Donna Gillies

Methylphenidate for attention-deficit/hyperactivity disorder in children and adolescents: Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials

Study question Is methylphenidate beneficial or harmful for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents? Methods Electronic databases were searched up to February 2015 for parallel and crossover randomised clinical trials comparing methylphenidate with placebo or no intervention in children and adolescents with ADHD. Meta-analyses and trial sequential analyses (TSA) were conducted. Quality was assessed using GRADE. Teachers, parents, and observers rated ADHD symptoms and general behaviour. Study answer and limitations The analyses included 38 parallel group trials (n=5111, median treatment duration 49 days) and 147 crossover trials (n=7134, 14 days). The average age across all studies was 9.7 years. The analysis suggested a beneficial effect of methylphenidate on teacher rated symptoms in 19 parallel group trials (standardised mean difference (SMD) −0.77, n=1698), corresponding to a mean difference of −9.6 points on the ADHD rating scale. There was no evidence that methylphenidate was associated with an increase in serious adverse events (risk ratio 0.98, nine trials, n=1532; TSA adjusted intervention effect RR 0.91). Methylphenidate was associated with an increased risk of non-serious adverse events (1.29, 21 trials, n=3132; TSA adjusted RR 1.29). Teacher rated general behaviour seemed to improve with methylphenidate (SMD −0.87, five trials, n=668) A change of 7 points on the child health questionnaire (CHQ) has been deemed a minimal clinically relevant difference. The change reported in a meta-analysis of three trials corresponds to a mean difference of 8.0 points on the CHQ (range 0-100 points), which suggests that methylphenidate may improve parent reported quality of life (SMD 0.61, three trials, n=514). 96.8% of trials were considered high risk of bias trials according to the Cochrane guidelines. All outcomes were assessed very low quality according to GRADE. What this study adds The results suggest that among children and adolescents with a diagnosis of ADHD, methylphenidate may improve teacher reported symptoms of ADHD and general behaviour and parent reported quality of life. However, given the risk of bias in the included studies, and the very low quality of outcomes, the magnitude of the effects is uncertain. Methylphenidate is associated with an increased risk of non-serious but not serious adverse events. Funding, competing interests, data sharing Region Zealand Research Foundation and Copenhagen Trial Unit. Competing interests are given in the full paper on bmj.com. Full data are available in the version of this review published in The Cochrane Library.

A Reliable Pain Assessment Tool for Clinical Assessment in the Neonatal Intensive Care Unit

OBJECTIVE The aim of this study was to validate a clinician-friendly pain assessment tool for all groups of critically ill infants cared for in the specific neonatal intensive care units (NICUs) studied. DESIGN A prospective study was undertaken to test the Pain Assessment Tool (PAT). Interrater reliability of the PAT score was assessed by two nurses who simultaneously determined an infants PAT score. The PAT was validated against the CRIES score--crying, requires increased oxygen administration, increased vital signs, expression, sleeplessness--and the mothers assessment of her infants discomfort using the Visual Analogue Scale (VAS). SETTING The NICUs at two childrens hospitals. PATIENTS Participants were 144 preterm and term infants. Infants on a ventilator and those who had undergone surgery were included. RESULTS The interrater reliability of the PAT was .85 with a mean difference of 0.17 (standard deviation: 1.73). There was a strong correlation between the PAT and CRIES scores (r = 0.76) and a moderate correlation (.38) between the PAT score and the VAS scores of the infants mother. The correlation coefficient between the PAT score and CRIES score was significant for all groups (p < .01). CONCLUSIONS The PAT score was shown in this study to be a valid, reliable, and clinician-friendly pain assessment measurement tool for all infants nursed in the NICU.

