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Abstract
We were interested to read J. J. Hutchinson and A. Puranik (1992) on journal clubs at St Edward's Hospital, and would like to share our experience of running journal clubs in Sheffield. As stated, the College does not provide guidelines on the format of journal clubs, but they do provide a suggested reading list. While this contains interesting and relevant papers, it does not provide a good basis for a journal club programme.
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Bauer R, Conell J, Glenn T, Alda M, Ardau R, Baune BT, Berk M, Bersudsky Y, Bilderbeck A, Bocchetta A, Bossini L, Castro AMP, Cheung EYW, Chillotti C, Choppin S, Zompo MD, Dias R, Dodd S, Duffy A, Etain B, Fagiolini A, Hernandez MF, Garnham J, Geddes J, Gildebro J, Gonzalez-Pinto A, Goodwin GM, Grof P, Harima H, Hassel S, Henry C, Hidalgo-Mazzei D, Kapur V, Kunigiri G, Lafer B, Larsen ER, Lewitzka U, Licht RW, Hvenegaard Lund A, Misiak B, Piotrowski P, Monteith S, Munoz R, Nakanotani T, Nielsen RE, O'donovan C, Okamura Y, Osher Y, Reif A, Ritter P, Rybakowski JK, Sagduyu K, Sawchuk B, Schwartz E, Scippa ÂM, Slaney C, Sulaiman AH, Suominen K, Suwalska A, Tam P, Tatebayashi Y, Tondo L, Vieta E, Vinberg M, Viswanath B, Volkert J, Zetin M, Whybrow PC, Bauer M. International multi-site survey on the use of online support groups in bipolar disorder. Nord J Psychiatry 2017; 71:473-476. [PMID: 28696841 DOI: 10.1080/08039488.2017.1334819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Peer support is an established component of recovery from bipolar disorder, and online support groups may offer opportunities to expand the use of peer support at the patient's convenience. Prior research in bipolar disorder has reported value from online support groups. AIMS To understand the use of online support groups by patients with bipolar disorder as part of a larger project about information seeking. METHODS The results are based on a one-time, paper-based anonymous survey about information seeking by patients with bipolar disorder, which was translated into 12 languages. The survey was completed between March 2014 and January 2016 and included questions on the use of online support groups. All patients were diagnosed by a psychiatrist. Analysis included descriptive statistics and general estimating equations to account for correlated data. RESULTS AND CONCLUSIONS The survey was completed by 1222 patients in 17 countries. The patients used the Internet at a percentage similar to the general public. Of the Internet users who looked online for information about bipolar disorder, only 21.0% read or participated in support groups, chats, or forums for bipolar disorder (12.8% of the total sample). Given the benefits reported in prior research, clarification of the role of online support groups in bipolar disorder is needed. With only a minority of patients using online support groups, there are analytical challenges for future studies.
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Affiliation(s)
- Rita Bauer
- a Department of Psychiatry and Psychotherapy , Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden , Germany
| | - Jörn Conell
- a Department of Psychiatry and Psychotherapy , Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden , Germany.,b AMEOS Klinika Holstein , Neustadt , Germany
| | - Tasha Glenn
- c ChronoRecord Association , Fullerton , CA , USA
| | - Martin Alda
- d Department of Psychiatry , Dalhousie University , Halifax , Nova Scotia , Canada
| | - Raffaella Ardau
- e Unit of Clinical Pharmacology , University Hospital of Cagliari , Cagliari , Italy
| | - Bernhard T Baune
- f Discipline of Psychiatry, School of Medicine , University of Adelaide , Adelaide , SA , Australia
| | - Michael Berk
- g IMPACT Strategic Research Centre, School of Medicine , Deakin University , Geelong , VIC , Australia.,h University Hospital Geelong, Barwon Health , Geelong , VIC , Australia.,i Department of Psychiatry , The University of Melbourne , Parkville , VIC , Australia.,j Florey Institute of Neuroscience and Mental Health , Parkville , VIC , Australia.,k Orygen Youth Health Research Centre , Parkville , VIC , Australia
| | - Yuly Bersudsky
- l Department of Psychiatry, Faculty of Health Sciences , Ben Gurion University of the Negev, Beer Sheva Mental Health Center , Beer Sheva , Israel
| | - Amy Bilderbeck
- m Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Alberto Bocchetta
- n Section of Neurosciences and Clinical Pharmacology, Department of Biomedical Sciences , University of Cagliari , Sardinia , Italy
| | - Letizia Bossini
- o Department of Molecular Medicine and Department of Mental Health (DAI) , University of Siena and University of Siena Medical Center (AOUS) , Siena , Italy
| | - Angela M Paredes Castro
- g IMPACT Strategic Research Centre, School of Medicine , Deakin University , Geelong , VIC , Australia.,h University Hospital Geelong, Barwon Health , Geelong , VIC , Australia
| | - Eric Y W Cheung
- p Department of General Adult Psychiatry , Castle Peak Hospital , Hong Kong , PR China
| | - Caterina Chillotti
- e Unit of Clinical Pharmacology , University Hospital of Cagliari , Cagliari , Italy
| | - Sabine Choppin
- q AP-HP , Hôpitaux Universitaires Henri-Mondor , Créteil , France
| | - Maria Del Zompo
- n Section of Neurosciences and Clinical Pharmacology, Department of Biomedical Sciences , University of Cagliari , Sardinia , Italy
| | - Rodrigo Dias
- r Bipolar Disorder Research Program, Department of Psychiatry , University of São Paulo Medical School , São Paulo , Brazil
| | - Seetal Dodd
- g IMPACT Strategic Research Centre, School of Medicine , Deakin University , Geelong , VIC , Australia.,h University Hospital Geelong, Barwon Health , Geelong , VIC , Australia.,i Department of Psychiatry , The University of Melbourne , Parkville , VIC , Australia
| | - Anne Duffy
- s Department of Psychiatry , University of Calgary , Calgary , Canada
| | - Bruno Etain
- t AP-HP , Hôpitaux Universitaires Henri-Mondor, INSERM U955 (IMRB), Université Paris Est , Créteil , France
| | - Andrea Fagiolini
- o Department of Molecular Medicine and Department of Mental Health (DAI) , University of Siena and University of Siena Medical Center (AOUS) , Siena , Italy
| | - Miryam Fernández Hernandez
- u Department of Psychiatry , University Hospital of Alava, University of the Basque Country, CIBERSAM , Vitoria , Spain
| | - Julie Garnham
- d Department of Psychiatry , Dalhousie University , Halifax , Nova Scotia , Canada
| | - John Geddes
- m Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Jonas Gildebro
- v Department of Affective Disorders, Q, Mood Disorders Research Unit , Aarhus University Hospital , Aarhus , Denmark
| | - Ana Gonzalez-Pinto
- u Department of Psychiatry , University Hospital of Alava, University of the Basque Country, CIBERSAM , Vitoria , Spain
| | - Guy M Goodwin
- m Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Paul Grof
- w Mood Disorders Center of Ottawa , Ottawa , Canada.,x Department of Psychiatry , University of Toronto , Ontario , Canada
| | - Hirohiko Harima
- y Department of Psychiatry , Tokyo Metropolitan Matsuzawa Hospital , Tokyo , Japan
| | - Stefanie Hassel
- z Department of Psychology & Aston Brain Centre , Aston University , Birmingham , UK
| | - Chantal Henry
- t AP-HP , Hôpitaux Universitaires Henri-Mondor, INSERM U955 (IMRB), Université Paris Est , Créteil , France.,aa Unité Perception et Mémoire , Institut Pasteur , Paris , France
| | - Diego Hidalgo-Mazzei
- ab Bipolar Disorders Program , Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM , Barcelona , Catalonia , Spain
| | - Vaisnvy Kapur
- ac Department of Clinical Psychology , NIMHANS , Bangalore , India
| | | | - Beny Lafer
- r Bipolar Disorder Research Program, Department of Psychiatry , University of São Paulo Medical School , São Paulo , Brazil
| | - Erik R Larsen
- v Department of Affective Disorders, Q, Mood Disorders Research Unit , Aarhus University Hospital , Aarhus , Denmark
| | - Ute Lewitzka
- a Department of Psychiatry and Psychotherapy , Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden , Germany
| | - Rasmus W Licht
- ae Psychiatry , Aalborg University Hospital , Aalborg , Denmark.,af Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - Anne Hvenegaard Lund
- v Department of Affective Disorders, Q, Mood Disorders Research Unit , Aarhus University Hospital , Aarhus , Denmark
| | - Blazej Misiak
- ag Department of Psychiatry , Wroclaw Medical University , Wroclaw , Poland
| | - Patryk Piotrowski
- ag Department of Psychiatry , Wroclaw Medical University , Wroclaw , Poland
| | - Scott Monteith
- ah Michigan State University College of Human Medicine , Traverse City Campus , Traverse City , MI , USA
| | - Rodrigo Munoz
- ai Department of Psychiatry , University of California San Diego , San Diego , CA , USA
| | - Takako Nakanotani
- aj Affective Disorders Research Project , Tokyo Metropolitan Institute of Medical Science , Tokyo , Japan
| | - René E Nielsen
- ae Psychiatry , Aalborg University Hospital , Aalborg , Denmark
| | - Claire O'donovan
- d Department of Psychiatry , Dalhousie University , Halifax , Nova Scotia , Canada
| | - Yasushi Okamura
- y Department of Psychiatry , Tokyo Metropolitan Matsuzawa Hospital , Tokyo , Japan
| | - Yamima Osher
- l Department of Psychiatry, Faculty of Health Sciences , Ben Gurion University of the Negev, Beer Sheva Mental Health Center , Beer Sheva , Israel
| | - Andreas Reif
- ak Department of Psychiatry, Psychosomatic Medicine and Psychotherapy , University Hospital Frankfurt, Goethe-University , Frankfurt am Main , Germany
| | - Philipp Ritter
- a Department of Psychiatry and Psychotherapy , Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden , Germany
| | - Janusz K Rybakowski
- al Department of Adult Psychiatry , Poznan University of Medical Sciences , Poznan , Poland
| | - Kemal Sagduyu
- am Department of Psychiatry , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Brett Sawchuk
- s Department of Psychiatry , University of Calgary , Calgary , Canada
| | | | - Ângela M Scippa
- ao Department of Neuroscience and Mental Health , Federal University of Bahia , Salvador , Brazil
| | - Claire Slaney
- d Department of Psychiatry , Dalhousie University , Halifax , Nova Scotia , Canada
| | - Ahmad H Sulaiman
- ap Department of Psychological Medicine, Faculty of Medicine , University of Malaya , Kuala Lumpur , Malaysia
| | - Kirsi Suominen
- aq Department of Social Services and Health Care, Psychiatry , City of Helsinki , Helsinki , Finland
| | - Aleksandra Suwalska
- al Department of Adult Psychiatry , Poznan University of Medical Sciences , Poznan , Poland
| | - Peter Tam
- ar Department of Psychiatry, Department of Medicine , University of Hong Kong , Hong Kong, PR China
| | - Yoshitaka Tatebayashi
- aj Affective Disorders Research Project , Tokyo Metropolitan Institute of Medical Science , Tokyo , Japan
| | - Leonardo Tondo
- as Harvard Medical School-McLean Hospital , Boston , MA , USA.,at Lucio Bini Center , Cagliari e Roma , Italy
| | - Eduard Vieta
- ab Bipolar Disorders Program , Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM , Barcelona , Catalonia , Spain
| | - Maj Vinberg
- au Psychiatric Center Copenhagen , Copenhagen , Denmark
| | - Biju Viswanath
- av Department of Psychiatry , NIMHANS , Bangalore , India
| | - Julia Volkert
- ak Department of Psychiatry, Psychosomatic Medicine and Psychotherapy , University Hospital Frankfurt, Goethe-University , Frankfurt am Main , Germany
| | - Mark Zetin
- aw Department of Psychology , Chapman University , Orange , CA , USA
| | - Peter C Whybrow
- ax Department of Psychiatry and Biobehavioral Sciences , Semel Institute for Neuroscience and Human Behavior University of California Los Angeles (UCLA) , Los Angeles , CA , USA
| | - Michael Bauer
- a Department of Psychiatry and Psychotherapy , Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden , Germany
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Marwood L, Taylor R, Goldsmith K, Romeo R, Holland R, Pickles A, Hutchinson J, Dietch D, Cipriani A, Nair R, Attenburrow MJ, Young AH, Geddes J, McAllister-Williams RH, Cleare AJ. Study protocol for a randomised pragmatic trial comparing the clinical and cost effectiveness of lithium and quetiapine augmentation in treatment resistant depression (the LQD study). BMC Psychiatry 2017; 17:231. [PMID: 28651526 PMCID: PMC5485607 DOI: 10.1186/s12888-017-1393-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Approximately 30-50% of patients with major depressive disorder can be classed as treatment resistant, widely defined as a failure to respond to two or more adequate trials of antidepressants in the current episode. Treatment resistant depression is associated with a poorer prognosis and higher mortality rates. One treatment option is to augment an existing antidepressant with a second agent. Lithium and the atypical antipsychotic quetiapine are two such add-on therapies and are currently recommended as first line options for treatment resistant depression. However, whilst neither treatment has been established as superior to the other in short-term studies, they have yet to be compared head-to-head in longer term studies, or with a superiority design in this patient group. METHODS The Lithium versus Quetiapine in Depression (LQD) study is a parallel group, multi-centre, pragmatic, open-label, patient randomised clinical trial designed to address this gap in knowledge. The study will compare the clinical and cost effectiveness of the decision to prescribe lithium or quetiapine add-on therapy to antidepressant medication for patients with treatment resistant depression. Patients will be randomised 1:1 and followed up over 12 months, with the hypothesis being that quetiapine will be superior to lithium. The primary outcomes will be: (1) time to all-cause treatment discontinuation over one year, and (2) self-rated depression symptoms rated weekly for one year via the Quick Inventory of Depressive Symptomatology. Other outcomes will include between group differences in response and remission rates, quality of life, social functioning, cost-effectiveness and the frequency of serious adverse events and side effects. DISCUSSION The trial aims to help shape the treatment pathway for patients with treatment resistant depression, by determining whether the decision to prescribe quetiapine is superior to lithium. Strengths of the study include its pragmatic superiority design, broad inclusion criteria (external validity) and longer follow up than previous studies. TRIAL REGISTRATION ISRCTN registry: ISRCTN16387615 , registered 28 February 2016. ClinicalTrials.gov: NCT03004521 , registered 17 November 2016.
