Agneta Pettersson

Ventilation Tube Treatment A Systematic Review of the Literature

Objective. The aim of this review was to study the effectiveness of ventilation tube (VT) treatment in children with secretory otitis media (SOM), assessed by improved hearing, normalized language and quality of life (QoL), and recurrent acute otitis media (rAOM), assessed by number of episodes of AOM and QoL. Data Sources. Cochrane Library, PubMed, and Embase databases were searched for randomized and nonrandomized controlled trials and cohort studies in English, Scandinavian, German, and French languages between 1966 and April 2007. Additional literature was retrieved from reference lists in the articles. Review Methods. A total of 493 abstracts were evaluated independently by 2 members of the project group, 247 full-text versions were assessed for inclusion criteria and quality using structured evaluation forms, and 63 articles were included in the review. Results and Conclusions. This review shows that there is strong scientific evidence (grade 1) that VT treatment of SOM improves hearing for at least 9 months and that QoL is improved for up to 9 months (grade 2 scientific evidence). There was insufficient evidence to support an effect of VT treatment for rAOM. There was also insufficient evidence to determine whether the design or material of the VT or the procedure used for insertion had any influence on the effect; however, there was some evidence (grade 3) that aspiration of secretion at insertion does not prolong VT treatment. Further research is needed to address these issues.

Bright white light therapy in depression: A critical review of the evidence

BACKGROUNDnLight therapy is an accepted treatment option, at least for seasonal affective disorder (SAD). Our aim was to critically evaluate treatment effects of bright white light (BWL) on the depressive symptoms in both SAD and non-seasonal depression.nnnMETHODSnThe systematic review was performed according to the PRISMA guidelines. PubMed, Embase, and PsycINFO were searched (December 1974 through June 2014) for randomized controlled trials published in peer-reviewed journals. Study quality was assessed with a checklist developed by the Swedish Council on Technology Assessment in Health Care. Only studies with high or medium quality were used in the meta-analyses.nnnRESULTSnEight studies of SAD and two studies of non-seasonal depression met inclusion and quality criteria. Effects on SAD were estimated in two meta-analyses. In the first, week by week, BWL reached statistical significance only at two and three weeks of treatment (Standardized Mean Difference, SMD: -0.50 (-CI 0.94, -0.05); -0.31 (-0.59, -0.03) respectively). The second meta-analysis, of endpoint data only, showed a SMD of -0.54 (CI: -0.95, -0.13), which indicates an advantage for BWL. No meta-analysis was performed for non-seasonal depression due to heterogeneity between studies.nnnLIMITATIONSnThis analysis is restricted to short-term effects of BWL measured as mean changes in scores derived from SIGH-SAD, SIGH-SAD self-report, or HDRS rating scales.nnnCONCLUSIONSnMost studies of BWL have considerable methodological problems, and the results of published meta-analyses are highly dependent on the study selection. Even though quality criteria are introduced in the selection procedures of studies, when the results are carefully scrutinized, the evidence is not unequivocal.

Which instruments to support diagnosis of depression have sufficient accuracy? A systematic review.

Abstract Background: Instruments are frequently used in case finding, diagnosis and severity grading of major depression, but the evidence supporting their utility is weak. Aim: To systematically review the specificity and sensitivity of instruments used to diagnose and grade the severity of depression. Methods: MEDLINE, PsycInfo, Embase and the Cochrane Library databases were searched until April 2014. Fifty studies fulfilled the inclusion criteria. Risk of bias was assessed with QUADAS. The average sensitivity and specificity of each instrument was estimated with hierarchical summary receiver operating characteristics analyses and the confidence in the estimates was evaluated using GRADE. Minimum acceptable sensitivity/specificity, with structured interview as the reference, was 80%/80% for structured interviews and 80%/70% for case-finding instruments. The minimum acceptable standard for severity measures was a correlation of 0.7 with DSM-IV classification. Results: Twenty instruments were investigated. The average sensitivity/specificity was 85%/92% for the Structured Clinical Interview for DSM-IV-Axis-I Disorders (SCID-I), 95%/84% for the Mini International Neuropsychiatric Interview (MINI), < 70%/85% for the Primary Care Evaluation of Mental Disorders (PRIME-MD), 88%/78% for the Patient Health Questionnaire-9 (PHQ-9) with a cut-off score of 10, 69%/95% for PHQ-9 as a diagnostic algorithm and 70%/83% for the Hospital Anxiety and Depression Scale (HADS) with a cut-off score of 7. The confidence in the estimates for the other instruments was very low. Conclusions: Only the SCID-I, MINI and PHQ-9 with a cut-off score of 10 fulfilled the minimum criteria for sensitivity and specificity. The use of the PRIME-MD and HADS is not supported by current evidence.