Timing of intravenous administration set changes: a systematic review

OBJECTIVE To determine the optimal time interval for the routine replacement of intravenous administration sets when crystalloids or parenteral nutrition are administered via a central or peripheral catheter in an acute care setting. DESIGN Systematic review of all randomized or systematically allocated controlled trials addressing the frequency of replacing intravenous administration sets. METHODS The Cochrane Controlled Trials Register (June 2001) and the Ovid databases (Medline, CINAHL, and CancerLit-July 2001) were searched. Bibliographies, relevant conference proceedings, and any product information were also checked for references. RESULTS Eighteen studies were selected for review. The 12 included studies were separated into 3 intravenous administration set change comparisons: 24 hours versus 48 hours or more; 48 hours versus 72 hours or more; and 72 hours versus 96 hours or more. There was good evidence that changing intravenous administration sets every 72 hours or more does not increase the risk of infusate-related bloodstream infection (BSI) in patients with central or peripheral catheters and a fair level of evidence that it does not increase the risk of catheter-related BSI. There were insufficient data regarding the incidence of BSI among patients receiving parenteral nutrition, particularly lipid-containing parenteral nutrition. CONCLUSIONS It appears that intravenous administration sets containing crystalloids can be changed in patients with central or peripheral catheters every 72 hours or more without increasing the risk of BSI. However, it is not possible to conclude that intravenous administration sets containing parenteral nutrition, particularly lipid-containing parenteral nutrition, can be changed at this interval.

Nursing handover within mental health rehabilitation: An exploratory study of practice and perception

Nursing handover is an established practice that involves an interchange of information between nurses to inform of the condition of patients. It is essential to nursing practice in terms of continuity and quality of patient care. However, there is a lack of agreement about the quality, content, and process of handover and, in particular, a lack of information specific to mental health contexts. This paper reports the results of exploratory research of the practice and beliefs about verbal nursing handover within an inpatient mental health rehabilitation setting. Qualitative data were obtained from audiotaped handovers and interviews with nurses and analysed using content analysis. Handovers were found to lack structure and content, be retrospective, problem-focused and inconsistent. The findings were fairly consistent with the literature and would likely be applicable across nursing settings; however, the need to appraise nursing handover in unique contexts was also revealed. The study raised questions about how nursing handover reflects the goals and philosophies of mental health rehabilitation and whether nursing handover is an activity fully integrated with the focus of mental health rehabilitation.

Benzodiazepine augmentation of antipsychotic drugs in schizophrenia: A meta-analysis and cochrane review of randomized controlled trials

Applying various psychopharmacological combination and augmentation strategies in schizophrenia is common clinical practice. This meta-analysis evaluated the efficacy of benzodiazepines added to antipsychotics. The Cochrane Schizophrenia Group trial register (until February 2011) and PubMed/Medline (until July 2012) were searched for randomized controlled trials (RCTs) with a minimum duration of one week that compared benzodiazepine augmentation of antipsychotics with a control group receiving antipsychotic monotherapy in schizophrenia and schizophrenia-like psychoses. Study selection and data extraction were conducted independently by at least two authors. The primary outcome was response to treatment. Secondary outcomes were positive and negative schizophrenic symptoms, anxiety symptoms, and dropouts due to any reason, inefficacy of treatment, and adverse events. Pooled risk ratios (RRs) with the 95% confidence intervals (CIs) were calculated using a random-effects model, with number-needed-to-treat/harm (NNT/H) calculations where appropriate. Overall, 16 relevant RCTs with 1045 participants were identified. Benzodiazepine augmentation was not associated with statistically significantly more responders (N=6; n=511; RR 0.97, 95% CI 0.77-1.22). Adjunctive benzodiazepines were well accepted and tolerated according to dropout-rates and adverse effects apart from dizziness (N=3; n=190; RR 2.58, 95% CI 1.08-6.15) and somnolence (N=2; n=118; RR 3.30, 95% CI 1.04-10.40). There is no evidence for antipsychotic efficacy of additional benzodiazepine medication in schizophrenia. Therefore, benzodiazepines should be considered primarily for desired ultra short-term sedation of acutely agitated patients but not for augmentation of antipsychotics in the medium- and long-term pharmacotherapy of schizophrenia and related disorders.