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Affiliation(s)
- L. Marwood
- 0000 0001 2322 6764grid.13097.3cCentre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,0000 0000 9439 0839grid.37640.36South London and Maudsley NHS Foundation Trust, London, UK
| | - R. Taylor
- 0000 0001 2322 6764grid.13097.3cCentre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,0000 0000 9439 0839grid.37640.36South London and Maudsley NHS Foundation Trust, London, UK
| | - K. Goldsmith
- 0000 0001 2322 6764grid.13097.3cBiostatistics & Health Informatics Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - R. Romeo
- 0000 0001 2322 6764grid.13097.3cHealth Services and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - R. Holland
- 0000 0001 2322 6764grid.13097.3cBiostatistics & Health Informatics Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - A. Pickles
- 0000 0001 2322 6764grid.13097.3cBiostatistics & Health Informatics Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - J. Hutchinson
- grid.451089.1Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK ,0000 0001 0462 7212grid.1006.7Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | | | - A. Cipriani
- 0000 0004 1936 8948grid.4991.5Department of Psychiatry, University of Oxford, Oxford, UK ,0000 0004 0573 576Xgrid.451190.8Oxford Health NHS Foundation Trust, Oxford, UK
| | - R. Nair
- grid.439606.eTees, Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - M.-J. Attenburrow
- 0000 0004 1936 8948grid.4991.5Department of Psychiatry, University of Oxford, Oxford, UK ,0000 0004 0573 576Xgrid.451190.8Oxford Health NHS Foundation Trust, Oxford, UK
| | - A. H. Young
- 0000 0001 2322 6764grid.13097.3cCentre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,0000 0000 9439 0839grid.37640.36South London and Maudsley NHS Foundation Trust, London, UK
| | - J. Geddes
- 0000 0004 1936 8948grid.4991.5Department of Psychiatry, University of Oxford, Oxford, UK ,0000 0004 0573 576Xgrid.451190.8Oxford Health NHS Foundation Trust, Oxford, UK
| | - R. H. McAllister-Williams
- grid.451089.1Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK ,0000 0001 0462 7212grid.1006.7Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - A. J. Cleare
- 0000 0001 2322 6764grid.13097.3cCentre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,0000 0000 9439 0839grid.37640.36South London and Maudsley NHS Foundation Trust, London, UK
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Atkinson LZ, Forrest A, Marriner L, Geddes J, Cipriani A. Implementing tools to support evidence-based practice: a survey and brief intervention study of the National Elf Service across Oxford Health NHS Foundation Trust. Evid Based Ment Health 2017; 20:41-45. [PMID: 28363988 PMCID: PMC10688520 DOI: 10.1136/eb-2017-102665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Technology and the internet has enabled rapid access to research but most mental health professionals do not have time to keep up with the vast and growing scientific literature. Secondary information sources, such as the National Elf Service (NES), aim to summarise the most important and up-to-date research to improve mental health professionals' access to information to support evidence-based medicine (EBM). OBJECTIVE To explore mental health professionals' attitudes towards evidence-based practice and methods used to keep up-to-date with research. To promote use of a digital evidence-based platform (the National Elf Service), assess its use and explore its potential to impact clinical practice. METHODS Baseline and follow-up surveys were distributed among staff of 5 adult mental health community teams and 2 early intervention services (n=331) in Oxford Health Foundation Trust (OHFT) prior to and following an intervention raising awareness of the National Elf Service. FINDINGS Of 133 baseline survey responders, the majority of staff reported their clinical practice was informed by evidence, mostly using existing clinical guidelines and online resources. Few had used the National Elf Service. 122 staff members completed the follow-up survey. Postintervention, 42 staff members indicated they had used the National Elf Service (compared with 13 preintervention) and that it had improved access to research. Lack of time was most often the barrier restricting evidence-based practice. CONCLUSIONS Mental health professionals are engaged with EBM and those that used the National Elf Service felt it did, or could have the potential to impact on their clinical practice. CLINICAL IMPLICATIONS Barriers and challenges to implement EBM more widely suggest targeted efforts should be made to embed evidence-based practice into the working culture.
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Affiliation(s)
- Lauren Z Atkinson
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK;
| | - Alexandra Forrest
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK;
| | - Leah Marriner
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK;
| | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK;
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK;
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Conell J, Bauer R, Glenn T, Alda M, Ardau R, Baune BT, Berk M, Bersudsky Y, Bilderbeck A, Bocchetta A, Bossini L, Paredes Castro AM, Cheung EYW, Chillotti C, Choppin S, Del Zompo M, Dias R, Dodd S, Duffy A, Etain B, Fagiolini A, Garnham J, Geddes J, Gildebro J, Gonzalez-Pinto A, Goodwin GM, Grof P, Harima H, Hassel S, Henry C, Hidalgo-Mazzei D, Kapur V, Kunigiri G, Lafer B, Lam C, Larsen ER, Lewitzka U, Licht RW, Lund AH, Misiak B, Piotrowski P, Monteith S, Munoz R, Nakanotani T, Nielsen RE, O'Donovan C, Okamura Y, Osher Y, Reif A, Ritter P, Rybakowski JK, Sagduyu K, Sawchuk B, Schwartz E, Scippa ÂM, Slaney C, Sulaiman AH, Suominen K, Suwalska A, Tam P, Tatebayashi Y, Tondo L, Vieta E, Vinberg M, Viswanath B, Volkert J, Zetin M, Zorrilla I, Whybrow PC, Bauer M. Erratum to: Online information seeking by patients with bipolar disorder: results from an international multisite survey. Int J Bipolar Disord 2017; 5:18. [PMID: 28364388 PMCID: PMC5376258 DOI: 10.1186/s40345-017-0082-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jörn Conell
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rita Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Tasha Glenn
- ChronoRecord Association, Fullerton, CA, USA
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Raffaella Ardau
- Unit of Clinical Pharmacology, University Hospital of Cagliari, Cagliari, Italy
| | - Bernhard T Baune
- Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia.,University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia.,Orygen Youth Health Research Centre, Parkville, VIC, Australia
| | - Yuly Bersudsky
- Department of Psychiatry, Faculty of Health Sciences, Ben Gurion University of the Negev; Beer Sheva Mental Health Center, Beer Sheva, Israel
| | - Amy Bilderbeck
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Alberto Bocchetta
- Section of Neurosciences and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Sardinia, Italy
| | - Letizia Bossini
- Department of Molecular Medicine, Department of Mental Health (DAI), University of Siena, University of Siena Medical Center (AOUS), Siena, Italy
| | - Angela Marianne Paredes Castro
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia.,University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Eric Yat Wo Cheung
- Department of General Adult Psychiatry, Castle Peak Hospital, Hong Kong, China
| | - Caterina Chillotti
- Unit of Clinical Pharmacology, University Hospital of Cagliari, Cagliari, Italy
| | - Sabine Choppin
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Créteil, France
| | - Maria Del Zompo
- Section of Neurosciences and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Sardinia, Italy
| | - Rodrigo Dias
- Bipolar Disorder Research Program, Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Seetal Dodd
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia.,University Hospital Geelong, Barwon Health, Geelong, VIC, Australia.,Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
| | - Anne Duffy
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Bruno Etain
- AP-HP, Hôpitaux Universitaires Henri-Mondor, INSERM U955 (IMRB), Université Paris Est, Créteil, France
| | - Andrea Fagiolini
- Department of Molecular Medicine, Department of Mental Health (DAI), University of Siena, University of Siena Medical Center (AOUS), Siena, Italy
| | - Julie Garnham
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Jonas Gildebro
- Department of Affective Disorders, Q, Mood Disorders Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Ana Gonzalez-Pinto
- Department of Psychiatry, University Hospital of Alava, University of the Basque Country, CIBERSAM, Vitoria, Spain
| | - Guy M Goodwin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Paul Grof
- Mood Disorders Center of Ottawa, Ottawa, Canada.,Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Hirohiko Harima
- Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Setagaya, Tokyo, Japan
| | - Stefanie Hassel
- Department of Psychology & Aston Brain Centre, Aston University, Birmingham, UK
| | - Chantal Henry
- AP-HP, Hôpitaux Universitaires Henri-Mondor, INSERM U955 (IMRB), Université Paris Est, Créteil, France.,Institut Pasteur, Unité Perception et Mémoire, 75015, Paris, France
| | - Diego Hidalgo-Mazzei
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Vaisnvy Kapur
- Department of Clinical Psychology, NIMHANS, Bangalore, 560029, India
| | | | - Beny Lafer
- Bipolar Disorder Research Program, Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Chun Lam
- Department of Psychiatry, Kowloon Hospital, Hong Kong, China
| | - Erik Roj Larsen
- Department of Affective Disorders, Q, Mood Disorders Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Ute Lewitzka
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rasmus W Licht
- Aalborg University Hospital, Psychiatry, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Hvenegaard Lund
- Department of Affective Disorders, Q, Mood Disorders Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Blazej Misiak
- Department of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Patryk Piotrowski
- Department of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Scott Monteith
- Michigan State University College of Human Medicine, Traverse City Campus, Traverse City, MI, USA
| | - Rodrigo Munoz
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Takako Nakanotani
- Affective Disorders Research Project, Tokyo Metropolitan Institute of Medical Science, Setagaya, Tokyo, Japan
| | - René E Nielsen
- Aalborg University Hospital, Psychiatry, Aalborg, Denmark
| | - Claire O'Donovan
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Yasushi Okamura
- Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Setagaya, Tokyo, Japan
| | - Yamima Osher
- Department of Psychiatry, Faculty of Health Sciences, Ben Gurion University of the Negev; Beer Sheva Mental Health Center, Beer Sheva, Israel
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Philipp Ritter
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences,, Poznan, Poland
| | - Kemal Sagduyu
- Department of Psychiatry, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Brett Sawchuk
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | | | - Ângela Miranda Scippa
- Department of Neuroscience and Mental Health, Federal University of Bahia, Salvador, Brazil
| | - Claire Slaney
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ahmad Hatim Sulaiman
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kirsi Suominen
- City of Helsinki, Department of Social Services and Health Care, Psychiatry, Helsinki, Finland
| | - Aleksandra Suwalska
- Department of Adult Psychiatry, Poznan University of Medical Sciences,, Poznan, Poland
| | - Peter Tam
- Department of Psychiatry, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Yoshitaka Tatebayashi
- Affective Disorders Research Project, Tokyo Metropolitan Institute of Medical Science, Setagaya, Tokyo, Japan
| | - Leonardo Tondo
- Harvard Medical School-McLean Hospital, Boston, MA, USA.,Lucio Bini Center, Cagliari e Roma, Italy
| | - Eduard Vieta
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Maj Vinberg
- Psychiatric Center Copenhagen, Copenhagen, Denmark
| | - Biju Viswanath
- Department of Psychiatry, NIMHANS, Bangalore, 560029, India
| | - Julia Volkert
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Mark Zetin
- Department of Psychology, Chapman University, Orange, CA, USA
| | - Iñaki Zorrilla
- Department of Psychiatry, University Hospital of Alava, University of the Basque Country, CIBERSAM, Vitoria, Spain
| | - Peter C Whybrow
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Bauer M, Glenn T, Monteith S, Bauer R, Whybrow PC, Geddes J. Ethical perspectives on recommending digital technology for patients with mental illness. Int J Bipolar Disord 2017; 5:6. [PMID: 28155206 PMCID: PMC5293713 DOI: 10.1186/s40345-017-0073-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/04/2017] [Indexed: 12/12/2022] Open
Abstract
The digital revolution in medicine not only offers exciting new directions for the treatment of mental illness, but also presents challenges to patient privacy and security. Changes in medicine are part of the complex digital economy based on creating value from analysis of behavioral data acquired by the tracking of daily digital activities. Without an understanding of the digital economy, recommending the use of technology to patients with mental illness can inadvertently lead to harm. Behavioral data are sold in the secondary data market, combined with other data from many sources, and used in algorithms that automatically classify people. These classifications are used in commerce and government, may be discriminatory, and result in non-medical harm to patients with mental illness. There is also potential for medical harm related to poor quality online information, self-diagnosis and self-treatment, passive monitoring, and the use of unvalidated smartphone apps. The goal of this paper is to increase awareness and foster discussion of the new ethical issues. To maximize the potential of technology to help patients with mental illness, physicians need education about the digital economy, and patients need help understanding the appropriate use and limitations of online websites and smartphone apps.