To score or not to score: a qualitative study on GPs views on the use of instruments for depression

BACKGROUNDnTo improve the detection, diagnosis and follow-up of depression in primary care patients, it has been proposed that GPs should employ assessment instruments as a complement to the consultation. However, most GPs do not use such instruments routinely.nnnOBJECTIVEnTo explore perceptions of Swedish GPs on the use of instruments in the medical consultation.nnnMETHODSnTwenty-seven GPs discussed in five focus groups that were digitally recorded, transcribed verbatim and analysed by systematic text condensation.nnnRESULTSnSix code groups emerged from the focus group discussions: (i) a perceived pressure from authorities and psychiatry to report depression scores; (ii) the scores were considered to be of limited value for the GP but could help the patient by facilitating sick leave compensation and hospitalization; (iii) instruments hampered the dialogue with the patient and non-verbal information was lost; (iv) the reliability of questionnaires was questioned; (v) instruments were seen as not fitting into primary care and GPs were uncertain how to use them and (vi) the main advantage of instruments was to promote communication with specific categories of patients.nnnCONCLUSIONSnUsing instruments to obtain a quantitative score of depression was of no benefit to the GPs. Given the weak evidence for the clinical relevance of many instruments, there is little reason to introduce them into practice. However, the instruments can facilitate communication with external actors and specific groups of patients.

Programs for prevention of externalizing problems in children : limited evidence for effect beyond 6 Months post intervention

BackgroundPreventing externalizing problems in children is a major societal concern, and a great number of intervention programs have been developed to this aim. To evaluate their preventive effects, well-controlled trials including follow-up assessments are necessary.MethodsThis is a systematic review of the effect of prevention programs targeting externalizing problems in children. The review covered peer reviewed publications in English, German, French, Spanish and Scandinavian languages. Experimental studies of standardized programs explicitly aiming at preventing externalizing mental ill-health in children (2–19xa0years), with outcome assessments at ≥6xa0months post intervention for both intervention and control groups, were included. We also included long-term trials with consecutive observations over several years, even in the absence of follow-up ≥6xa0months post intervention. Studies of clinical populations or children with impairments, which substantially increase the risk for mental disorders, were excluded.ResultsThirty-eight controlled trials assessing 25 different programs met inclusion criteria. Only five programs were supported by scientific evidence, representing selective parent training (Incredible Years and Triple-P), indicated family support (Family Check-Up), and school-based programs (Good Behavior Game, universally delivered, and Coping Power, as an indicated intervention). With few exceptions, effects after 6–12xa0months were small. Long-term trials showed small and inconsistent effects.ConclusionsDespite a vast literature, the evidence for preventive effects is meager, largely due to insufficient follow-up post intervention. Long-term follow up assessment and effectiveness studies should be given priority in future evaluations of interventions to prevent externalizing problems in children.

The Mini-International Neuropsychiatric Interview is useful and well accepted as part of the clinical assessment for depression and anxiety in primary care: a mixed-methods study

