Trial of risperidone in India--concerns

Intervention trials for adults with bipolar disorder in low-income and lower-middle-income countries: A systematic review

BACKGROUND

The treatment gap for bipolar disorder is aggravated by economic inequality. Around half of the world's population live in a low-or lower-middle-income country, where research on treatment is scarce. Hence, this review aims to determine the number and types of intervention studies conducted on adults with bipolar disorder in low-income and lower-middle-income countries and analyze the effect of these interventions on symptom severity, medical adherence, and quality of life.

METHODS

A systematic review was conducted in June and November 2021 using eight databases. Controlled intervention trials on adults with bipolar disorder on data from low-income and lower-middle-income countries at time of publication were included. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or The Risk Of Bias In Non-randomized Studies of Interventions assessment tool.

RESULTS

Twenty-one studies met the inclusion criteria. These were divided into four subtypes based on the intervention; pharmacotherapy (=12), psychosocial (=7), electroconvulsive therapy (=1), and traditional medicine (=1). Three studies were from low-income countries. A high risk of bias characterized the studies; only four studies reported the procedures used for randomization. Most studies, however, identified a beneficial effect on symptom severity, and in addition, medical adherence could be improved with psychosocial interventions.

LIMITATIONS

Heterogeneity across studies prevented any meaningful pooling of data to meta-analyses.

CONCLUSION

Data for treatment interventions contextualized to the local setting for bipolar disorder remains sparse, particularly from low-resource settings. Further studies are urgently needed to target the treatment gap for bipolar disorder.

TRIAL REGISTRATION

PROSPERO: CRD42020170953.

Introduction: case studies in the ethics of mental health research

This collection presents six case studies on the ethics of mental health research, written by scientific researchers and ethicists from around the world. We publish them here as a resource for teachers of research ethics and as a contribution to several ongoing ethical debates. Each consists of a description of a research study that was proposed or carried out and an in-depth analysis of the ethics of the study.

Trussed in evidence? Ambiguities at the interface between clinical evidence and clinical practice

This article considers the dominance that randomized controlled trials (RCTs) of psychotropic agents currently have in relation to the practice of psychiatry in mental health and primary care settings. In contemporary psychiatry, data of marginal significance based on rating scale measures are privileged as evidence that treatments are effective, while judgments of drug effects based on clinical practice are downgraded. The dominance of RCTs has also led to an increasing promotion of rating scales in clinical practice, described here as ;rating scale mongering.' The logical consequence of current interpretations of RCT data is that clinicians should adhere to guidelines which are based on a systematic assembly of such data, but the selective publication of trial data and ghostwriting of publications, lays the basis for guideline capture, and a corresponding capture of evidence-based clinical practice by pharmaceutical companies.

Ethical questions in human clinical psychopharmacology: should the focus be on placebo administration?

Of all ethical issues in clinical trial designs, only placebo use is dealt with acrimony and unwarranted, rhetoric emphasis. Many misconceptions are biased and may hamper research in the mechanisms of healing and recovery if placebo is banned from clinical trials, as some influential ethicists propose. Current treatments in psychiatry are by no means optimal and may vary in their effect across studies, rendering difficult to find the best available therapeutic method with which to compare new drugs. Because drugs possess specific mechanisms, it is not possible to compare drugs with different mechanisms as to their relevance in the pathophysiology of a given disorder. Placebo acts through non-specific mechanisms and is the ideal control for any disorder whose pathophysiology is relatively unknown and its treatment is still suboptimal. Sticking to short-term patient benefit in a trial reflects an individualistically oriented thinking in contemporary ethics and is likely to limit further research and efforts to better understand the mechanisms of disease and drug action, but also those related to general body reactance and self-healing, which are enhanced by placebo administration. Because in history ethics are swinging between two opposed views, it is possible that in the near future, the balance will move towards communitarianism, which is more likely to better serve long-term patient needs. Ethicists should also consider some other aspects of human experimentation, such as the consistency of research lines and the trend to substitute older drugs with their metabolites or enantiomers.