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Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Tasha Glenn
- ChronoRecord Association, Inc., Fullerton, CA, 92834, USA
| | - Scott Monteith
- Michigan State University College of Human Medicine, Traverse City Campus, 1400 Medical Campus Drive, Traverse City, MI, 49684, USA
| | - Rita Bauer
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Peter C Whybrow
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior University of California Los Angeles (UCLA), 300 UCLA Medical Plaza, Los Angeles, CA, 90095, USA
| | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
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Barnes TRE, Leeson VC, Paton C, Costelloe C, Simon J, Kiss N, Osborn D, Killaspy H, Craig TKJ, Lewis S, Keown P, Ismail S, Crawford M, Baldwin D, Lewis G, Geddes J, Kumar M, Pathak R, Taylor S. Antidepressant Controlled Trial For Negative Symptoms In Schizophrenia (ACTIONS): a double-blind, placebo-controlled, randomised clinical trial. Health Technol Assess 2017; 20:1-46. [PMID: 27094189 DOI: 10.3310/hta20290] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence suggests that a combination of antipsychotic and antidepressant medication may be effective in treating negative symptoms, it is too limited to allow any firm conclusions. OBJECTIVE To establish the clinical effectiveness and cost-effectiveness of augmentation of antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia. DESIGN A multicentre, double-blind, individually randomised, placebo-controlled trial with 12-month follow-up. SETTING Adult psychiatric services, treating people with schizophrenia. PARTICIPANTS Inpatients or outpatients with schizophrenia, on continuing, stable antipsychotic medication, with persistent negative symptoms at a criterion level of severity. INTERVENTIONS Eligible participants were randomised 1 : 1 to treatment with either placebo (one capsule) or 20 mg of citalopram per day for 48 weeks, with the clinical option at 4 weeks to increase the daily dosage to 40 mg of citalopram or two placebo capsules for the remainder of the study. MAIN OUTCOME MEASURES The primary outcomes were quality of life measured at 12 and 48 weeks assessed using the Heinrich's Quality of Life Scale, and negative symptoms at 12 weeks measured on the negative symptom subscale of the Positive and Negative Syndrome Scale. RESULTS No therapeutic benefit in terms of improvement in quality of life or negative symptoms was detected for citalopram over 12 weeks or at 48 weeks, but secondary analysis suggested modest improvement in the negative symptom domain, avolition/amotivation, at 12 weeks (mean difference -1.3, 95% confidence interval -2.5 to -0.09). There were no statistically significant differences between the two treatment arms over 48-week follow-up in either the health economics outcomes or costs, and no differences in the frequency or severity of adverse effects, including corrected QT interval prolongation. LIMITATIONS The trial under-recruited, partly because cardiac safety concerns about citalopram were raised, with the 62 participants recruited falling well short of the target recruitment of 358. Although this was the largest sample randomised to citalopram in a randomised controlled trial of antidepressant augmentation for negative symptoms of schizophrenia and had the longest follow-up, the power of statistical analysis to detect significant differences between the active and placebo groups was limited. CONCLUSION Although adjunctive citalopram did not improve negative symptoms overall, there was evidence of some positive effect on avolition/amotivation, recognised as a critical barrier to psychosocial rehabilitation and achieving better social and community functional outcomes. Comprehensive assessment of side-effect burden did not identify any serious safety or tolerability issues. The addition of citalopram as a long-term prescribing strategy for the treatment of negative symptoms may merit further investigation in larger studies. FUTURE WORK Further studies of the viability of adjunctive antidepressant treatment for negative symptoms in schizophrenia should include appropriate safety monitoring and use rating scales that allow for evaluation of avolition/amotivation as a discrete negative symptom domain. Overcoming the barriers to recruiting an adequate sample size will remain a challenge. TRIAL REGISTRATION European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2009-009235-30 and Current Controlled Trials ISRCTN42305247. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 29. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Thomas R E Barnes
- Centre for Mental Health, Imperial College London, London, UK.,West London Mental Health NHS Trust, London, UK
| | - Verity C Leeson
- Centre for Mental Health, Imperial College London, London, UK
| | - Carol Paton
- Centre for Mental Health, Imperial College London, London, UK.,Oxleas NHS Foundation Trust, Dartford, UK
| | - Céire Costelloe
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Judit Simon
- Department of Health Economics, Centre for Public Health, Medical University of Vienna, Vienna, Austria
| | - Noemi Kiss
- Department of Health Economics, Centre for Public Health, Medical University of Vienna, Vienna, Austria
| | - David Osborn
- Division of Psychiatry, University College London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Helen Killaspy
- Division of Psychiatry, University College London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Tom K J Craig
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Shôn Lewis
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Patrick Keown
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Shajahan Ismail
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Mike Crawford
- Centre for Mental Health, Imperial College London, London, UK
| | - David Baldwin
- Mental Health Group, University of Southampton Faculty of Medicine, Southampton, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Manoj Kumar
- South Staffordshire and Shropshire Healthcare NHS Foundation Trust, Stafford, UK
| | - Rudresh Pathak
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | - Simon Taylor
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
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60
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Abstract
The delivery of psychiatric care is changing with a new emphasis on integrated care, preventative measures, population health, and the biological basis of disease. Fundamental to this transformation are big data and advances in the ability to analyze these data. The impact of big data on the routine treatment of bipolar disorder today and in the near future is discussed, with examples that relate to health policy, the discovery of new associations, and the study of rare events. The primary sources of big data today are electronic medical records (EMR), claims, and registry data from providers and payers. In the near future, data created by patients from active monitoring, passive monitoring of Internet and smartphone activities, and from sensors may be integrated with the EMR. Diverse data sources from outside of medicine, such as government financial data, will be linked for research. Over the long term, genetic and imaging data will be integrated with the EMR, and there will be more emphasis on predictive models. Many technical challenges remain when analyzing big data that relates to size, heterogeneity, complexity, and unstructured text data in the EMR. Human judgement and subject matter expertise are critical parts of big data analysis, and the active participation of psychiatrists is needed throughout the analytical process.
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Affiliation(s)
- Scott Monteith
- />Michigan State University College of Human Medicine, Traverse City Campus, 1400 Medical Campus Drive, Traverse City, MI 49684 USA
| | - Tasha Glenn
- />ChronoRecord Association, Inc, Fullerton, CA 92834 USA
| | - John Geddes
- />Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, OX3 7JX UK
| | - Peter C. Whybrow
- />Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior University of California Los Angeles (UCLA), 300 UCLA Medical Plaza, Los Angeles, CA 90095 USA
| | - Michael Bauer
- />Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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Hanger C, Geddes J, Wilkinson T, Lee M, Pearson S, Butler A, Badami K. Improving the use and timeliness of anticoagulation reversal for warfarin related intracranial haemorrhage. N Z Med J 2016; 129:35-49. [PMID: 27857237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Warfarin-related intracranial haemorrhage (WRICH) is a life-threatening complication of warfarin use. Rapid and complete reversal of the coagulopathy is required. Reversal protocols which include prothrombin complex concentrates (PCC) are now recommended. We report on a quality improvement project to implement and refine such a protocol. METHODS Retrospective and then prospective audits of all WRICH patients presenting to a single centre. The protocol development and subsequent refinements are described. Outcomes included times to scanning, treatment and overall door-needle times, as well as use of PCC. RESULTS Across the three cohorts, use of PCC increased over time from 15% to 100% of eligible patients (p<0.001). There were significant improvements in median time to scanning (1.9 to 1.5 to 1.3 hours, p=0.03) and median door-needle times (4.5 to 2.9 to 1.9 hours, p=0.018). Key steps in the change process included (1) identifying need for change, (2) utilising senior clinical opinion leaders, (3) using "Plan-do-study-act" cycles, (4) involvement of all relevant stakeholders, (5) having a broad implementation and education plan, (6) a "change friendly" environment and (7) collaborating across departments. CONCLUSION The introduction (and revisions) of an anticoagulation reversal strategy for WRICH has led to increased PCC use and reduced times to both diagnosis and treatment. Further work is required to improve door-needle times and monitoring.
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Affiliation(s)
- Carl Hanger
- Older Persons Health Specialist Service, Burwood Hospital, Stroke Service, Christchurch Hospital, Department of Medicine, University of Otago, Christchurch
| | - John Geddes
- Older Persons Health Specialist Service, Burwood Hospital, Department of Medicine, University of Otago, Christchurch
| | - Tim Wilkinson
- Older Persons Health Specialist Service, Burwood Hospital, Department of Medicine, University of Otago, Christchurch
| | - Michele Lee
- Older Persons Health Specialist Service, Burwood Hospital, Department of General Medicine, Christchurch Hospital, Christchurch
| | - Scott Pearson
- Emergency Department, Christchurch Hospital, Christchurch
| | - Andrew Butler
- Haematology Department, Christchurch Hospital, Department of Medicine, University of Otago, Christchurch
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Abstract
BACKGROUND Bipolar disorder is a common recurrent illness with high levels of chronicity. Previous trials have suggested that the anticonvulsant topiramate may be efficacious in bipolar disorder. This is an update of a previous Cochrane review (last published 2006) on the role of topiramate in bipolar disorder. OBJECTIVES To assess the effects of topiramate for acute mood episodes in bipolar disorder in adults compared to placebo, alternative pharmacological treatment, and combination pharmacological treatment as measured by treatment of symptoms on specific rating scales for individual episodes. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Controlled Trials Register to 13 October 2015, which includes records from the Cochrane Central Register of Controlled Trials (CENTRAL) all years; MEDLINE 1950-; EMBASE 1974-; and PsycINFO 1967-.We performed handsearching, reviewing of grey literature and reference lists, and correspondence with authors and pharmaceutical companies. SELECTION CRITERIA Randomised controlled trials comparing topiramate with placebo or with active agents in the treatment of acute mood episodes in adult male and female patients with bipolar disorder. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and methodological quality assessment. For analysis, we used odds ratio (OR) for binary efficacy outcomes and mean difference (MD) for continuously distributed outcomes. MAIN RESULTS This review included six studies with a total of 1638 male and female participants, of all ethnic backgrounds in both inpatient and outpatient settings. In five studies, participants were experiencing a manic or mixed episode, and in the other study the participants met the criteria for a depressive phase. Topiramate was compared with placebo and alternative pharmacological treatment as both monotherapy and as adjunctive treatment.Moderate-quality evidence showed topiramate to be no more or less efficacious than placebo as monotherapy, in terms of mean change on Young Mania Rating Scale (YMRS) (range 0 to 60), at endpoint 3 weeks (MD 1.17, 95% confidence interval (CI) -0.52 to 2.86; participants = 664; studies = 3; P = 0.17) and at endpoint 12 weeks (MD -0.58, 95% CI -3.45 to 2.29; participants = 212; studies = 1; P = 0.69; low-quality evidence). For the same outcome, low-quality evidence also showed topiramate to be no more or less efficacious than placebo as add-on therapy (endpoint 12 weeks) (MD -0.14, 95% CI -2.10 to 1.82; participants = 287; studies = 1; P = 0.89) in the treatment of manic and mixed episodes. We found high-quality evidence that lithium was more efficacious than topiramate as monotherapy in the treatment of manic and mixed episodes in terms of mean change on YMRS (range 0 to 60) (endpoint 12 weeks) (MD 8.46, 95% CI 5.86 to 11.06; participants = 449; studies = 2; P < 0.00001).For troublesome side effects experienced of any nature, we found no difference between topiramate and placebo as monotherapy (endpoint 12 weeks) (OR 0.68, 95% CI 0.33 to 1.40; participants = 212; studies = 1; P = 0.30; low-quality evidence) or as add-on therapy (endpoint 12 weeks) (OR 1.10, 95% CI 0.58 to 2.10; participants = 287; studies = 1; P = 0.76; low-quality evidence). In terms of participants experiencing side effects of any nature, we found no difference between topiramate and an alternative drug as monotherapy (endpoint 12 weeks) (OR 0.87, 95% CI 0.50 to 1.52; participants = 230; studies = 1; P = 0.63; low-quality evidence) or as add-on therapy (endpoint 8 weeks) (OR 1.57, 95% CI 0.42 to 5.90; participants = 36; studies = 1; P = 0.50; very low-quality evidence).We considered five of the studies to be at low risk of selection bias for random sequence generation, performance, detection, attrition, and reporting biases, and at unclear risk for allocation concealment and other potential sources of bias. We considered the McIntyre 2000 study to be at high risk of performance bias; unclear risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, and other potential sources of bias; and at low risk for attrition bias and reporting bias. AUTHORS' CONCLUSIONS It is not possible to draw any firm conclusions about the use of topiramate in clinical practice from this evidence. The only high-quality evidence found was that lithium is more efficacious than topiramate when used as monotherapy in the treatment of acute affective episodes in bipolar disorder, and we note that this evidence came from only two studies. Moderate-quality evidence showed that topiramate was no more or less efficacious than placebo as monotherapy when a 3-week endpoint was used, but the quality of the evidence for this outcome at a 12-week endpoint dropped to low. As we graded the quality of the evidence for the other findings as low and very low, it was not possible to draw any conclusions from the results.To best address this research question, if investigators see the indication in so doing, more double-blind randomised controlled trials could be conducted that are more explicit with regard to methodological issues. In particular, investigators could compare placebo, alternative, and combination treatments (including a wide range of mood stabilisers), atypical antipsychotics for manic and mixed episodes, and antidepressants in combination with mood stabilisers or atypical antipsychotics for depressive episodes.
