Category: Systematic review

Systematic reviews are the cream of the research crop. Those who understand their value thrive at an opportunity to learn more about them.

The prevalence of common mental and substance use disorders in general practice: new paper out now

The World Health Organization has long recommended that conditions like depression or anxiety are identified and treated early because they burden the healthcare system, patients and their families.

When we looked at the medical literature published and indexed by the US National Library of Medicine, National Institutes of Health in the last 10 years, we found that not much has changed. The unmet need for primary mental health care – identified by the World Health Organization a decade ago – remains unmet.

To read more about our review of literature, visit the publisher’s website:  http://www.tandfonline.com/doi/full/10.1080/17523281.2014.939221#.U9I1pONkSAg

Citation:
The prevalence of common mental and substance use disorders in general practice: a literature review and discussion paper
Jan Klimas, Anna Neary, Claire McNicholas, David Meagher, Walter Cullen

Mental Health and Substance Use.

76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous

Not one, but two conferences in Puerto Rico made my trip fantastic. As usual, the NIDA International forum happened for the 15th time on the weekend before the Conference of the College on Problems of Drug Dependence. The lines below offer some insights from these meetings.

Integration of addiction treatment into primary care: the portals of entry

Is abstinence related with good health? Is decreased drug use related with good health?
Tae Woo Park and Richard Saitz asked these questions in a secondary analysis of data from a clinical trial of 589 patients using cocaine or cannabis with very low dependence proportion among the sample (ASSIST score >27). To answer their questions, they used clinical measures of good health, such as, SIP-D, PHQ-9, and EUROQoL. Health outcomes were associated with decreases in illicit drug use in primary. However, abstinence and decreased use may represent very different magnitudes. Self-reports related dysphoria could also play a role in the differences. It takes a long time to make improvement in those consequences? 6 months of follow up observations may not be enough. Patient-preferred outcomes are paramount: do they want to have a score lower than XY on PHQ-9? What outcomes are important for them?
The TOPCARE (www.mytopcare.org) project implemented guidelines for potential opioid misuse (Jan Liebschutz). Her slides blew up half-way through the presentation but she delivered the talk excellently. Nurse care management was a component of the guideline implementation trial. Academic detailing (45min, with opioid prescribing expert) included principles of prescribing brochure and difficult case discussion. Is academic detailing effective? The Cochranesystematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager programme is a no brainer.
Rich Saitz commented on the sad state of affairs in the addiction treatment, where only 10% of people with addiction are in treatment. Integrated care is the best thing since the sliced bread, but where’s the evidence? His research showed no added benefit of integrated versus care as usual. Why? Maybe, addiction is not a one thing, but we treat it like one thing. Dr Tai provoked the audience with a question: “Do our patients with addiction have the capability to participate in the treatment planning and referral?” If they seek medical care for their broken leg and we refer them to an addiction specialist, will they go? most likely not.
But it is the same with hypertension. Referral is a process and not a once-off thing. Although they may not follow our advice at the first visit, a rapport built by a skilled professional over a series of discussions can help them get the most appropriate care.

Does the efficacy of medications for addiction decrease over time?

An old saying among doctors states “One should prescribe a new medication quickly before it loses its efficacy”. Elias Klemperer pooled the data from several Cochrane systematic reviews on addiction medicines, such as, NIRT gum, Acamprosate, or Buproprion. Their effectiveness decreased over time. The changes in methodologies might have caused the decline; also the sponsorship of trials, target populations or publication bias.

Write, wrote, written

Primary author is in the driver’s seat, others are passengers. Primary author pulls the train. Dr Adam Carrico(UCSF) asked us “What are you really passionate about?” Find it and use your passion for those themes to drive your writing habit. Decide to be fearless& fabulous. Develop a writing routine. Put together a queue of writing projects and don’t churn out 2 products at the same time, one of them will suffer. Schedule writing retreats with colleagues. Set Timelines for writing grant and programme time for reviews by trusted people, give people a warning that this is what you’re planning to do. The JAMA June 2014 issue offers useful tips on how to write an editorial.

Dr Knudsen reported on the editorial internship of the Journal of Substance Abuse Treatment – JSAT, which started in 2006, with Dr McGovern (current editor) and Knudsen as the 1stfellows. Success rate of the fellowship applications is 2/30-45, prior involvement is appreciated (peer reviewer, submission). The new 2014 fellows are: Drs Madson and Rash. In the one year of the fellowship, the fellows typically review 12-15 manuscripts, some years, as a managing editor of a special issue. The Drug and Alcohol Dependence journal has a similar scheme.

