Steve MacGillivray

Efficacy and tolerability of tricyclic antidepressants and SSRIs compared with placebo for treatment of depression in primary care: a meta-analysis.

PURPOSE Depression is common in primary care. There are no systematic reviews of depression treatment comparing antidepressants with placebo; hence, we do not know whether these medications are effective in primary care. METHODS We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Group register of controlled trials, MEDLINE, International Pharmaceutical abstracts, PsycINFO, and EMBASE. Abstracts of potential studies were reviewed independently by 2 authors. Studies needed to include randomized controlled trials of either a tricyclic antidepressant (TCA) or selective serotonin reuptake inhibitor (SSRI), or both, and placebo in a primary care setting. The data and quality of the studies were extracted and assessed by 2 authors blind to the other’s choice. Disagreements were resolved by discussion. The main outcome measures were the standardized mean difference and weighted mean difference of the final mean depression scores, the relative risk of improvement, and the number withdrawing because of side effects. Pooling of results was done using Review Manager 4.2.2. RESULTS There were 10 studies in which TCAs were compared with placebo, 3 in which SSRIs were compared with placebo, and 2 with both compared with placebo. One half of the studies were of low methodological quality, and nearly all studies were of short duration, typically 6 to 8 weeks. Pooled estimates of efficacy data showed a relative risk of 1.26 (95% CI, 1.12–1.42) for improvement with TCAs compared with placebo; For SSRIs, relative risk was 1.37 (95% CI, 1.21–1.55). Most patients, 56% to 60%, responded well to active treatment compared with 42% to 47% for placebo. The number needed to treat for TCAs was about 4, and for SSRIs it was 6. The numbers needed to harm (for withdrawal caused by side effects) ranged from 5 to 11 for TCAs and 21 to 94 for SSRIs. Low-dose (100 mg or 75 mg) as well as high-dose TCAs were effective. CONCLUSION This systematic review is the first comparing antidepressants with placebo for treatment of depression in primary care. Both TCAs and SSRIs are effective. This review is also the first to show that low-dose TCAs are effective in primary care. Prescribing antidepressants in primary care is a more effective clinical activity than prescribing placebo.

Efficacy and tolerability of selective serotonin reuptake inhibitors compared with tricyclic antidepressants in depression treated in primary care: systematic review and meta-analysis

Abstract Objective: To compare the efficacy and tolerability of tricyclic antidepressants with selective serotonin reuptake inhibitors in depression in primary care. Design: Systematic review and meta-analysis of randomised controlled trials. Data sources: Register of the Cochrane Collaborations depression, anxiety, and neurosis group. Reference lists of initial studies and other relevant review papers. Selected authors and experts. Selection of studies: Studies had to meet minimum requirements on: adequacy of sample size, adequate allocation concealment, clear description of treatment, representative source of subjects, use of diagnostic criteria or clear specification of inclusion criteria, details regarding number and reasons for withdrawal by group, and outcome measures described clearly or use of validated instruments. Main outcome measures: Standardised mean difference of final mean depression scores and relative risk of response when using the clinical global impression score. Relative risk of withdrawing from treatment at any time, and the number withdrawing due to side effects. Results: 11 studies (2951 participants) compared a selective serotonin reuptake inhibitor with a tricyclic antidepressant. Efficacy between selective serotonin reuptake inhibitors and tricyclics did not differ significantly (standardised weighted mean difference, fixed effects 0.07, 95% confidence interval −0.02 to 0.15; z=1.59, P<0.11). Significantly more patients receiving a tricyclic withdrew from treatment (relative risk 0.78, 95% confidence interval 0.68 to 0.90; z=3.37, P<0.0007) and withdrew specifically because of side effects (0.73, 0.60 to 0.88; z=3.24, P<0.001). Most studies included were small and supported by commercial funding. Many studies were of low methodological quality or did not present adequate data for analysis, or both, and were of short duration, typically six to eight weeks. Conclusion: The evidence on the relative efficacy of selective serotonin reuptake inhibitors and tricyclic antidepressants in primary care is sparse and of variable quality. The study setting is likely to be an important factor in assessing the efficacy and tolerability of treatment with antidepressant drugs. What is already known on this topic Previous meta-analyses have included comparatively large numbers of secondary care based studies that indicate no significant differences in efficacy between selective serotonin reuptake inhibitors and tricyclics Previous meta-analyses are conflicting regarding the relative tolerability between selective serotonin reuptake inhibitors and tricyclics, but do suggest a small but significant difference in favour of selective serotonin reuptake inhibitors Such meta-analyses show notable heterogeneity What this study adds Selective serotonin reuptake inhibitors are better tolerated than tricyclics by primary care patients and may be better tolerated by primary care patients than secondary care patients Study setting seems to be important and should be considered before licences are given to specific antidepressants Although there are limited high quality data, available evidence shows that the most commonly prescribed classes of antidepressants in primary care (selective serotonin reuptake inhibitors and tricyclics) are equally effective in the short term for primary care patients, but the literature has many gaps