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Affiliation(s)
- Katie Pigott
- Institute of Pyschiatry, King's Collegec/o Ms Caroline Loveland, Centre for Affective DisordersPO72, De Crespigny ParkDenmark HillLondonUKSE5 8AF
| | - Ilaria Galizia
- King's College London, Institute of PsychiatryCentre for Affective DisordersDe Crespigny ParkLondonUKSE5 8AF
- Department of Basic Medical Science, Neuroscience and Sense Organs, Aldo Moro UniversityBariItaly
| | - Kamini Vasudev
- Western UniversityDepartments of Psychiatry and medicineVictoria HospitalLondonONCanada
| | - Stuart Watson
- Wolfson Research CentreAcademic Psychiatry and Regional Affective Disorders ServiceCampus for Ageing and VitalityNewcastle‐upon‐TyneTyne and WearUKNE4 5PL
| | - John Geddes
- University of Oxford/Warneford HospitalDepartment of PsychiatryOxfordUKOX3 7JX
| | - Allan H Young
- Institute of Psychiatry, King's College LondonCentre for Affective DisordersPO72, De Crespigny ParkDenmark HillLondonUKSE5 8AF
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63
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Bauer R, Conell J, Glenn T, Alda M, Ardau R, Baune BT, Berk M, Bersudsky Y, Bilderbeck A, Bocchetta A, Bossini L, Castro AMP, Cheung EY, Chillotti C, Choppin S, Del Zompo M, Dias R, Dodd S, Duffy A, Etain B, Fagiolini A, Hernandez MF, Garnham J, Geddes J, Gildebro J, Gonzalez-Pinto A, Goodwin GM, Grof P, Harima H, Hassel S, Henry C, Hidalgo-Mazzei D, Kapur V, Kunigiri G, Lafer B, Larsen ER, Lewitzka U, Licht RW, Lund AH, Misiak B, Monteith S, Munoz R, Nakanotani T, Nielsen RE, O'Donovan C, Okamura Y, Osher Y, Piotrowski P, Reif A, Ritter P, Rybakowski JK, Sagduyu K, Sawchuk B, Schwartz E, Scippa ÂM, Slaney C, Sulaiman AH, Suominen K, Suwalska A, Tam P, Tatebayashi Y, Tondo L, Vieta E, Vinberg M, Viswanath B, Volkert J, Zetin M, Whybrow PC, Bauer M. Internet use by patients with bipolar disorder: Results from an international multisite survey. Psychiatry Res 2016; 242:388-394. [PMID: 27391371 DOI: 10.1016/j.psychres.2016.05.055] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/30/2016] [Accepted: 05/30/2016] [Indexed: 02/03/2023]
Abstract
There is considerable international interest in online education of patients with bipolar disorder, yet little understanding of how patients use the Internet and other sources to seek information. 1171 patients with a diagnosis of bipolar disorder in 17 countries completed a paper-based, anonymous survey. 81% of the patients used the Internet, a percentage similar to the general public. Older age, less education, and challenges in country telecommunications infrastructure and demographics decreased the odds of using the Internet. About 78% of the Internet users looked online for information on bipolar disorder or 63% of the total sample. More years of education in relation to the country mean, and feeling very confident about managing life decreased the odds of seeking information on bipolar disorder online, while having attended support groups increased the odds. Patients who looked online for information on bipolar disorder consulted medical professionals plus a mean of 2.3 other information sources such as books, physician handouts, and others with bipolar disorder. Patients not using the Internet consulted medical professionals plus a mean of 1.6 other information sources. The percentage of patients with bipolar disorder who use the Internet is about the same as the general public. Other information sources remain important.
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Affiliation(s)
- Rita Bauer
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Jörn Conell
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Tasha Glenn
- ChronoRecord Association, Fullerton, CA, USA
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Raffaella Ardau
- Unit of Clinical Pharmacology, University Hospital of Cagliari, Cagliari, Italy
| | - Bernhard T Baune
- Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia; University Hospital Geelong, Barwon Health, Geelong, VIC, Australia; Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia; Orygen Youth Health Research Centre, Parkville, VIC, Australia
| | - Yuly Bersudsky
- Beer Sheva Mental Health Center, Beer Sheva, Israel; Department of Psychiatry, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Amy Bilderbeck
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Alberto Bocchetta
- Section of Neurosciences and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Sardinia, Italy
| | - Letizia Bossini
- Department of Molecular Medicine and Department of Mental Health (DAI) and University of Siena and University of Siena Medical Center (AOUS), Siena, Italy
| | - Angela M Paredes Castro
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia; University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Eric Yw Cheung
- Department of General Adult Psychiatry, Castle Peak Hospital, Hong Kong
| | - Caterina Chillotti
- Unit of Clinical Pharmacology, University Hospital of Cagliari, Cagliari, Italy
| | - Sabine Choppin
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Créteil, France
| | - Maria Del Zompo
- Section of Neurosciences and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Sardinia, Italy
| | - Rodrigo Dias
- Bipolar Disorder Research Program, Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Seetal Dodd
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia; University Hospital Geelong, Barwon Health, Geelong, VIC, Australia; Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
| | - Anne Duffy
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Bruno Etain
- AP-HP, Hôpitaux Universitaires Henri-Mondor, INSERM U955 (IMRB), Université Paris Est, Créteil, France
| | - Andrea Fagiolini
- Department of Molecular Medicine and Department of Mental Health (DAI) and University of Siena and University of Siena Medical Center (AOUS), Siena, Italy
| | - Miryam Fernández Hernandez
- Department of Psychiatry, University Hospital of Alava, University of the Basque Country, CIBERSAM, Vitoria, Spain
| | - Julie Garnham
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Jonas Gildebro
- Department of Affective Disorders, Q, Mood Disorders Research Unit, Aarhus University Hospital, Denmark
| | - Ana Gonzalez-Pinto
- Department of Psychiatry, University Hospital of Alava, University of the Basque Country, CIBERSAM, Vitoria, Spain
| | - Guy M Goodwin
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Paul Grof
- Mood Disorders Center of Ottawa, Ottawa, Canada; Department of Psychiatry, University of Toronto, Ontario, Canada
| | - Hirohiko Harima
- Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Setagaya, Tokyo, Japan
| | - Stefanie Hassel
- Department of Psychology & Aston Brain Centre, Aston University, Birmingham, UK
| | - Chantal Henry
- AP-HP, Hôpitaux Universitaires Henri-Mondor, INSERM U955 (IMRB), Université Paris Est, Créteil, France; Institut Pasteur, Unité Perception et Mémoire, F-75015 Paris, France
| | - Diego Hidalgo-Mazzei
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Vaisnvy Kapur
- Department of Clinical Psychology, NIMHANS, Bangalore 560029, India
| | | | - Beny Lafer
- Bipolar Disorder Research Program, Department of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Erik R Larsen
- Department of Affective Disorders, Q, Mood Disorders Research Unit, Aarhus University Hospital, Denmark
| | - Ute Lewitzka
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Rasmus W Licht
- Aalborg University Hospital, Psychiatry, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Hvenegaard Lund
- Department of Affective Disorders, Q, Mood Disorders Research Unit, Aarhus University Hospital, Denmark
| | - Blazej Misiak
- Department of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Scott Monteith
- Michigan State University College of Human Medicine, Traverse City Campus, Traverse City, MI, USA
| | - Rodrigo Munoz
- Department of Psychiatry, University of California San Diego, San Diego, CA USA
| | - Takako Nakanotani
- Affective Disorders Research Project, Tokyo Metropolitan Institute of Medical Science, Setagaya, Tokyo, Japan
| | - René E Nielsen
- Aalborg University Hospital, Psychiatry, Aalborg, Denmark
| | - Claire O'Donovan
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Yasushi Okamura
- Department of Psychiatry, Tokyo Metropolitan Matsuzawa Hospital, Setagaya, Tokyo, Japan
| | - Yamima Osher
- Beer Sheva Mental Health Center, Beer Sheva, Israel; Department of Psychiatry, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Patryk Piotrowski
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany; University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Philipp Ritter
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Kemal Sagduyu
- Department of Psychiatry, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Brett Sawchuk
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | | | - Ângela M Scippa
- Department of Neuroscience and Mental Health, Federal University of Bahia, Salvador, Brazil
| | - Claire Slaney
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ahmad H Sulaiman
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kirsi Suominen
- City of Helsinki, Department of Social Services and Health Care, Psychiatry, Helsinki, Finland
| | - Aleksandra Suwalska
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Peter Tam
- Department of Psychiatry, Department of Medicine, University of Hong Kong, Hong Kong
| | - Yoshitaka Tatebayashi
- Affective Disorders Research Project, Tokyo Metropolitan Institute of Medical Science, Setagaya, Tokyo, Japan
| | - Leonardo Tondo
- Harvard Medical School-McLean Hospital, Boston, MA, USA; Lucio Bini Center, Cagliari e Roma, Italy
| | - Eduard Vieta
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Maj Vinberg
- Psychiatric Center Copenhagen, Copenhagen, Denmark
| | - Biju Viswanath
- Department of Psychiatry, NIMHANS, Bangalore 560029, India
| | - Julia Volkert
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Mark Zetin
- Department of Psychology, Chapman University, Orange, CA, USA
| | - Peter C Whybrow
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Germany.
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Geddes J, Deans KA, Cormack A, Motherwell D, Paterson K, O'Reilly DSJ, Fisher BM. Cardiac troponin I concentrations in people presenting with diabetic ketoacidosis. Ann Clin Biochem 2016; 44:391-3. [PMID: 17594788 DOI: 10.1258/000456307780945750] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Elevated troponin concentrations may be observed in a wide spectrum of medical disorders in people without evidence of overt ischaemic heart disease. The prospective relationship between serum cardiac troponin I (cTnI) and diabetic ketoacidosis (DKA) has not been examined in adults. Methods: Forty patients (14 male and 26 female) with type 1 diabetes were recruited. cTnI, creatine kinase (CK), cystatin C and beta-hydroxybutyrate were measured on admission and at 24, 48 and 72 h post-admission. Daily electrocardiographs were also performed. Results: Four out of forty subjects presenting with DKA had an increase in cTnI (median (SD) 0.06 (0.31) μg/L). One of the subjects had multiple possible reasons for the elevated cTnI concentration. However, the other three subjects had no obvious precipitating factors. This cohort underwent echocardiography and thallium-201 scintigraphy, which revealed no abnormalities. Conclusions: Minor troponin elevations appear to occur in a small number of subjects with type 1 diabetes presenting with DKA. The clinical relevance of this at this stage remains unknown and further large-scale studies are suggested.
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Affiliation(s)
- J Geddes
- Department of Diabetes, Glasgow Royal Infirmary, Glasgow, Scotland, UK
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Abstract
Rationale Trials of new treatments for neurological disorders like stroke require imaging as part of the patient assessment, but need to be large enough to obtain reliable results if treatment effects are likely to be modest. However, multicentre trials use many different scanners in different hospitals and present complex problems for image data collection, interpretation and analysis and long-term secure archiving. Aims NeuroGrid aims to develop and test grid technologies for collecting, analysing and interpreting, and secure archiving of neuroimaging data for large multicentre trials in common neurological and psychiatric disorders. Design A 3-year multicentre consortium of clinicians, neuroimaging centres and e-scientists are designing a Grid storage network, mechanisms for uploading, curating and retrieving image and metadata, combining image data from different scanners and an analysis tool box. Three clinical exemplars – stroke, dementia and psychosis – provide the data and ‘real-world’ clinical trial applications, and a set of specific and typical problems encountered with image data in multicentre trials for NeuroGrid to address. The stroke exemplar is using image data from two multicentre stroke trials: Third International Stroke Trial and Efficacy of Nitric Oxide in Stroke. Outcomes The final product is intended to appear as an integrated capability consisting of services, both database and analyses, accessed through simple portals. These will include image submission, automated scan quality control, appropriate metadata linkage, streamlined image review and coding tools and long-term secure storage for future multicentre stroke trials.
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Affiliation(s)
- J. M. Wardlaw
- Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - Philip Bath
- Division of Stroke Medicine, University of Nottingham, Nottingham, UK
| | - Peter Sandercock
- Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - David Perry
- Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - Jeb Palmer
- Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - Graham Watson
- Division of Stroke Medicine, University of Nottingham, Nottingham, UK
| | - Sharon Lloyd
- Computing Laboratory, University of Oxford, Oxford, UK and
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Andrew Farrall
- Division of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
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Abstract
BACKGROUND People with serious mental illness have consistently higher levels of mortality and morbidity than the general population. They have greater levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these people, lifestyle and environmental factors such as smoking, obesity, poor diet, and low levels of physical activity play a prominent part. OBJECTIVES To review the effects of dietary advice for schizophrenia and schizophrenia-like psychosis. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (September 09, 2013 and February 24, 2016). SELECTION CRITERIA We planned to include all randomised clinical trials focusing on dietary advice versus standard care. DATA COLLECTION AND ANALYSIS The review authors (RP, KTP) independently screened search results but did not identify any studies that fulfilled the review's criteria. MAIN RESULTS We did not identify any studies that met our inclusion criteria. AUTHORS' CONCLUSIONS Dietary advice has been shown to improve the dietary intake of the general population. Research is needed to determine whether dietary advice can have a similar benefit in people with serious mental illness.
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Affiliation(s)
- Robert Pearsall
- Monklands HospitalDepartment of PsychiatryMonkscourt AvenueAirdrieUKML6 0JS
| | - Kudlar Thyarappa Praveen
- South West Yorkshire Mental Health NHS trustCrisis resolution teamFieldhead hospital, Ouchthorpe LaneWakefieldUKWF1 3SP
| | - Anthony Pelosi
- St John's HospitalRegional Eating Disorders UnitLivingstoneUK
| | - John Geddes
- University of Oxford/Warneford HospitalDepartment of PsychiatryOxfordUKOX3 7JX
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Cipriani A, Geddes J. Predicting treatment outcome in depression: so far, so good. Lancet Psychiatry 2016; 3:192-4. [PMID: 26803398 DOI: 10.1016/s2215-0366(15)00542-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 11/21/2015] [Accepted: 11/23/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK.
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK
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Gulati G, Cornish R, Al-Taiar H, Miller C, Khosla V, Hinds C, Price J, Geddes J, Fazel S. Web-Based Violence Risk Monitoring Tool in Psychoses: Pilot Study in Community Forensic Patients. J Forensic Psychol Pract 2016; 16:49-59. [PMID: 26924945 PMCID: PMC4743616 DOI: 10.1080/15228932.2016.1128301] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We describe the development and pilot testing of a novel, web-based, violence risk monitoring instrument for use in community patients with psychoses. We describe the development of the tool, including drawing on systematic reviews of the field, how item content was operationalized, the development of a user interface, and its subsequent piloting. Sixty-eight patients were included from three English counties, who had been discharged from forensic psychiatric services. Over 12 months, 310 questionnaires were completed on the sample by professionals from several disciplines and qualitative feedback collected relating to the use of the tool using an electronic survey. Strengths of this approach for risk assessment, and potential limitations and areas for future research, are discussed.
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Affiliation(s)
- Gautam Gulati
- Oxford Health NHS Foundation Trust, Oxford, England; Department of Psychiatry, University of Oxford, Oxford, England
| | | | | | | | - Vivek Khosla
- Oxford Health NHS Foundation Trust , Oxford , England
| | | | - Jonathan Price
- Department of Psychiatry, University of Oxford , Oxford , England
| | - John Geddes
- Department of Psychiatry, University of Oxford , Oxford , England
| | - Seena Fazel
- Department of Psychiatry, University of Oxford , Oxford , England
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Abstract
Big data are coming to the study of bipolar disorder and all of psychiatry. Data are coming from providers and payers (including EMR, imaging, insurance claims and pharmacy data), from omics (genomic, proteomic, and metabolomic data), and from patients and non-providers (data from smart phone and Internet activities, sensors and monitoring tools). Analysis of the big data will provide unprecedented opportunities for exploration, descriptive observation, hypothesis generation, and prediction, and the results of big data studies will be incorporated into clinical practice. Technical challenges remain in the quality, analysis and management of big data. This paper discusses some of the fundamental opportunities and challenges of big data for psychiatry.
