Interventions for improving the adoption of shared decision making by healthcare professionals

Cochrane Reviews, 15 September 2014

Summary

When there are several treatments possible, healthcare professionals can involve patients in the process of making decisions about their care so that the patients can choose care that meets their needs and reflects what is important to them. We call this ‘shared decision making’. Although the results are better when patients are involved, healthcare professionals often do not involve their patients in these decisions. We wanted to know more about what can be done to encourage healthcare professionals to share decision making with their patients. In our review we identified 39 studies that tested what activities work in helping healthcare professionals involve their patients more in the decision-making process. We learned that any such activity was better than none, and that activities for healthcare professionals and patients together worked somewhat better than activities just for patients or just for healthcare professionals. However, given the small number of studies and the differences across the studies, it was difficult to know which activities worked best. This review suggested ways to better evaluate how much healthcare professionals involve patients in healthcare decisions so that we can understand this process better in the future.

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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.

Click on the title above to gain full-text access to the Cochrane review

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