The effect of mammography pain on repeat participation in breast cancer screening: A systematic review

Uptake is crucial to reducing breast cancer mortality through screening. This review synthesised all available evidence on mammography pain as a deterrent to subsequent breast screening. Ten databases were searched. Studies containing empirical data relating mammography pain to breast screening re-attendance were included (n = 20). In the most robust studies asking women why they had not re-attended, 25%-46% cited pain, equivalent to approximately 47,000-87,000 women per year in England. The most robust evidence for an association between pain experienced at a previous mammogram and subsequent rates of re-attendance suggests that women who previously experienced pain are more likely than those who did not to fail to re-attend: RR 1.34 (95% CI: 0.94-1.91). The complexity of the pain phenomenon and of screening behaviours must be recognised. However, there is sufficient evidence to conclude that painful mammography contributes to non-re-attendance. Given the importance of cumulative participation, effective pain-reducing interventions in mammography are needed.

Audio-visual recording of patient–GP consultations for research purposes: A literature review on recruiting rates and strategies

OBJECTIVE To identify ethical processes and recruitment strategies, participation rates of studies using audio or video recording of primary health care consultations for research purposes, and the effect of recording on the behaviour, attitudes and feelings of participants. METHODS A structured literature review using Medline, Embase, Cochrane Library, and Psychinfo. This was followed by extensive hand search. RESULTS Recording consultations were regarded as ethically acceptable with some additional safeguards recommended. A range of sampling and recruitment strategies were identified although specific detail was often lacking. Non-participation rates in audio-recording studies ranged from 3 to 83% for patients and 7 to 84% for GPs; in video-recording studies they ranged from 0 to 83% for patients and 0 to 93% for GPs. There was little evidence to suggest that recording significantly affects patient or practitioner behaviour. CONCLUSIONS Research involving audio or video recording of consultations is both feasible and acceptable. More detailed reporting of the methodical characteristics of recruitment in the published literature is needed. PRACTICE IMPLICATIONS Researchers should consider the impact of diverse sampling and recruitment strategies on participation levels. Participants should be informed that there is little evidence that recording consultations negatively affects their content or the decisions made. Researchers should increase reporting of ethical and recruitment processes in order to facilitate future reviews and meta-analyses.

A systematic review of interventions for eating and drinking problems following treatment for head and neck cancer suggests a need to look beyond swallowing and trismus

PURPOSE The incidence of head and neck cancer (HNC) is increasing, and treatment advances have contributed to improvements in survival. However, a growing number of HNC survivors now live with the long-term consequences of cancer treatment, in particular, problems with eating. The combined effects of HNC cancer, intensive chemotherapy, radiotherapy and surgery have a profound impact on functional, psychological, social and physical aspects of eating. Evidence is needed to underpin new rehabilitation approaches to address these complex problems. This review aimed to identify and summarise the evidence for rehabilitation interventions aimed at alleviating eating problems after HNC treatment. METHODS A systematic review of studies indexed in Medline, CinAHL and PsycINFO using search terms relevant to a wide range of aspects of eating. Publications reporting empirical findings regarding physical, functional and/or psychosocial factors were included. RESULTS Twenty-seven studies were identified. Fifteen focussed on swallowing exercises, eight on interventions to improve jaw mobility and four on swallowing and jaw exercises. None included interventions to address the complex combination of functional, physical and psychological problems associated with eating in this patient group. CONCLUSIONS This review highlights that, whilst there is some evidence to support interventions aimed at improving swallowing and jaw mobility following treatment for HNC, studies are limited by their size and scope. Larger, high quality studies, which include patient-reported outcome measures, are required to underpin the development of patient-centred rehabilitation programmes. There is also a particular need to develop and evaluate interventions, which address the psychological and/or social aspects of eating.

The Importance of Psychological and Social Factors in Influencing the Uptake and Maintenance of Physical Activity after Stroke: A Structured Review of the Empirical Literature

Background. People with stroke are not maintaining adequate engagement in physical activity (PA) for health and functional benefit. This paper sought to describe any psychological and social factors that may influence physical activity engagement after stroke. Methods. A structured literature review of studies indexed in MEDLINE, CinAHL, P&BSC, and PsycINFO using search terms relevant to stroke, physical disabilities, and PA. Publications reporting empirical findings (quantitative or qualitative) regarding psychological and/or social factors were included. Results. Twenty studies from 19 publications (9 surveys, 1 RCT, and 10 qualitative studies) were included. Seventeen studies reported findings pertinent to psychological factors and fourteen findings pertinent to social factors. Conclusion. Self-efficacy, physical activity beliefs, and social support appear particularly relevant to physical activity behaviour after stroke and should be included in theoretically based physical interventions. The Transtheoretical Model and the Theory of Planned Behaviour are candidate behavioural models that may support intervention development.