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Affiliation(s)
- Scott Monteith
- Michigan State University College of Human Medicine, Traverse City Campus, 1400 Medical Campus Drive, Traverse City, MI, 49684, USA.
| | - Tasha Glenn
- ChronoRecord Association, Inc., Fullerton, CA, 92834, USA.
| | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK.
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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Affiliation(s)
| | - Rebecca McKnight
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
| | | | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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Leucht S, Samara M, Heres S, Patel MX, Furukawa T, Cipriani A, Geddes J, Davis JM. Dose Equivalents for Second-Generation Antipsychotic Drugs: The Classical Mean Dose Method. Schizophr Bull 2015; 41:1397-402. [PMID: 25841041 PMCID: PMC4601707 DOI: 10.1093/schbul/sbv037] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The concept of dose equivalence is important for many purposes. The classical approach published by Davis in 1974 subsequently dominated textbooks for several decades. It was based on the assumption that the mean doses found in flexible-dose trials reflect the average optimum dose which can be used for the calculation of dose equivalence. We are the first to apply the method to second-generation antipsychotics. METHODS We searched for randomized, double-blind, flexible-dose trials in acutely ill patients with schizophrenia that examined 13 oral second-generation antipsychotics, haloperidol, and chlorpromazine (last search June 2014). We calculated the mean doses of each drug weighted by sample size and divided them by the weighted mean olanzapine dose to obtain olanzapine equivalents. RESULTS We included 75 studies with 16 555 participants. The doses equivalent to 1 mg/d olanzapine were: amisulpride 38.3 mg/d, aripiprazole 1.4 mg/d, asenapine 0.9 mg/d, chlorpromazine 38.9 mg/d, clozapine 30.6 mg/d, haloperidol 0.7 mg/d, quetiapine 32.3mg/d, risperidone 0.4 mg/d, sertindole 1.1 mg/d, ziprasidone 7.9 mg/d, zotepine 13.2 mg/d. For iloperidone, lurasidone, and paliperidone no data were available. CONCLUSIONS The classical mean dose method is not reliant on the limited availability of fixed-dose data at the lower end of the effective dose range, which is the major limitation of "minimum effective dose methods" and "dose-response curve methods." In contrast, the mean doses found by the current approach may have in part depended on the dose ranges chosen for the original trials. Ultimate conclusions on dose equivalence of antipsychotics will need to be based on a review of various methods.
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Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München Klinikum rechts der Isar, Ismaningerstr. 22, 81675 Munich, Germany; Institute of Psychiatry, Psychology and Neuroscience, King's College London, Department of Psychosis Studies, London, UK;
| | - Myrto Samara
- Department of Psychiatry and Psychotherapy, Technische Universität München Klinikum rechts der Isar, Ismaningerstr. 22, 81675 Munich, Germany
| | - Stephan Heres
- Department of Psychiatry and Psychotherapy, Technische Universität München Klinikum rechts der Isar, Ismaningerstr. 22, 81675 Munich, Germany
| | - Maxine X. Patel
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Department of Psychosis Studies, London, UK
| | - Toshi Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | | | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - John M. Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL
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Freeman D, Waite F, Startup H, Myers E, Lister R, McInerney J, Harvey AG, Geddes J, Zaiwalla Z, Luengo-Fernandez R, Foster R, Clifton L, Yu LM. Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial. Lancet Psychiatry 2015; 2:975-83. [PMID: 26363701 PMCID: PMC4641164 DOI: 10.1016/s2215-0366(15)00314-4] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/10/2015] [Accepted: 07/03/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sleep disturbance occurs in most patients with delusions or hallucinations and should be treated as a clinical problem in its own right. However, cognitive behavioural therapy (CBT)-the best evidence-based treatment for insomnia-has not been tested in this patient population. We aimed to pilot procedures for a randomised trial testing CBT for sleep problems in patients with current psychotic experiences, and to provide a preliminary assessment of potential benefit. METHODS We did this prospective, assessor-blind, randomised controlled pilot trial (Better Sleep Trial [BEST]) at two mental health centres in the UK. Patients (aged 18-65 years) with persistent distressing delusions or hallucinations in the context of insomnia and a schizophrenia spectrum diagnosis were randomly assigned (1:1), via a web-based randomisation system with minimisation to balance for sex, insomnia severity, and psychotic experiences, to receive either eight sessions of CBT plus standard care (medication and contact with the local clinical team) or standard care alone. Research assessors were masked to group allocation. Assessment of outcome was done at weeks 0, 12 (post-treatment), and 24 (follow-up). The primary efficacy outcomes were insomnia assessed by the Insomnia Severity Index (ISI) and delusions and hallucinations assessed by the Psychotic Symptoms Rating Scale (PSYRATS) at week 12. We did analysis by intention to treat, with an aim to provide confidence interval estimation of treatment effects. This study is registered with ISRCTN, number 33695128. FINDINGS Between Dec 14, 2012, and May 22, 2013, and Nov 7, 2013, and Aug 26, 2014, we randomly assigned 50 patients to receive CBT plus standard care (n=24) or standard care alone (n=26). The last assessments were completed on Feb 10, 2015. 48 (96%) patients provided follow-up data. 23 (96%) patients offered CBT took up the intervention. Compared with standard care, CBT led to reductions in insomnia in the large effect size range at week 12 (adjusted mean difference 6.1, 95% CI 3.0-9.2, effect size d=1.9). By week 12, nine (41%) of 22 patients receiving CBT and one (4%) of 25 patients receiving standard care alone no longer had insomnia, with ISI scores lower than the cutoff for insomnia. The treatment effect estimation for CBT covered a range from reducing but also increasing delusions (adjusted mean difference 0.3, 95% CI -2.0 to 2.6) and hallucinations (-1.9, -6.5 to 2.7). Three patients, all in the CBT group, had five adverse events, although none were regarded as related to study treatment. INTERPRETATION Our findings show that CBT for insomnia might be highly effective for improving sleep in patients with persistent delusions or hallucinations. A larger, suitably powered phase 3 study is now needed to provide a precise estimate of the effects of CBT for sleep problems, both on sleep and psychotic experiences. FUNDING Research for Patient Benefit Programme, National Institute for Health Research.
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Affiliation(s)
- Daniel Freeman
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.
| | - Felicity Waite
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Helen Startup
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Sussex Partnership NHS Trust, Worthing, West Sussex
| | - Elissa Myers
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Rachel Lister
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Josephine McInerney
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Allison G Harvey
- Department of Psychology, University of California, Berkeley, CA, USA
| | - John Geddes
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Zenobia Zaiwalla
- Oxford Non-Respiratory Sleep Disorder Service, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK
| | - Russell Foster
- Sleep and Circadian Neurosciences Institute, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Lei Clifton
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Abstract
BACKGROUND Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009. OBJECTIVES 1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment. SEARCH METHODS A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted. SELECTION CRITERIA All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies. MAIN RESULTS The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria. AUTHORS' CONCLUSIONS Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.
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Affiliation(s)
- Jaap Wijkstra
- Department of Psychiatry, UMCU, B.01.206, Postbox 85500, 3508 GA, Utrecht, Netherlands
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Ostacher MJ, Perlis RH, Geddes J. Monotherapy Antidepressant Treatment is Not Associated With Mania in Bipolar I Disorder. Am J Psychiatry 2015; 172:586. [PMID: 26029807 DOI: 10.1176/appi.ajp.2015.14111443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Michael J Ostacher
- From the Department of Psychiatry, VA Palo Alto Health Care System, Palo Alto, Calif. and the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Calif.; the Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston; and the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom
| | - Roy H Perlis
- From the Department of Psychiatry, VA Palo Alto Health Care System, Palo Alto, Calif. and the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Calif.; the Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston; and the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom
| | - John Geddes
- From the Department of Psychiatry, VA Palo Alto Health Care System, Palo Alto, Calif. and the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Calif.; the Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston; and the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom
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Cleare A, Pariante CM, Young AH, Anderson IM, Christmas D, Cowen PJ, Dickens C, Ferrier IN, Geddes J, Gilbody S, Haddad PM, Katona C, Lewis G, Malizia A, McAllister-Williams RH, Ramchandani P, Scott J, Taylor D, Uher R. Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015; 29:459-525. [PMID: 25969470 DOI: 10.1177/0269881115581093] [Citation(s) in RCA: 399] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.
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Affiliation(s)
- Anthony Cleare
- Professor of Psychopharmacology & Affective Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - C M Pariante
- Professor of Biological Psychiatry, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - A H Young
- Professor of Psychiatry and Chair of Mood Disorders, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, London, UK
| | - I M Anderson
- Professor and Honorary Consultant Psychiatrist, University of Manchester Department of Psychiatry, University of Manchester, Manchester, UK
| | - D Christmas
- Consultant Psychiatrist, Advanced Interventions Service, Ninewells Hospital & Medical School, Dundee, UK
| | - P J Cowen
- Professor of Psychopharmacology, Psychopharmacology Research Unit, Neurosciences Building, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - C Dickens
- Professor of Psychological Medicine, University of Exeter Medical School and Devon Partnership Trust, Exeter, UK
| | - I N Ferrier
- Professor of Psychiatry, Honorary Consultant Psychiatrist, School of Neurology, Neurobiology & Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - J Geddes
- Head, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - S Gilbody
- Director of the Mental Health and Addictions Research Group (MHARG), The Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - P M Haddad
- Consultant Psychiatrist, Cromwell House, Greater Manchester West Mental Health NHS Foundation Trust, Salford, UK
| | - C Katona
- Division of Psychiatry, University College London, London, UK
| | - G Lewis
- Division of Psychiatry, University College London, London, UK
| | - A Malizia
- Consultant in Neuropsychopharmacology and Neuromodulation, North Bristol NHS Trust, Rosa Burden Centre, Southmead Hospital, Bristol, UK
| | - R H McAllister-Williams
- Reader in Clinical Psychopharmacology, Institute of Neuroscience, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - P Ramchandani
- Reader in Child and Adolescent Psychiatry, Centre for Mental Health, Imperial College London, London, UK
| | - J Scott
- Professor of Psychological Medicine, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - D Taylor
- Professor of Psychopharmacology, King's College London, London, UK
| | - R Uher
- Associate Professor, Canada Research Chair in Early Interventions, Dalhousie University, Department of Psychiatry, Halifax, NS, Canada
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Armstrong N, Price J, Geddes J. Serious but not solemn: Rebalancing the assessment of risks and benefits of patient recruitment materials. Research Ethics 2015. [DOI: 10.1177/1747016114552338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recruiting patients to participate in health research is challenging, and most studies struggle. Failure to recruit can jeopardise the quality of research, and threatens efforts to improve healthcare. Despite this, recruitment materials tend to be conservatively designed and unimaginative. One reason for this is ethical concerns regarding the risk of coercion and offence posed by recruitment materials. The OXTEXT research programme gave patients a leading role in the design of new recruitment materials, in an area (mental health) where stigma and discrimination make ethical risks particularly acute. We discovered that our patient-designed recruitment materials were much bolder than usual, and they put the existing ethical boundaries to the test. The materials were effective and well liked – patients regarded them as neither unacceptable nor coercive. This suggests we may need to rethink the ethics of recruitment to research such that we permit more creative recruitment materials. In addition, it suggests a new role for patient input into research as designers of recruitment materials.
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Cipriani A, Reid K, Young AH, Macritchie K, Geddes J. Valproic acid, valproate and divalproex in the maintenance treatment of bipolar disorder. BJPsych advances 2015. [DOI: 10.1192/apt.21.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Pearsall R, Smith DJ, Pelosi A, Geddes J. Exercise therapy in adults with serious mental illness: a systematic review and meta-analysis. BMC Psychiatry 2014; 14:117. [PMID: 24751159 PMCID: PMC4018503 DOI: 10.1186/1471-244x-14-117] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 03/26/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Individuals with serious mental illness are at a higher risk of physical ill health. Mortality rates are at least twice those of the general population with higher levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these patients, lifestyle and environmental factors such as levels of smoking, obesity, poor diet, and low levels of physical activity also play a prominent part. METHODS We conducted a systematic review and meta-analysis of randomised controlled trials comparing the effect of exercise interventions on individuals with serious mental illness.Searches were made in Ovid MEDLINE, Embase, CINAHL, PsycINFO, Biological Abstracts on Ovid, and The Cochrane Library (January 2009, repeated January 2013) through to February 2013. RESULTS Eight RCTs were identified in the systematic search. Six compared exercise versus usual care. One study assessed the effect of a cycling programme versus muscle strengthening and toning exercises. The final study compared the effect of adding specific exercise advice and motivational skills to a simple walking programme. The review found that exercise improved levels of exercise activity (n = 13, standard mean difference [SMD] 1.81, CI 0.44 to 3.18, p = 0.01). No beneficial effect was found on negative (n = 84, SMD = -0.54, CI -1.79 to 0.71, p = 0.40) or positive symptoms of schizophrenia (n = 84, SMD = -1.66, CI -3.78 to 0.45, p = 0.12). No change was found on body mass index compared with usual care (n = 151, SMD = -0.24, CI -0.56 to 0.08, p = 0.14), or body weight (n = 77, SMD = 0.13, CI -0.32 to 0.58, p = 0.57). No beneficial effect was found on anxiety and depressive symptoms (n = 94, SMD = -0.26, CI -0.91 to 0.39, p = 0.43), or quality of life in respect of physical and mental domains. CONCLUSIONS This systematic review showed that exercise therapies can lead to a modest increase in levels of exercise activity but overall there was no noticeable change for symptoms of mental health, body mass index, and body weight.