Check out the http://www.cpddblog.com/

How to measure performance in the addiction and mental health services? A new paper out now

As part of her final year research project in the Graduate Entry Medical School, University of Limerick, Dr Carla Henderson queried the literature about the methods of development and content of key performance indicators for MESUDS – the mental and substance use disorders – as she named them.

Figure 1. Journal cover

Her searches revealed a great variety in the methodologies of indicator development for MESUDS – including expert opinion, literature review, stakeholder consultation, and the structured consensus method. 

The paper in Mental Health and Substance use journal (see Figure 1) highlighted several problems in the performance indicators: (1) A bias in the level of performance assessment toward system/health plan evaluation followed by program/service evaluation; (2) Similarly, there was a large skew toward indicators that reflected evaluation of processes. Especially in the addiction health services research, we don’t know whether improvement of care processes is linked to improvement of patients’ health: “such changes have thus far demonstrated only minimal impact on patient outcomes” (Humphreys et al, 2011, see Figure 2). 

Figure 2. Dr Keith Humphreys

Read the full paper at the journal’s website:  http://www.tandfonline.com/doi/abs/10.1080/17523281.2014.901402#.U0LiuvldWg4

Cited works:

  • Carla Henderson, Jan Klimas, Colum Dunne, Des Leddin, David Meagher, Thomas O’Toole, Walter Cullen (2014). Key performance indicators for mental health and substance use disorders: a literature review and discussion paper. Mental Health and Substance Use, Early Online. 
  • Keith Humphreys, A. Thomas McLellan (2011). A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients. Addiction, Volume 106, Issue 12, pages 2058–2066

Conference of Cochrane Evidence: Useful, Usable & Used #CE3U

My journey with Cochrane started one summer afternoon in 2010, when I interviewed a Tallaghtdoctor (Tallaght is a rough suburb in Dublin, Ireland) about treatments for drinking problems of people who also use other drugs. I emphasized that brief psychosocial interventions were the treatment of choice for patients who don’t use other drugs and that there’s no reason why this should be different for drug users. He asked me whether I was Swedish, because of my accent, and replied by a single question which kept me awake at night and started my career as an addiction investigator: “Does it work?” I decided to celebrate the four years of trying to find an answer to his question at the Cochrane conference in Manchester, UK.
Wednesday 23rd April 2014
This year’s conference of UK and Irish Cochrane contributors’ swapped plenaries and workshops – Wednesday kicked off with two sessions of developmental workshops. The motto of the priority setting workshop was  “Don’t start a journey that you can’t finish”. Pragmatism is a very important part of priority setting. The value of setting priorities in healthcare is the expected gain from reducing the uncertainty. In another words, to reduce the probability that somebody somewhere is getting a wrong treatment.
Figure 1. Bees were the theme of Cochrane conference
The key question of the public health workshop was How to produce good reviews quickly? Growing number of people are interested in doing reviews under the public health group. Most public health studies are non-randomised. Evidence forms just one part of the complex process of public health policy – timeliness is the big factor. The idea of local context permeates all policies – is this relevant to your local area? All of us, as Cochrane reviewers, give shades of grey and they [policy makers] want black& white answers.
The first afternoon plenary started a faithful member of the Cochrane family, Nicky Cullum. She described how easy reviews were in the past. Her talk inspired 12 new tweets in the first 5 minutes of the plenary (#CE3Useful). The beginning of Cochrane nursing group was accompanied by skepticism “Are RCTs possible in nursing?  Is experimentation at odds with caring?” The explosion of nursing trials in the recent years posed new challenges “How on earth do we help non-academic clinicians to have both clinical and academic career?” Trisha Greenhalghconcluded the first with provocative lecture about boringness of Cochrane reviews. She used the example of young doctor Archie Cochrane in a German camp to demonstrate that the art of rhetoric consists of logos, ethos and pathos. Her other work on how innovations rise and how they spread further supported the rhetoric argument. While a logo is the only thing in scholarship rhetoric, factual knowledge can be rarely separated from ethical or social context. By trying to do so, the Cochrane researchers are stripping away the very thing they need to be exploring – how to change the world through science. The methodological fetishism developed in Cochrane collaboration (linked to control, rationalism and accountability) hinders production of more realist and interesting reviews.
Thursday morning plenaries helped the delegates to confer after the gala dinner last night. Rich Rosenfeld, a Professor and Chairman of Otolaryngology, explained how Cochrane reviewers can help policy makers by rapid reviews – Good is ok, perfect we don’t need [for guidelines]. A health economist, Karl Claxton, continued the discussion on when no more evidence is needed. Research takes long time and evidence that we already have can inform allocation of research funds for new projects. However, we should be cautious about judging the usefulness trials with hindsight, it’s wrong because we don’t know the context. Neal Maskery made the audience “lol” with very entertaining and interactive plenary which focused on what we know about how people make decisions. Our brain is so good at patterns recognition – it wants to do it all the time. This phenomenon is called Base rate neglect – a cognitive bias. Biases such as this one hinder innovation and affect our decisions in all areas from buying a car to prescribing medicines. Al Mulley, an expert on shared decision making, finished morning lectures with a story of how every patient brings their own context by using examples from his research on how bothersome is urinary dysfunction.