Psychometric properties of the 16-item Quick Inventory of Depressive Symptomatology: A systematic review and meta-analysis

Effective management of depression is predicated upon reliable assessment. The Quick Inventory of Depressive Symptomatology (QIDS) is a depression severity scale with both self-rated (QIDS-SR16) and clinician-rated (QIDS-C16) versions. Although widely used in research, the psychometric properties of the QIDS16 have not been systematically reviewed. We performed a systematic review of studies of the psychometric properties (factor structure, internal consistency, convergent validity, discriminant validity, test-retest reliability and responsiveness to change) of the QIDS-SR16 or QIDS-C16. Six databases were searched: MEDLINE, EMBASE, PsycINFO, CinAHL, Web of Science and the Cochrane Central Register of Controlled Trials. Findings were summarised, bias assessed and correlations with reference standards were pooled. 37 studies (17,118 participants) were included in the review. Both versions of the QIDS16 were unidimensional. Cronbachs alpha ranged from 0.69 to 0.89 for the QIDS-SR16 and 0.65 to 0.87 for the QIDS-C16. The QIDS-SR16 correlated moderately to highly with several depression severity scales. Seven studies were pooled where QIDS-SR16 was correlated with the HRSD-17 (r = 0.76, CI 0.69, 0.81) in patients diagnosed with depression. Four studies examined convergent validity with the QIDS-C16. Four studies examined discriminant validity, for the QIDS-SR16 alone. Eighteen studies had at least one author who was a co-author of the original QIDS16 study. Most studies were conducted in the USA (n = 26). The QIDS-SR16 and the QIDS-C16 are unidimensional rating scales with acceptable internal consistency. To justify the use of the QIDS16 scale in clinical practice, more research is needed on convergent and discriminant validity, and in populations outside the USA.

Reducing the volume, exposure and negative impacts of advertising for foods high in fat, sugar and salt to children: A systematic review of the evidence from statutory and self-regulatory actions and educational measures.

PURPOSE To identify and review evidence on 1) the effectiveness of statutory and self-regulatory actions to reduce the volume, exposure or wider impact of advertising for foods high in fat, sugar and salt (HFSS) to children, and 2) the role of educational measures. DESIGN/METHODOLOGY/APPROACH A systematic review of three databases (Medline, CINAHL and PsycINFO) and grey literature was carried out. Relevant evidence included studies evaluating advertising bans and restrictions, advertising literacy programmes and parental communication styles. Relevant media included TV, internet, radio, magazines and newspaper advertising. No studies were excluded based on language or publication date. FINDINGS Forty-seven publications were included: 19 provided evidence for the results of statutory regulation, 25 for self-regulation, and six for educational approaches. Outcome measures varied in approach, quality and results. Findings suggested statutory regulation could reduce the volume of and childrens exposure to advertising for foods HFSS, and had potential to impact more widely. Self-regulatory approaches showed varied results in reducing childrens exposure. There was some limited support for educational measures. DISCUSSION Consistency in measures from evaluations over time would assist the development and interpretation of the evidence base on successful actions and measures to reduce the volume, exposure and impact of advertising for foods HFSS to children.

Efficacy and tolerability of antidepressants for sub-threshold depression and for mild major depressive disorder

BACKGROUND It is commonly assumed that robust evidence exists for the lack of efficacy of antidepressants at the milder end of the depression severity spectrum. In light of specific limitations of existing reviews, we assess if antidepressants are efficacious and tolerable for sub-threshold or mild major depressive disorder (MDD). METHOD Systematic review and meta-analysis of randomised controlled trials of adults with sub-threshold depression or mild MDD (initial baseline symptom severity of HRSD≤20) comparing an antidepressant with placebo or treatment as usual (TAU) however defined. A pre-specified protocol was published (Prospero reference: CRD42013004505). RESULTS 8 trials were included: 5 trials (453 participants) of sub-threshold depression and 3 trials (502 participants) of mild MDD. Trials of sub-threshold depression exhibited low risk of bias whereas those of mild MDD exhibited high risk. Two trials of sub-threshold depression were pooled (n=102) to assess efficacy and favoured antidepressants over placebo statistically but the difference was small and unlikely to be clinically meaningful: mean difference -1.39 (-2.41, -0.36). Due to heterogeneity, no trials of mild MDD could be pooled for efficacy. There was no difference between antidepressant treatment and placebo for drop out due to adverse events. The maximum proportion in those receiving antidepressants dropping out due to adverse events was 17%, with indication of a dose effect. LIMITATIONS Not all data from identified trials could be included in the meta-analyses due to a lack of availability of relevant data. CONCLUSION There is insufficient evidence to support or contest the efficacy of antidepressant medication for sub-threshold depression or mild MDD. More trials, with adequate follow up, are required to address this question.

Increased prescription of antidepressants shows correction of inadequate duration of treatment of depression

Godlee draws attention to the Organisation for Economic Co-ordination and Development’s report that “the world’s rich nations have doubled their use of antidepressants in the past 10 years” and links this with Dowrick and Frances’ opinion piece “medicalising unhappiness” to suggest that antidepressants are being used inappropriately.1 2 3 Hence her advice: “Don’t keep taking the tablets.” However, the raw prescription data reported tell us nothing about the appropriateness …