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Affiliation(s)
| | - Daniel J Smith
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Anthony Pelosi
- Regional Eating Disorders Unit, St John’s Hospital, Livingston, UK
| | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
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Pearsall R, Hughes S, Geddes J, Pelosi A. Understanding the problems developing a healthy living programme in patients with serious mental illness: a qualitative study. BMC Psychiatry 2014; 14:38. [PMID: 24524248 PMCID: PMC4098648 DOI: 10.1186/1471-244x-14-38] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 02/03/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND People with serious mental illness are at an increased risk of physical ill health. Mortality rates are around twice those of the general population with higher levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these patients, lifestyle and environmental factors such as smoking, obesity, poor diet, and low levels of physical activity play a prominent part. METHODS A qualitative grounded theory approach was used to understand the problems experienced by these individuals when asked to attend a healthy living programme. Three main areas were explored: the influence of potential barriers, health problems, and general attitudes towards healthy living. RESULTS Thirteen patients were interviewed during the study. Many did not recall receiving an initial invitation letter to the programme. Several believed that there was no necessity to attend as they had already had recent routine health checks by their general practitioner. The patients' current level of mental and physical health was important with symptoms such as depression, anxiety or arthritis affecting interest in the programme. Patients described that they found smoking enjoyable or calming in its effect. Dietary intake was determined by taste or gaining pleasure in eating certain types of food. Several lessons were learnt during this research that may aid future research and practice. Participation seemed to be better if the approach was first made by the patient's own community keyworker. This contact may have provided a greater opportunity to explain the purpose and importance of the programme. Alternative appointments should be considered when certain patients are in better physical and mental health. Healthy living programmes need to be flexible and adaptive to individual patient needs. Assistance from their community worker may help engagement. Simple measures may improve participation and reduce potential barriers. CONCLUSION These findings highlighted some of the problems encountered by patients when attempting to participate in a healthy living programme. These results may be useful when implementing future healthy living interventions for patients with serious mental disorders.
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Affiliation(s)
| | | | - John Geddes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Anthony Pelosi
- Regional Eating Disorders Unit, St John’s Hospital, Livingston, UK
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Williams A, Mackintosh J, Bateman B, Holland S, Rushworth A, Brooks A, Geddes J. The development of a designated dental pathway for looked after children. Br Dent J 2014; 216:E6. [DOI: 10.1038/sj.bdj.2014.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2013] [Indexed: 11/09/2022]
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Abstract
BACKGROUND Bipolar disorder is a mental disorder characterised by episodes of elevated or irritable mood (manic or hypomanic episodes) and episodes of low mood and loss of energy (depressive episodes). Drug treatment is the first-line treatment for acute mania with the initial aim of rapid control of agitation, aggression and dangerous behaviour. Aripiprazole, an atypical antipsychotic, is used in the treatment of mania both as monotherapy and combined with other medicines. The British Association of Psychopharmacology guidelines report that, in monotherapy placebo-controlled trials, the atypical antipsychotics, including aripiprazole, have been shown to be effective for acute manic or mixed episodes. OBJECTIVES To assess the efficacy and tolerability of aripiprazole alone or in combination with other antimanic drug treatments, compared with placebo and other drug treatments, in alleviating acute symptoms of manic or mixed episodes. Other objectives include reviewing the acceptability of treatment with aripiprazole, investigating the adverse effects of aripiprazole treatment, and determining overall mortality rates among those receiving aripiprazole treatment. SEARCH METHODS The Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) was searched, all years to 31st July 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also searched Bristol-Myers Squibb clinical trials register, the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov (to August 2013). SELECTION CRITERIA Randomised trials comparing aripiprazole versus placebo or other drugs in the treatment of acute manic or mixed episodes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, including adverse effect data, from trial reports and assessed bias. The drug manufacturer or the trial authors were contacted for missing data. MAIN RESULTS Ten studies (3340 participants) were included in the review. Seven studies compared aripiprazole monotherapy versus placebo (2239 participants); two of these included a third comparison arm-one study used lithium (485 participants) and the other used haloperidol (480 participants). Two studies compared aripiprazole as an adjunctive treatment to valproate or lithium versus placebo as an adjunctive treatment (754 participants), and one study compared aripiprazole versus haloperidol (347 participants). The overall risk of bias was unclear. A high dropout rate from most trials (> 20% for each intervention in eight of the trials) may have affected the estimates of relative efficacy. Evidence shows that aripiprazole was more effective than placebo in reducing manic symptoms in adults and children/adolescents at three and four weeks but not at six weeks (Young Mania Rating Scale (YMRS); mean difference (MD) at three weeks (random effects) -3.66, 95% confidence interval (CI) -5.82 to -2.05; six studies; N = 1819, moderate quality evidence) - a modest difference. Aripiprazole was compared with other drug treatments in three studies in adults-lithium was used in one study and haloperidol in two studies. No statistically significant differences between aripiprazole and other drug treatments in reducing manic symptoms were noted at three weeks (YMRS MD at three weeks (random effects) 0.07, 95% CI -1.24 to 1.37; three studies; N = 972, moderate quality evidence) or at any other time point up to and including 12 weeks. Compared with placebo, aripiprazole caused more movement disorders, as measured on the Simpson Angus Scale (SAS), on the Barnes Akathisia Scale (BAS) and by participant-reported akathisia (high quality evidence), with more people requiring treatment with anticholinergic medication (risk ratios (random effects) 3.28, 95% CI 1.82 to 5.91; two studies; N = 730, high quality evidence). Aripiprazole also led to more gastrointestinal disturbances (nausea (high quality evidence), and constipation) and caused more children/adolescents to have a prolactin level that fell below the lower limit of normal. Significant heterogeneity was present in the meta-analysis of movement disorders associated with aripiprazole and other treatments and was most likely due to the different side effect profiles of lithium and haloperidol. At the three-week time point, meta-analysis was not possible because of lack of data; however, at 12 weeks, haloperidol resulted in significantly more movement disorders than aripiprazole, as measured on the SAS, the BAS and the Abnormal Involuntary Movement Scale (AIMS) and by participant-reported akathisia. By 12 weeks, investigators reported no difference between aripiprazole and lithium (SAS, BAS, AIMS), except in terms of participant-reported akathisia (RR 2.97, 95% CI 1.37 to 6.43; one study; N = 313). AUTHORS' CONCLUSIONS Aripiprazole is an effective treatment for mania in a population that includes adults, children and adolescents, although its use leads to gastrointestinal disturbances and movement disorders. Comparative trials with medicines other than haloperidol and lithium are few, so the precise place of aripiprazole in therapy remains unclear.
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Affiliation(s)
- Rachel Brown
- Clinical Pharmacy Support Unit, Oxford Health NHS Foundation Trust, Unit 46, Sandford Lane, Kennington, Oxford, UK, OX1 5RW
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Abstract
BACKGROUND Evidence is limited regarding the most effective pharmacological treatment for psychotic depression: combination of an antidepressant plus an antipsychotic, monotherapy with an antidepressant or monotherapy with an antipsychotic. This is an update of a review first published in 2005 and last updated in 2009. OBJECTIVES 1. To compare the clinical efficacy of pharmacological treatments for patients with an acute psychotic depression: antidepressant monotherapy, antipsychotic monotherapy and the combination of an antidepressant plus an antipsychotic, compared with each other and/or with placebo.2. To assess whether differences in response to treatment in the current episode are related to non-response to prior treatment. SEARCH METHODS A search of the Cochrane Central Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) was carried out (to 12 April 2013). These registers include reports of randomised controlled trials from the following bibliographic databases: EMBASE (1970-), MEDLINE (1950-) and PsycINFO (1960-). Reference lists of all studies and related reviews were screened and key authors contacted. SELECTION CRITERIA All randomised controlled trials (RCTs) that included participants with acute major depression with psychotic features, as well as RCTs consisting of participants with acute major depression with or without psychotic features, that reported separately on the subgroup of participants with psychotic features. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in the included studies, according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. Data were entered into RevMan 5.1. We used intention-to-treat data. For dichotomous efficacy outcomes, the risk ratio (RR) with 95% confidence intervals (CIs) was calculated. For continuously distributed outcomes, it was not possible to extract data from the RCTs. Regarding the primary outcome of harm, only overall dropout rates were available for all studies. MAIN RESULTS The search identified 3659 abstracts, but only 12 RCTs with a total of 929 participants could be included in the review. Because of clinical heterogeneity, few meta-analyses were possible. The main outcome was reduction of severity (response) of depression, not of psychosis.We found no evidence for the efficacy of monotherapy with an antidepressant or an antipsychotic.However, evidence suggests that the combination of an antidepressant plus an antipsychotic is more effective than antidepressant monotherapy (three RCTs; RR 1.49, 95% CI 1.12 to 1.98, P = 0.006), more effective than antipsychotic monotherapy (four RCTs; RR 1.83, 95% CI 1.40 to 2.38, P = 0.00001) and more effective than placebo (two identical RCTs; RR 1.86, 95% CI 1.23 to 2.82, P = 0.003).Risk of bias is considerable: there were differences between studies with regard to diagnosis, uncertainties around randomisation and allocation concealment, differences in treatment interventions (pharmacological differences between the various antidepressants and antipsychotics) and different outcome criteria. AUTHORS' CONCLUSIONS Psychotic depression is heavily understudied, limiting confidence in the conclusions drawn. Some evidence indicates that combination therapy with an antidepressant plus an antipsychotic is more effective than either treatment alone or placebo. Evidence is limited for treatment with an antidepressant alone or with an antipsychotic alone.
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Affiliation(s)
- Jaap Wijkstra
- Department of Psychiatry, UMCU, B.01.206, Postbox 85500, 3508 GA, Utrecht, Netherlands
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Abstract
BACKGROUND Bipolar disorder is a recurrent illness that is amongst the top 30 causes of disability worldwide and is associated with significant healthcare costs. In the past, emphasis was placed solely on the treatment of acute episodes of bipolar disorder; recently, the importance of episode prevention and of minimisation of iatrogenicity has been recognised. For many years, lithium was the only mood stabiliser in common use, and it remains an agent of first choice in the preventative treatment of bipolar disorder. However, an estimated 20% to 40% of patients may not respond adequately to lithium. Valproate is an anticonvulsant drug that has been shown to be effective in acute mania and is frequently used in maintenance treatment of bipolar disorder. When the acceptability of long-term treatment is considered, together with efficacy, the adverse event profile of a medication is also important. This is an update of a Cochrane review first published in 2001 and last updated in 2009. OBJECTIVES 1. To determine the efficacy of valproate continuation and maintenance treatment:a) in preventing or attenuating manic, depressive and mixed episodes of bipolar disorder;b) in preventing or attenuating episodes of bipolar disorder in patients with rapid cycling disorder; and; c) in improving patients' general health and social functioning, as measured by global clinical impression, employment and marital stability.2. To review the acceptability to patients of long-term valproate treatment, as measured by numbers of dropouts and reasons for dropping out, by compliance and by reference to patients' expressed views regarding treatment.3. To investigate the adverse effects of valproate treatment (including general prevalence of side effects) and overall mortality rates. SEARCH METHODS Search of the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register (CCDANCTR) (to January 2013), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE, (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). No language restrictions were applied. Reference lists of relevant papers and previous systematic reviews were handsearched. Pharmaceutical companies marketing valproate and experts in this field were contacted for supplemental data. SELECTION CRITERIA Randomised controlled trials allocating participants with bipolar disorder to long-term treatment with valproate or any other mood stabiliser, or antipsychotic drugs, or placebo. Maintenance treatment was defined as treatment instituted specifically or mainly to prevent further episodes of illness. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data. A double-entry procedure was employed by two review authors. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy, acceptability and tolerability. For dichotomous data, risk ratios were calculated with 95% confidence intervals (CIs). For statistically significant results, we calculated the number needed to treat for an additional beneficial outcome (NNTB) and the number needed to treat for an additional harmful outcome (NNTH). For continuous data, mean differences (MDs) or standardised mean differences (SMDs) were calculated along with 95% CIs. MDs were used when the same scale was used to measure an outcome; SMDs were employed when different scales were used to measure the same outcome. The primary analysis used a fixed-effect model. Binary outcomes were calculated on a strict intention-to-treat (ITT) basis; dropouts were included in this analysis. When data were missing and the method of "last observation carried forward" (LOCF) had been used to do an ITT analysis, then the LOCF data were used. MAIN RESULTS Six randomised controlled trials (overall 876 participants) lasting 6 to 24 months were included. Two studies (overall 312 participants) compared valproate with placebo, four studies (overall 618 participants) valproate with lithium, one study (overall 23 participants) valproate with olanzapine and one study (overall 220 participants) valproate with the combination of valproate plus lithium. In terms of study quality, most studies reported the methods used to generate random sequence; however, only one study reported enough details on allocation concealment. Four of six included studies described their design as "double blind", but only two trials reported full details about blinding. Valproate was more effective than placebo in preventing study withdrawal due to any mood episode (RR 0.68, 95% CI 0.49 to 0.93; NNTB 8), but no difference in efficacy was found between valproate and lithium (RR 1.02, 95% CI 0.87 to 1.20). Valproate was associated with fewer participants dropping out of treatment for any cause when compared with placebo or lithium (RR 0.82, 95% CI 0.71 to 0.95 and RR 0.87, 95% CI 0.77 to 0.98, respectively). However, combination therapy with lithium plus valproate was more likely to prevent relapse than was monotherapy with valproate (RR 0.78, 95% CI 0.63 to 0.96). Significant differences in adverse event frequencies were found, and lithium was associated with more frequent diarrhoea, polyuria, increased thirst and enuresis, whereas valproate was associated with increased sedation and infection. AUTHORS' CONCLUSIONS Limited evidence supports the efficacy of valproate in the long-term treatment of bipolar disorder. Clinicians and patients should consider acceptability and tolerability profile when choosing between lithium and valproate-their combination or other agents-as long-term treatment for bipolar disorder.