BackgroundPsychiatric complaints are common among primary care patients, with depression and anxiety being the most frequent. Diagnosis of anxiety and depression can be difficult, potentially leading to over- as well as under-diagnosis. The diagnostic process can be facilitated by incorporating structured interviews as part of the assessment. One such instrument, the Mini-International Neuropsychiatric Interview (MINI), has been established and accepted in psychiatric care. The purpose of this study was to explore the experiences and perceptions of the paper-and-pen version of MINI version 6.0 among patients and staff in primary care centers in Sweden.MethodsThe MINI was introduced at three primary care centers and was conducted by either therapists or general practitioners. Patients presented with symptoms that could suggest depression or anxiety disorders. The duration of the interview was recorded. The experiences and perceptions of 125 patients and their interviewers were collected using a structured questionnaire. Global satisfaction was measured with a visual-analog scale (0–100). Semi-structured interviews were conducted with 24 patients and three therapists, and focus groups were held with 17 general practitioners. Qualitative content analysis was used for the interviews and focus groups. The findings across the groups were triangulated with results from the questionnaires.ResultsThe median global satisfaction with the MINI was 80 for patients and 86 for interviewers. General practitioners appreciated that the MINI identified comorbidities, as one-third of the patients had at least two psychiatric diagnoses. The MINI helped general practitioners attain a more accurate diagnosis. Patients appreciated that the MINI helped them recognize and verbalize their problems and did not find it intrusive. Patients and interviewers had mixed experiences with the yes-no format of the MINI, and the risk of subjective interpretations was acknowledged. Patients, general practitioners and therapists stated that the MINI contributed to appropriate treatment. The MINI assessment lasted 26xa0min on average (range 12 to 60xa0min).ConclusionsThe paper-and-pen version of the MINI could be useful in primary care as part of the clinical assessment of patients with problems suggestive of depression or anxiety disorders. The MINI was well accepted by patients, general practitioners and therapists.

Patients’ perspectives on the use of the Montgomery-Asberg depression rating scale self-assessment version in primary care

Abstract Objective: The aim of the current study was to better understand how patients with depression perceive the use of MADRS-S in primary care consultations with GPs. Design: Qualitative study. Focus group discussion and analysis through Systematic Text Condensation. Setting: Primary Health Care, Region Västra Götaland, Sweden. Subjects: Nine patients with mild/moderate depression who participated in a RCT evaluating the effects of regular use of the Montgomery-Åsberg Depression Self-assessment scale (MADRS-S) during the GP consultations. Main Outcome measure: Patients’ experiences and perceptions of the use of MADRS-S in primary care. Results: Three categories emerged from the analysis: (I) confirmation; MADRS-S shows that I have depression and how serious it is, (II) centeredness; the most important thing is for the GP to listen to and take me seriously and (III) clarification; MADRS-S helps me understand why I need treatment for depression. Conclusion: Use of MADRS-S was perceived as a confirmation for the patients that they had depression and how serious it was. MADRS-S showed the patients something black on white that describes and confirms the diagnosis. The informants emphasized the importance of patient-centeredness; of being listened to and to be taken seriously during the consultation. Use of self-assessment scales such as MADRS-S could find its place, but needs to adjust to the multifaceted environment that primary care provides. Key Points Patients with depression in primary care perceive that the use of a self-assessment scale in the consultation purposefully can contribute in several ways. The scale contributes to Confirmation: MADRS-S shows that I have depression and how serious it is. Centeredness: The most important thing is for the GP to listen to and take me seriously. Clarification: MADRS-S helps me understand why I need treatment for depression.

Effects of Hesel-coil deep transcranial magnetic stimulation for depression - a systematic review.

Abstract Background: One third of the depressed patients are not improved by antidepressant drugs and psychological treatments, and there is a need for additional treatments. Repetitive transcranial magnetic stimulation (rTMS) is being developed towards an alternative in treatment-resistant depression. Deep transcranial stimulation (dTMS) with the Hesel-coil (H-coil) is a further development of rTMS aiming to enhance the effect by getting the magnetic pulses to penetrate deeper into the brain. Aims: This report aims to assess the evidence-base for dTMS for depression. The report also includes an assessment of the ethical and economic aspects involved. Methods: A systematic review of the effects of H-coil dTMS on depression was conducted and the scientific support was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Results: Only one controlled study was identified. In the sham-controlled randomized study, 212 participants with major depression that had not responded to antidepressant medication were enrolled. A two-point superiority in Hamilton Depression Rating Scale was observed in the dTMS arm vs the sham-arm at 4 weeks, but the difference was not statistically significant. No serious adverse events were reported apart from rare cases of epileptic seizures. Conclusions: The existing scientific support for H-coil dTMS therapy for depression is insufficient. The clinical implication is that the use of dTMS in depression should be restricted to the framework of clinical trials pending further studies. Fortunately, additional studies are underway and the evidence base should presumably improve over the next several years.