psychosocial well-being of children affected by HIV and AIDS were included in the review. This included psychological therapy, psychosocial support and/or care, medical interventions and social interventions. Psychosocial outcomes were defined as any intervention that measures psychological and/or social factors.

Data collection and analysis

Two of the authors independently screened the results of the search. The full text of all potentially relevant studies were obtained and were independently assessed by the two reviewers using pre-determined criteria.

Main results

No studies of interventions for improving the psychosocial well-being of children affected by HIV and AIDS were identified.

Authors’ conclusions

Current practice is based on anecdotal knowledge, descriptive studies and situational analyses. Such studies do not provide a strong evidence base for the effectiveness of these interventions.

Implications for research  

This systematic review has identified the need for high quality intervention studies. In order to increase the quality and quantity of such studies there is a need for greater partnerships between program implementers and researchers.

Implications for practice

In the absence of rigorous intervention studies, the body of knowledge available consists of “lessons learned,” child psychological theory and other related research in the adult population. However, such knowledge should not replace the urgent need for rigorous monitoring and evaluation of existing programs and intervention studies to ensure evidence-based practice and policy, and prevent subjecting children to interventions which show no benefit or interventions that could unintentionally lead to harm.

Cochrane Review – Olanzapine in long-term treatment for bipolar disorder

Olanzapine in long-term treatment for bipolar disorder, Cipriani A, Rendell JM, Geddes J. Olanzapine in long-term treatment for bipolar disorder. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004367.

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Background
Many patients with bipolar disorder require long-term treatment to prevent recurrence. Antipsychotic drugs are often used to treat acute manic episodes. It is important to clarify whether olanzapine could have a role in long-term prevention of manic and depressive relapses.

 

Objectives

To assess the effects of olanzapine, as monotherapy or adjunctive treatment, in preventing manic, depressive and mixed episodes in patients with bipolar affective disorder.

 

Psychological therapy & Psychosocial intervention – Cochrane Systematic Review

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers, 21st January 2009, Systematic Review, Cochrane

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Abstract:

Background

Mental health problems are common in primary care and mental health workers MHWs are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers PCPs.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

Most people with mental health problems are treated by their family physician or general practitioner. Physicians will treat these problems, often without referral to mental health specialists, and at times the care is not consistent and could be improved.

This review investigated whether having mental health workers on-site to work with physicians at their offices would change the care that physicians provide. Forty-two studies were reviewed in which on-site mental health workers, such as counsellors or psychiatrists, worked alongside physicians to provide therapy to patients. The review found that when there were mental health workers on-site, patients may reduce the number of visits to their doctors; doctors may reduce how often they refer patients to off-site mental health specialists; doctors may reduce the number of drugs they prescribe to the patients who see the mental health workers; and the costs related to those drugs may be lower. However, these reductions were small and not found consistently in all the studies.

The review also found that there may be little or no difference in how the doctors prescribe drugs or refer patients who have mental health problems but are not seeing the on-site mental health workers. It is also not known what the effect of on-site mental health workers had on how well physicians recognised and diagnosed mental health problems.

Cochrane – Interventions for learning disabled sex offenders

Interventions for learning disabled sex offenders, Cochrane, Systematic Review, 23rd January 2008

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Abstract:

The management of sex offenders is a major public concern. Behavioural and pharmacological interventions have been used for many years and more recently cognitive behavioural based interventions have become popular around the world. Programmes designed for the general population have been modified for those sex offenders with learning disability, to address their cognitive deficits. The efficacy of these modified programmes is unclear.

Dementia, Evidence & Cochrane – Physical activity programs for persons with dementia

Physical activity programs for persons with dementia, 16th July 2008, Cochrane, Systematic Review

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Abstract:

Background

There is some evidence that physical activity delays the onset of dementia in healthy older adults and slows down cognitive decline to prevent the onset of cognitive disability. Studies using animal models suggest that physical activity has the potential to attenuate the pathophysiology of dementia. ‘Physical activity’ refers to ‘usual care plus physical activity’.

Objectives

Primary: do physical activity programs maintain or improve cognition, function, behaviour, depression, and mortality compared to usual care in older persons with dementia?

Secondary: do physical activity programs have an indirect positive impact on family caregivers’ health, quality of life, and mortality compared to family caregivers of older persons with dementia who received usual care alone? Do physical activity programs reduce the use of health care services (e.g., visits to the emergency department) compared to usual care in older persons with dementia and their family caregiver?

Search strategy

The trials were identified from searches of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS on 9 September 2007 using the search terms: exercise OR “physical activity” OR cycling OR swim* OR gym* OR walk* OR danc* OR yoga OR “tai chi”.

Cochrane & Depression – Interventions to improve occupational health in depressed people

Interventions to improve occupational health in depressed people , 16th April 2008, Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006237

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Abstract:

Interventions to improve occupational health in depressed people.

Work disability such as sickness absence or suboptimal work functioning is common in people with depression. However, we do not know how to effectively improve work ability in this group. The objective of this review is to evaluate the effectiveness of work- and worker-directed interventions in reducing work disability of depressed workers. We found eleven studies, involving 2556 participants. None of the studies was work-directed. Of the worker-directed studies, only one study specifically addressed work issues during treatment but that study did not show an effect of the intervention. The other interventions studied were antidepressant medication (4 studies), psychodynamic therapy (1 study), computerised cognitive behavioural intervention (1 study), problem-solving therapy (1 study), and enhanced primary care (3 studies). One study found an effect of tricyclic antidepressant medication combined with psychodynamic therapy but none of the other studies did neither with short term nor with long term follow-up. We conclude that there is no evidence that medication alone or enhanced primary care reduces work disability in depressed workers. In addition, there is no evidence for or against the effectiveness of psychological interventions in reducing work disability of depressed workers.

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