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Affiliation(s)
- Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUKOX3 7JX
| | - Keith Reid
- Northumberland Tyne and Wear NHS Foundation TrustBamburgh ClinicJubilee RoadNewcastleUKNE3 3XT
| | - Allan H Young
- Imperial College LondonDivision of Brain Sciences, Centre for Mental HealthLondonUKW6 8RP
| | - Karine Macritchie
- University of EdinburghDivision of PsychiatryRoyal Edinburgh HospitalEdinburghUKEH10 5HF
| | - John Geddes
- University of Oxford/Warneford HospitalDepartment of PsychiatryOxfordUKOX3 7JX
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Freeman D, Startup H, Myers E, Harvey A, Geddes J, Yu LM, Zaiwalla Z, Luengo-Fernandez R, Foster R, Lister R. The effects of using cognitive behavioural therapy to improve sleep for patients with delusions and hallucinations (the BEST study): study protocol for a randomized controlled trial. Trials 2013; 14:214. [PMID: 23845104 PMCID: PMC3717119 DOI: 10.1186/1745-6215-14-214] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 07/01/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with psychosis frequently report difficulties getting or staying asleep (insomnia). Dissatisfaction with sleep is high. Insomnia should be treated in this group, but typically it is not even assessed. Importantly, recent evidence indicates that insomnia triggers and exacerbates delusions and hallucinations. The clinical implication is that if the insomnia is treated then the psychotic symptoms will significantly lessen. In a case series with 15 patients with persecutory delusions resistant to previous treatment this is exactly what we found: cognitive behavioural therapy for insomnia (CBT-I) led to large reductions in both the insomnia and delusions. The clear next step is a pilot randomized controlled test. The clinical aim is to test whether CBT-I can reduce both insomnia and psychotic symptoms. The trial will inform decisions for a definitive large-scale evaluation. METHODS/DESIGN We will carry out a randomized controlled trial (the Better Sleep Trial, or the BEST study) with 60 patients with distressing delusions or hallucinations in the context of a schizophrenia spectrum diagnosis. Half of the participants will be randomized to receive CBT-I, in addition to their standard treatment, for up to eight sessions over 12 weeks. The other half will continue with treatment as usual. Blind assessments will take place at 0 weeks, 12 weeks (post-treatment) and 24 weeks (follow-up). The primary outcome hypotheses are that CBT-I added to treatment as usual will improve sleep, delusions and hallucinations compared with only treatment as usual. All main analyses will be carried out at the end of the last follow-up assessments and will be based on the intention-to-treat principle. The trial is funded by the NHS National Institute for Health Research (NIHR) Research for Patient Benefit Programme. Data collection will be complete by the end of 2014. DISCUSSION This will be the first controlled test of CBT-I for patients with delusions and hallucinations. It will provide significant evidence for an easily administered intervention that is likely to prove very popular with patients experiencing the difficult-to-treat problems of delusions and hallucinations. TRIAL REGISTRATION Current Controlled Trials ISRCTN 33695128.
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Affiliation(s)
- Daniel Freeman
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Helen Startup
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Elissa Myers
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Allison Harvey
- Department of Psychology, University of California, Berkeley, 3210 Tolman Hall, Berkeley CA 94720-1650, USA
| | - John Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Ly-Mee Yu
- Centre for Statistics in Medicine, University of Oxford, Wolfson College Annexe, Linton Road, Oxford OX2 6UD, UK
| | - Zenobia Zaiwalla
- Oxford Non-respiratory Sleep Disorder Service, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Russell Foster
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rachel Lister
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
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McKnight R, Geddes J. ACP Journal Club: cognitive-behavioral therapy improved response and remission at 6 and 12 months in treatment-resistant depression. Ann Intern Med 2013; 158:JC7. [PMID: 23588772 DOI: 10.7326/0003-4819-158-8-201304160-02007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
BACKGROUND Bipolar disorder is a common recurrent illness with high levels of chronicity. Treatment resistance persists despite the use of established medications, such as lithium and valproate. New medications are required for the treatment of refractory cases. Some open-label reports have suggested that the anticonvulsant tiagabine may be efficacious in bipolar disorder. There is a need to clarify the evidence available, in the form of randomised controlled trials, for its use in the treatment of acute affective episodes in bipolar disorder. OBJECTIVES To review the evidence for the efficacy and acceptability of tiagabine in the treatment of acute mood episodes in bipolar disorder. SEARCH METHODS In this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) to October 2012. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We examined reference lists of relevant papers and major textbooks of affective disorder. We contacted authors, other experts in the field and pharmaceutical companies for knowledge of suitable published or unpublished trials. We handsearched specialist journals and conference proceedings. SELECTION CRITERIA Randomised controlled trials, which compared tiagabine with placebo or with active agents in the treatment of any acute mood episodes in bipolar disorder in adults, male and female, aged 18 to 74 years. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction and methodological quality assessment independently. For analysis, we planned to use risk ratio for binary efficacy outcomes and mean difference or standardised mean difference for continuously distributed outcomes. MAIN RESULTS In this updated review we found no studies which fulfilled the Cochrane criteria for randomised controlled trials. AUTHORS' CONCLUSIONS We found no randomised controlled trials of tiagabine in the treatment of acute episodes of bipolar disorder. However, there are reports that a number of patients suffered episodes of syncope or seizure. Further investigation of the efficacy and acceptability of tiagabine in the treatment of acute affective episodes of bipolar disorder should await the clarification of the nature of the reported episodes of syncope and seizure-like activity and an examination of the level of risk involved.
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Affiliation(s)
- Akshya Vasudev
- University ofWesternOntario, London Health Sciences Centre, Victoria Hospital, London, Canada.
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Goldstraw P, Strivens E, Kennett C, Lie D, Geddes J, Thwaites J. The care of older people during and after disasters: A review of the recent experiences in Queensland, Australia and Christchurch, New Zealand. Australas J Ageing 2012; 31:69-71. [DOI: 10.1111/j.1741-6612.2012.00613.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Threlkeld EF, Little L, Park JY, Varin P, Geddes J, Sarang-Sieminski A. Structural Adaptation of Microvessels in Disease States. FASEB J 2012. [DOI: 10.1096/fasebj.26.1_supplement.983.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | - John Geddes
- Franklin W. Olin College of EngineeringNeedhamMA
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Abstract
BACKGROUND Oxcarbazepine, a keto derivative of the 'mood stabiliser' carbamazepine, may have efficacy in the treatment of acute episodes of bipolar disorder. Potentially, it may offer pharmacokinetic advantages over carbamazepine. OBJECTIVES To review the efficacy and acceptability of oxcarbazepine compared to placebo and other agents in the treatment of acute bipolar episodes including mania, mixed episodes and depression. SEARCH METHODS Electronic databases were searched up to 2 September 2011. Specialist journals and conference proceedings were handsearched. Authors, experts in the field and pharmaceutical companies were contacted requesting information on published and unpublished trials. SELECTION CRITERIA Randomised controlled trials (RCTs) which compared oxcarbazepine with placebo or alternative agents, where the stated intent of intervention was the acute treatment of bipolar affective disorder were sought. Participants with bipolar disorder of either sex and of all ages were included. DATA COLLECTION AND ANALYSIS Data were extracted from the original reports individually by two review authors. For dichotomous data, odds ratios (ORs) were calculated with 95% confidence intervals (CI). Continuous data were analysed using standardised mean differences (with 95% CI). MAIN RESULTS Seven studies were included in the analysis (368 participants in total). All were on mania, hypomania, mixed episodes or rapid-cycling disorder. Overall, their methodological quality was relatively low.There was no difference in the primary outcome analysis - a fall of 50% or more on the Young Mania Rating Scale (YMRS) - between oxcarbazepine and placebo (N=1, n=110, OR =2.10, 95% CI 0.94 to 4.73) in one study, conducted in children; no studies were available in adult participants.In comparison with other mood stabilisers, there was no difference between oxcarbazepine and valproate as an antimanic agent using the primary outcome (50% or more fall in YMRS, OR=0.44, 95% CI 0.10 to 1.97, 1 study, n=60, P=0.273) or the secondary outcome measure (differences in YMRS between the two groups, SMD=0.18, 95% CI -0.24 to 0.59, 2 studies, n=90, P=0.40). No primary or secondary efficacy outcome measures were found comparing oxcarbazepine with lithium monotherapy.As an adjunctive treatment to lithium, oxcarbazepine reduced depression rating scale scores more than carbamazepine in a group of manic participants on the Montgomery-Åsberg Depression Rating Scale (MADRS) (SMD=- 1.12, 95% CI -1.71 to -0.53, 1 study, n=52, P=0.0002) and on the Hamilton Depression Rating Scale (HDRS) (SMD=- 0.77, 95% CI -1.35 to -0.20, 1 study, n=52, P=0.008).There was a higher incidence of adverse effects, particularly neuropsychiatric, in participants randomised to oxcarbazepine compared to those on placebo (1 study, n=115, 17% to 39% of participants on oxcarbazepine had at least one such event compared to 7% to 10% on placebo).There was no difference in adverse events rates between oxcarbazepine and other mood stabilisers or haloperidol. AUTHORS' CONCLUSIONS Currently, there are insufficient trials of adequate methodological quality on oxcarbazepine in the acute treatment of bipolar disorder to inform us on its efficacy and acceptability. Studies predominantly examine the treatment of mania: there are data from subgroup analysis on mixed affective, hypomania and rapid-cycling states.From the few studies included in this review, oxcarbazepine did not differ in efficacy compared to placebo in children and adolescents. It did not differ from other active agents in adults. It may have a poorer tolerability profile compared to placebo. No data were found on outcomes relevant to patients and clinicians, such as length of hospital admission. There is a need for adequately powered randomised controlled trials of good methodological quality to inform us of the therapeutic potential of oxcarbazepine across the spectrum of acute episodes in bipolar disorder.
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Affiliation(s)
- Akshya Vasudev
- University of Western Ontario, London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, PO BOX 5010, London, Ontario, Canada
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Abstract
BACKGROUND Tiagabine, an anticonvulsant, has been reported to have efficacy in prophylactic treatment of bipolar disorder in case reports and in case series. OBJECTIVES To assess the efficacy and acceptability of tiagabine, relative to placebo, and other agents in the prevention or attenuation, or both, of episodes of bipolar disorder in adults. The efficacy and acceptability of tiagabine were considered in terms of mood symptoms, mortality, general health, social functioning, adverse effects and overall acceptability to participants. SEARCH METHODS The Cochrane Collaboration Depression, Anxiety and Neurosis review group's specialised registers (CCDANCTR-Studies and CCDANCTR-References) were searched to 1 October 2011. These registers contains relevant randomised controlled trials from: The Cochrane Library (all years to date), EMBASE, (1974 to date) MEDLINE (1950 to date) and PsycINFO (1967 to date). Reference lists of relevant papers and major textbooks of affective disorder were examined. Authors, other experts in the field and pharmaceutical companies were contacted for knowledge of suitable published or unpublished trials. Specialist journals and conference proceedings were handsearched. SELECTION CRITERIA Randomised controlled trials of tiagabine versus placebo, alternative mood stabilisers or antipsychotics, for the maintenance treatment of bipolar disorder in adults, male and female, aged 18 to 74 years. DATA COLLECTION AND ANALYSIS Data were to be extracted from the original reports of included studies independently by two authors. The main outcomes to be assessed were:(1) the efficacy of tiagabine treatment in preventing or attenuating further episodes of bipolar disorder, including its efficacy in rapid cycling disorder; (2) the acceptability of tiagabine treatment to participants; (3) the prevalence of side effects; and (4) mortality, if any, on tiagabine treatment.Outcomes concerning relapse or recurrence were to be analysed excluding data from studies using discontinuation protocols, which were to be analysed separately. Subgroup analyses were to be performed to examine the effects of tiagabine treatment in rapid cycling bipolar disorder and previous mood stabiliser non-responders. Data were to be analysed using Review Manager 5. MAIN RESULTS No randomised controlled trials of tiagabine in the maintenance treatment of bipolar disorder were found. AUTHORS' CONCLUSIONS There is an insufficient methodologically rigorous evidence base to draw any conclusions regarding the use of tiagabine in the maintenance treatment of bipolar disorder. There is a need for randomised controlled trials examining the therapeutic potential of this agent in bipolar disorder. There have been some reports of syncope or seizures, or both, when tiagabine has been used for the acute treatment of mania. It needs to be established if such adverse effects occur in the maintenance phase as well.
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Affiliation(s)
- Akshya Vasudev
- University of Western Ontario, London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, PO BOX 5010, London, Ontario, Canada
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91
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Cipriani A, Barbui C, Butler R, Hatcher S, Geddes J. Depression in adults: drug and physical treatments. BMJ Clin Evid 2011; 2011:1003. [PMID: 21609510 PMCID: PMC3217759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Depression may affect up to 10% of the population, with half of affected people having recurrence of their symptoms. In mild to moderate depression, there is no reliable evidence that any one treatment is superior in improving symptoms of depression, but the strength of evidence supporting different treatments varies. In severe depression, only prescription antidepressants and electroconvulsive therapy are known to improve symptoms. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in mild to moderate and severe depression, and in treatment-resistant depression? Which interventions reduce relapse rates? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 88 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: antidepressant drugs (tricyclic antidepressants [including low-dose tricyclic antidepressants], selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or venlafaxine), continuing prescription antidepressant drugs, electroconvulsive therapy, exercise, lithium augmentation, pindolol augmentation, and St John's wort.