Cannabis and schizophrenia

BACKGROUND Many people with schizophrenia smoke cannabis, and it is unclear why a large proportion do so and if the effects are harmful or beneficial. It is also unclear what the best method is to allow people with schizophrenia to alter their cannabis intake. OBJECTIVES To assess the effects of specific psychological treatments for cannabis reduction in people with schizophrenia. To assess the effects of antipsychotics for cannabis reduction in people with schizophrenia. To assess the effects of cannabinoids (cannabis-related chemical compounds derived from cannabis or manufactured) for symptom reduction in people with schizophrenia. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (August 2013) and all references of articles selected for further relevant trials. We contacted the first author of included studies for unpublished trials or data. SELECTION CRITERIA We included all randomized controlled trials involving cannabinoids and schizophrenia/schizophrenia-like illnesses, which assessed: (1) treatments to reduce cannabis use in people with schizophrenia and (2) the effects of cannabinoids on people with schizophrenia. CONCLUSIONS Results are limited and inconclusive due to the small number and size of randomized controlled trials available and quality of data reporting within these trials. Currently, there is no evidence to demonstrate that one type of adjunct psychological therapy or one type of drug therapy is more effective than another. There is also insufficient evidence to show that cannabidiol has an antipsychotic effect.

Characteristics of patients referred by police to a psychiatric hospital.

To identify any differences between patients referred by police compared with patients referred from other sources, to a psychiatric hospital in Australia, a retrospective audit of 200 patient files was undertaken. The two most common reasons for the involuntary referral of patients by police were bizarre ideas (33%) and threats of suicide (28%). When 101 patients referred by police were compared with 99 patients from other sources, police referrals were three times more likely to be diagnosed with a mental and behavioural disorder because of psychoactive substance use, less likely to be diagnosed with a mood disorder, and less likely to be diagnosed as psychotic. Police referrals were more likely to have worse functional scores; exhibit aggressive behaviour; spend fewer days in hospital; more likely to be admitted to the psychiatric intensive care unit, and to be secluded. The most important predictor for a police referral was drug or alcohol problems. The study indicates that patients referred by the police were more likely to demonstrate particular characteristics compared with patients referred by other sources.

Interpersonal violence and mental illness: A literature review

Abstract There is a perception that people with a mental illness are dangerous. However, there are still arguments in the research literature as to whether the evidence supports this perception. The major aim of this paper is to review the findings of these studies in regard to the risk of violent behaviour in people with mental illness. An additional aim is to give an overview of the risk factors for violence in people with a mental illness. This systematic search of the literature resulted in good evidence that diagnoses such as schizophrenia and personality disorder are associated with an increased risk of violent behaviour. Substance abuse was the risk factor most associated with an increase in the risk of violent behaviour in people with a mental illness. However, there are substantial differences in the methods used in studies of the risk in violence in people with mental illness resulting in a large variability in the estimates of risk. One of the major causes of variation may be due to the different definitions of violence that are used. The need remains, therefore, for a meta-analysis of this literature based on clear definitions of violence in order to get a more accurate estimate of the risk of violence in people with a mental illness.

Children visiting parents in inpatient psychiatric facilities: Perspectives of parents, carers, and children

A significant number of clients utilizing mental health services will also be parents. Being a child of a parent with mental illness increases health risks for the child, and hospitalization of the parent has been identified as one of the most difficult times for children. However, few proactive measures have been taken to understand or provide for the needs of children visiting psychiatric inpatient facilities. The aim of this exploratory study was to identify the perspectives children, their parents, nominated carers, and clinicians from their experience of children visiting. The study used qualitative data gathered from interviews to develop an understanding of the issues. The purpose of this paper was to present the findings from parents, carers, and children. Children indicated that they wanted to visit and to remain involved with their parent, but that there was little support from staff. Families indicated that children visiting psychiatric inpatient facilities were not well managed, and they received little support about decisions around children visiting. The issue of children visiting psychiatric facilities when they have a parent who is an inpatient appears not to have been addressed in models of inpatient mental health care.

Commentary on ‘Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)’

This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: Reichow B, Steiner AM, Volkmar F. Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD008511. DOI: 10.1002/14651858.CD008511.pub2. Further information for this Cochrane review is available in this issue of EBCH in the accompanying Summary article.