The special addition to the conference was presence of Students 4 Best Evidence, some of whom won prizes from UK Cochrane centre, including free travel and conference participation. Read more about their winning entries on prostatecancer, dentalhealth, smoking, and long-term illness.

From a personal perspective, starting a Cochrane review took me on a journey which led from a clinical question (from the Tallaght doctor), to policy development, medical education and further research in a very short time. I still don’t know whether counselling works for drink problems in people who also use other drugs, but I’ve learned how to find an answer using the Cochrane methodology.

Beg, steel or borrow: getting physicians to recruit patients in clinical trials

Leaflets, adverts and phone calls have all been used to recruit patients in clinical trials with some results. Still, the personal contact remains the most reliable method, if you can get the recruiter to do it. In this post, I explore some of the barriers of clinicians’ recruitment activity in randomised controlled trials.

Lack of time, specialist staff and patient motivation are the most frequently reported barriers that prevent clinicians to recruit their patients into clinical trials. Even though the physician signs up for the study and is informed about what is involved, they often do not complete the job. Some are distracted by competing clinical priorities, while others cannot get a positive answer from their patients. Regardless of the reason, the research suffers because of low participation numbers and prolonged study set-up.
iStockphotos.com


Researchers from the University Of Birmingham, UK, looked at all ways that improve the clinicians’ recruitment activity. Their systematic reviewof scientific literature compared the impact of different recruitment strategies and underlying clinician attitudes. To recruit successfully, the clinicians should be incentivised or supported in some way. Unfortunately, many researchers use supports that don’t work. What’s more worrying is that nobody knows how to boost clinicians’ recruitment rates. The study authors recommend that each clinical trial uses qualitative methods to ask clinicians what would work for them and use their suggestions. Another issue was what clinicians think of clinical trials. Misconceptions about trials methods still prevail and clinicians do not see the positives of trials; nor do their patients. Improved education and communication from researchers to physicians can overcome these issues.

Paying research participants for taking part can increase the number of people who agree to take part in the study, the so-called consent rate. It has become a norm in the Western world studies. Still, some studies and countries are unable to provide financial incentives to patients who volunteer for research. Direct payments may also be viewed as introducing unwanted bias into research results. Some may think that people who get paid for research would not participate if they did not get anything. Human motivation is a mysterious subject and money is part of it. It is the currency of modern society.

Is it ethical?

The healing relationship between the patient and doctor can be viewed as unsuitable for recruiting patients into clinical trials. Patients may feel obliged to agree, without making a fully informed decision. Ideally, the recruitment should be done by someone who isn’t involved in patients’ care; however, this is often not feasible in the real life. On one hand, the participants should make an informed decision about their participation and decide voluntarily. On the other hand, the researchers should not surprise patients who attend medical services for non-research purposes. The way to overcome this problem is through a two-stage recruitment process, as used in our study. The first step is to give information. The care provider gives a leaflet with information about the study to potential participants. The person goes home and reads the leaflet at their leisure. When they come to see their doctor next time, they can ask questions about the study, and decide to take, or not to take, part in the study.

Recruitment to randomised trials will probably always remain an issue for science. With an open mind, the investigators and clinicians can seek better solutions for creating trials that would attract human participants and help advance science for the benefit of all.

Cited articles:
Ben Fletcher, Adrian Gheorghe, David Moore, Sue Wilson, Sarah Damery: Improving the recruitment activity of clinicians in randomised controlled trials: a systematic review. BMJ Open 2012;2:1 e000496 doi:10.1136/bmjopen-2011-000496

Klimas J, Anderson R, Bourke M, Bury G, Field CA, Kaner E, Keane R, Keenan E, Meagher D, Murphy B, O’Gorman CSM, O’Toole TP, Saunders J, Smyth BP, Dunne C, Cullen W: Psychosocial Interventions for Alcohol Use Among Problem Drug Users: Protocol for a Feasibility Study in Primary Care. JMIR Res Protocols 2013;2(2):e26
doi: 10.2196/resprot.2678