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Affiliation(s)
- Andrea Cipriani
- Department of Public Health and Community Medicine, Section of Psychiatry and Clinical Psychology, University of Verona, Verona, Italy
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Ogundipe OO, Geddes J, Leckie AM, Frier BM. Impaired hypoglycaemia awareness and employment in people with Type 1 diabetes. Occup Med (Lond) 2011; 61:241-6. [DOI: 10.1093/occmed/kqr027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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93
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Abstract
AIMS To characterize the frequency and the nature (symptomatic vs. asymptomatic) of hypoglycaemia in people with Type 1 diabetes with impaired awareness of hypoglycaemia. METHODS A group of 19 patients with Type 1 diabetes with normal hypoglycaemia awareness were matched for age, sex, duration of diabetes and glycaemic control with 19 patients with impaired awareness of hypoglycaemia. Frequency of severe hypoglycaemia in the preceding year was estimated retrospectively. Capillary blood glucose was monitored prospectively four times daily, over a 4-week period. All blood glucose values < 3 mmol/l were recorded and classified by symptom response. RESULTS The patients with impaired awareness of hypoglycaemia exhibited twice the frequency of all episodes of hypoglycaemia over the 4-week monitoring period than those with normal awareness (mean ±sd 7.9 ± 5.4 vs. 3.7 ± 3.6, P = 0.003). No differences between the two subgroups were observed in the total number of symptomatic hypoglycaemia episodes (4.2 ± 3.3 vs. 3.2 ± 3.4, P = 0.25). The group with impaired awareness of hypoglycaemia had a sevenfold higher incidence of asymptomatic hypoglycaemia than those with normal awareness (3.7 ± 5.3 vs. 0.5 ± 1.2, P = 0.001); these episodes comprised 47% of all glucose values < 3.0 mmol/l in this group, compared with 14% in the normal awareness group. The annual prevalence of severe hypoglycaemia for patients with impaired awareness of hypoglycaemia was 53% compared with 5% for patients with normal awareness, and these patients had a significantly higher incidence of severe events (1.6 ± 2.8 vs. 0.1 ± 0.3, P = 0.001). CONCLUSIONS Adults with Type 1 diabetes who have impaired awareness of hypoglycaemia are exposed to a much higher incidence of asymptomatic hypoglycaemia than those with normal awareness and are at higher risk of developing severe hypoglycaemia.
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Affiliation(s)
- J E Schopman
- Department of Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
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94
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Kivimäki M, Jokela M, Hamer M, Geddes J, Ebmeier K, Kumari M, Singh-Manoux A, Hingorani A, Batty GD. Examining overweight and obesity as risk factors for common mental disorders using fat mass and obesity-associated (FTO) genotype-instrumented analysis: The Whitehall II Study, 1985-2004. Am J Epidemiol 2011; 173:421-9. [PMID: 21248310 DOI: 10.1093/aje/kwq444] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Mendelian randomization approach exploits genetic variants to improve causal inference when using observational data. The authors examined the relation between long-term obesity and common mental disorders (CMD) by utilizing the known relation between fat mass and obesity-associated (FTO) genotype and body mass index (BMI; weight (kg)/height (m)(2)). Data collection in 2,981 men and 1,164 women (mean age at baseline = 44 years) from the Whitehall II Study (London, United Kingdom) included 4 repeated examinations of BMI and CMD over a 19-year follow-up period (1985-2004), plus an assessment of FTO polymorphism rs1421085. In men, there was an association of FTO genotype with all measures of adiposity (mean BMI, number of times obese, and, in nonobese persons, number of times overweight). FTO was also associated with CMD in men. This was independent of adiposity, thus potentially violating the exclusion restriction assumption. According to both conventional and FTO-instrumented regression analysis, measurement of obesity was associated with an increased occurrence of CMD. In the FTO-instrumented analysis only, higher BMI and overweight were also associated with CMD. In women, there was no link between FTO and adiposity. Mendelian randomization analyses supported the status of long-term obesity as a risk factor for CMD in men-a finding that should be interpreted cautiously because the function of the FTO gene is unknown.
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Affiliation(s)
- Mika Kivimäki
- Department of Epidemiology and Public Health, Faculty of Biomedical Sciences, University College London, United Kingdom
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95
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Choudhary P, Geddes J, Freeman JV, Emery CJ, Heller SR, Frier BM. Frequency of biochemical hypoglycaemia in adults with Type 1 diabetes with and without impaired awareness of hypoglycaemia: no identifiable differences using continuous glucose monitoring. Diabet Med 2010; 27:666-72. [PMID: 20546285 DOI: 10.1111/j.1464-5491.2010.03006.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Impaired awareness of hypoglycaemia (IAH) is a major risk factor for severe hypoglycaemia in Type 1 diabetes. Although biochemical hypoglycaemia is asserted to be more frequent in IAH, this has not been estimated accurately. The aim of this study was to use Continuous Glucose Monitoring (CGM) to quantify hypoglycaemia in IAH and evaluate its use in identifying impaired awareness of hypoglycaemia. METHODS Ninety-five patients with Type 1 diabetes were classified as having normal (n = 74) or impaired awareness (n = 21) using an established method of assessing hypoglycaemia awareness. Hypoglycaemia exposure was assessed prospectively over 9-12 months using weekly 4-point capillary home blood glucose monitoring (HBGM), 5 days of CGM and prospective reporting of severe hypoglycaemia. The frequencies of biochemical and severe hypoglycaemia were compared in patients with normal and impaired awareness of hypoglycaemia. RESULTS Patients with impaired awareness had a 3-fold higher incidence of severe hypoglycaemia than those with normal awareness [incidence rate ratio (IRR) 3.37 (95% CI 1.30-8.7); P = 0.01] and 1.6-fold higher incidence of hypoglycaemia on weekly HBGM [IRR 1.63 (95% CI 1.09-2.44); P = 0.02]. No significant differences were observed with CGM [IRR for sensor glucose < or = 3.0 mmol/l 1.47 (95% CI 0.91-2.39); P = 0.12; IRR for sensor glucose < or = 2.2 mmol/l 1.23 (95% CI 0.76-1.98); P = 0.40]. CONCLUSIONS Patients with Type 1 diabetes with impaired awareness had a 3-fold higher risk of severe hypoglycaemia and 1.6-fold higher incidence of biochemical hypoglycaemia measured with weekly glucose monitoring compared with normal awareness, but 5 days of CGM did not differentiate those with impaired from those with normal awareness.
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Affiliation(s)
- P Choudhary
- Academic Department of Diabetes, University of Sheffield, Sheffield, UK
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96
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Kingwell E, Koch M, Leung B, Isserow S, Geddes J, Rieckmann P, Tremlett H. Cardiotoxicity and other adverse events associated with mitoxantrone treatment for MS. Neurology 2010; 74:1822-6. [PMID: 20427751 DOI: 10.1212/wnl.0b013e3181e0f7e6] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Mitoxantrone is used for aggressive multiple sclerosis (MS), but concerns about safety, including cardiotoxicity and other laboratory measures, prevail. OBJECTIVE To evaluate the incidence and potential predictors of adverse events associated with mitoxantrone at the MS Clinic, University of British Columbia, Canada. METHODS Retrospective review of patients treated with mitoxantrone by standard protocol; maximum cumulative dose = 120 mg/m(2). Left ventricular ejection fraction (LVEF) was measured with regular multiple-gated acquisition (MUGA) scans; blood cell counts and biochemical liver tests were performed before infusions. Generalized estimating equations were used to examine potential predictors of adverse events (graded according to the Common Toxicity Criteria, version 4) in patients with normal baseline and > or =1 follow-up MUGA or laboratory assessment. RESULTS All 163 patients (58% women) treated with mitoxantrone from 1999 to 2007 were reviewed. Mean baseline age was 41.9 (SD 10.8) years, cumulative dose was 59.7 (SD 26.0) mg/m(2), and median follow-up duration was 14 months (maximum 6.5 years). By study end, 14% developed de novo cardiotoxicity (grade > or =2) as measured by decreased LVEF, 27% neutropenia (grade > or =1), 15% anemia (grade > or =1), and 15% liver toxicity (grade > or =1). Possible predictors of adverse events included sex, age, disease duration, and cumulative dose; only women exposed to a higher cumulative dose were at a greater risk of anemia (adjusted odds ratio 1.26, 95% confidence interval 1.08-1.48 per 10 mg/m(2)). CONCLUSIONS Based on cardiac and laboratory assessments, mitoxantrone was reasonably well tolerated. However, cardiotoxicity was evident after doses well below current maximum recommended levels. A dose-response effect was not apparent. Findings emphasize the importance of monitoring; the long-term effects of mitoxantrone in multiple sclerosis require investigation.
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Affiliation(s)
- E Kingwell
- Faculty of Medicine, UBC Hospital, 2211 Wesbrook Mall, University of British Columbia, Vancouver, BC, V6T 2B5 Canada.
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Whale R, Terao T, Cowen P, Freemantle N, Geddes J. Pindolol augmentation of serotonin reuptake inhibitors for the treatment of depressive disorder: a systematic review. J Psychopharmacol 2010; 24:513-20. [PMID: 18832428 DOI: 10.1177/0269881108097714] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Adding pindolol to serotonergic antidepressant treatment offers a potential strategy for producing a more rapid onset of action and an enhanced antidepressant effect. This review investigated whether pindolol enhances the efficacy of serotonergic antidepressant treatment in adult patients with depressive disorders at sequential time points up to 6 weeks. SEARCH STRATEGY Cochrane Collaboration Depression, Anxiety and Neurosis-Controlled Trials Register plus unpublished trial data. STUDY SELECTION Randomised trials including depressed patients, comparing serotonergic antidepressants + pindolol with serotonergic antidepressants + placebo and using depressive symptom clinical outcomes scales. DATA EXTRACTION Clinical response at time points up to 6 weeks as defined by >50% depression scale score reduction was extracted for each trial as possible. Eleven studies were identified including unpublished data. The pooled odds ratios for dichotomous response to treatment at time points from 1 to 6 weeks were 2.39 (95% CI 1.40-4.06), 2.39 (1.74-3.29), 1.94 (1.46-2.58), 1.59 (1.16-2.18), 1.42 (0.87-2.31) and 1.28 (0.91-1.81). Time-to-event analysis showed a greater response with pindolol augmentation versus placebo (P = 0.04). There was significant heterogeneity between studies at some time points. Dropout rates did not significantly differ between treatment arms. This review suggests an overall beneficial clinical effect of pindolol augmentation, most clearly up to 4 weeks of treatment.
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Affiliation(s)
- R Whale
- Institute of Postgraduate Medicine, Brighton and Sussex Medical School, Brighton, UK.
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98
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O'Grady JT, Thompson C, Geddes J. Light therapy for seasonal affective disorder. Hippokratia 2009. [DOI: 10.1002/14651858.cd004516.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
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. SEARCH STRATEGY We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (September 2006), the Cochrane Central Register of Controlled Trials (September 2006), MEDLINE (1966-December 2007), EMBASE (1980-2006), CINAHL (1982-2006), PsycINFO (1872-2006) and reference lists. We also contacted experts, trialists and pharmaceutical companies in the field. SELECTION CRITERIA Randomised controlled trials comparing olanzapine with placebo or other active treatment in long-term treatment of bipolar disorder. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS Five trials (1165 participants) were included in the review. There was no statistically significant difference between olanzapine and placebo (either alone or in combination with lithium or valproate) in terms of number of participants who experienced relapse into mood episode (random effects RR 0.68, 95% CI 0.43 to 1.07, p = 0.09; 2 studies, n=460), however restricting the analysis to the trial that compared olanzapine monotherapy versus placebo, there was a statistically significant difference in favour of olanzapine (RR 0.58, 95% CI 0.49 to 0.69, p<0.00001). No statistically significant difference was found between olanzapine and other mood stabilisers (lithium or valproate) in preventing symptomatic relapse for any mood episode, however, olanzapine was more effective than lithium in preventing symptomatic manic relapse (RR 0.59, 95% CI 0.39 to 0.89, p = 0.01; 1 study, n=361). Olanzapine either alone or as adjunctive treatment to mood stabilisers was associated with significantly greater weight gain than placebo. By contrast, olanzapine was associated with a lower rate of manic worsening, but with a higher rate of weight increase and depression than lithium. AUTHORS' CONCLUSIONS Though based on a limited amount of information, there is evidence that olanzapine may prevent further mood episodes in patients who have responded to olanzapine during an index manic or mixed episode and who have not previously had a satisfactory response to lithium or valproate. However, notwithstanding these positive results, the current evidence is stronger for lithium as first line maintenance treatment of bipolar disorder.
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Affiliation(s)
- Andrea Cipriani
- Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Policlinico "G.B.Rossi", Pzz.le L.A. Scuro, 10, Verona, Italy, 37134.
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Ceron-Litvoc D, Soares BG, Geddes J, Litvoc J, de Lima MS. Comparison of carbamazepine and lithium in treatment of bipolar disorder: a systematic review of randomized controlled trials. Hum Psychopharmacol 2009; 24:19-28. [PMID: 19053079 DOI: 10.1002/hup.990] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To review data from randomized controlled trials (RCTs) assessing the comparative efficacy of carbamazepine and lithium in treatment of acute manic and maintenance phase of bipolar disorder (BD). DESIGN RCTs were identified through a search strategy that included: electronic databases, reference cross-checking, hand search of non-indexed publications, and book chapters on the treatment of BD comparing carbamazepine with lithium. Outcomes investigated were antimanic effect, trial withdrawal, relapse, hospitalization, need for rescue medication, and presence of adverse effects. Selection of studies and data analysis were performed independently by authors. Whenever possible, data from trials were combined through meta-analyses. Relative risks (RR) were estimated for dichotomous data. RESULTS In acute mania, carbamazepine was similar to lithium on the following outcomes: trial withdrawal due to adverse effects, number of participants with at least one adverse effect, improvement in the Clinical Global Impression (CGI). In acute mania, carbamazepine was associated with fewer trial withdrawals. In maintenance treatment, carbamazepine was similar to lithium in relapses and hospitalization, but there were fewer trial withdrawals due to adverse effects on lithium. CONCLUSION This review suggests that carbamazepine might be comparable to lithium in terms of efficacy and safety, and therefore a valuable option in the treatment of both manic and maintenance phases.
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Affiliation(s)
- Daniela Ceron-Litvoc
- Department of Psychiatry, Medical College, Federal University of São Paulo, Brazil.
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