Abstracts of Cochrane Systematic Reviews
Journal:
July-December 2009 Volume 6(2)Cochrane Corner
Author(s):
Page No:
99
In
Cochrane corner we have again selected three important systematic
reviews. First one is designed to evaluate the efficacy of Olanzapine in
prophylaxis of Bipolar Affective Disorder and the other two are related
to psychological interventions in the management of schizophrenia and
post traumatic stress disorder, respectively. All these relate to the
clinical problems we face in common practice, particularly the last
review in view of current situation in Pakistan.
1. We
know that Bipolar Affective Disorder (BAD) is a severe and common
psychiatric disorder characterized by its recurrent nature. It
emphasizes for the importance of effective long term intervention
strategies to prevent relapse and decrease social and functional
disability. Until recently, mood stabilizers were the mainstay of the
prophylaxis but clinical studies show at best partial efficacy of these
drugs. In this review an antipsychotic, Olanzapine has been evaluated in
the long term management of BAD. Though only five studies could fulfil
the inclusion criteria but the total sample size (1165 participants) was
quiet reasonable. No statistically significant difference was found
between Olanzapine and other mood stabilizers in preventing symptomatic
relapse for any mood episode. However, Olanzapine was found more
effective in preventing manic relapse as compared to Lithium. This has
major implications. Lithium is difficult drug to manage , especially in
developing country settings where the optimum conditions for monitoring
lithium therapy may not always be present. However, it is important to
remember that the depressive episodes in Bipolar Affaective Disorder
last longer and are more disabling and this poses major challenge for
any mood stabilizer.
2 . Prognosis
in schizophrenia has rightly been a major concern for clinicians. Poor
prognosis in schizophrenic patients, besides many other factors, is
usually attributed to inadequate drug adherence. As a result, compliance
therapy is a major focus of attention among mental health professionals
working in the field of schizophrenia. In this review, effect of
compliance therapy has been assessed on antipsychotic medication
adherence. It appears that authors have used fairly strict criteria for
selecting studies as there are many studies which address the
interventions to improve the drug adherence. (For a comprehensive
systematic review please see, Zygmunt A, Olfson M, Boyer CA, Mechanic D.
The interventions to improve medication adherence in schizophrenia. Am J
Psychiatry 2002;159:1653-64. This review presents a different
coclusion). Only one study (n=56) qualified the inclusion criteria,
showing no significant difference between compliance therapy and non
specific counseling on primary outcome measure. However results of a
single study with such a small sample size cannot be generalized and
further studies with different designs are proposed to evaluate the
effectiveness of this important psychological intervention in the
management of schizophrenia.
3 In
view of widespread terrorist activities in Pakistan, prevention of long
term psychological distress following traumatic events is a major
challenge for mental health professionals. In the past, single session
psychological debriefing has been widely tried, but with poor outcome.
In this review, effect of multiple session early psychological
intervention has been examined in eleven studies with 941 participants.
Again, there was no significant difference between treatment and control
group to prevent the future psychological events. Alarmingly, there was
some evidence for worse outcome in intervention group. This highlights
the need to apply only evidence based intervention at the time of
disaster as useful resources are often wasted during the initial phase
of trauma on the intervention which may not work or perhaps make
condition worse. This review presents major challenege for health
professionals who arrive soon after disaster or trauma and provide
counseling during the early phase.
1. OLANZAPINE, IN LONG-TERM TREATMENT FOR BIPOLAR DISORDER
Andrea Cipriani, Jennifer M Rendell, John Geddes
ABSTRACT
Background:
Many patients with bipolar disorder require long-term treatment to
prevent recurrence. Antipsychotic drugs are often used to treat acute
manic episodes. It is important to clarify whether olanzapine could have
a role in long-term prevention of manic and depressive relapses.
Objectives:
To assess the effects of olanzapine, as monotherapy or adjunctive
treatment, in preventing manic, depressive and mixed episodes in
patients with bipolar affective disorder.
Search strategy: We
searched the Cochrane Collaboration Depression, Anxiety and Neurosis
Controlled Trials Register (September 2006), the Cochrane Central
Register of Controlled Trials (September 2006), MEDLINE (1966-December
2007), EMBASE (1980- 2006), CINAHL (1982-2006), PsycINFO (1872-2006) and
reference lists. We also contacted experts, trialists and
pharmaceutical companies in the field.
Selection criteria
Randomised
controlled trials comparing olanzapine with placebo or other active
treatment in longterm treatment of bipolar disorder.
Data collection and analysis
Two
review authors independently assessed trial quality and extracted data.
We contacted study authors for additional information.
Main results
Five
trials (1165 participants) were included in the review. There was no
statistically significant difference between olanzapine and placebo
(either alone or in combination with lithium or valproate) in terms of
number of participants who experienced relapse into mood episode (random
effects RR 0.68, 95% CI 0.43 to 1.07, p = 0.09; 2 studies, n=460),
however restricting the analysis to the trial that compared olanzapine
monotherapy versus placebo, there was a statistically significant
difference in favour of olanzapine (RR 0.58, 95% CI 0.49 to 0.69,
p<0.00001). No statistically significant difference was found between
olanzapine and other mood stabilisers (lithium or valproate) in
preventing symptomatic relapse for any mood episode, however, olanzapine
was more effective than lithium in preventing symptomatic manic relapse
(RR 0.59, 95% CI 0.39 to 0.89, p = 0.01; 1 study, n=361). Olanzapine
either alone or as adjunctive treatment to mood stabilisers was
associated with significantly greater weight gain than placebo. By
contrast, olanzapine was associated with a lower rate of manic
worsening, but with a higher rate of weight increase and depression than
lithium.
Authors’ conclusions
Though
based on a limited amount of information, there is evidence that
olanzapine may prevent further mood episodes in patients who have
responded to olanzapine during an index manic or mixed episode and who
have not previously had a satisfactory response to lithium or valproate.
However, notwithstanding these positive results, the current evidence
is stronger for lithium as first line maintenance treatment of bipolar
disorder.
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
COMPLIANCE THERAPY FOR SCHIZOPHRENIA
Andrew McIntosh, Louise Conlon, Stephen Lawrie, Andrew C Stanfield.
ABSTRACT
Background: Schizophrenia
is a severe mental illness characterised by delusions and
hallucinations. Antipsychotic drugs does reduce these symptoms, but at
least half of people given these drugs do not comply with the treatment
regimen prescribed.
Objectives: To assess the effects of compliance therapy on antipsychotic medication adherence for people with schizophrenia.
Search strategy: Cochrane Schizophrenia Group Trials Register (June 2005).
Selection criteria
We
included all randomised controlled trials of ‘compliance therapy’ for
people with schizophrenia or related severe mental disorders.
Data collection and analysis
We
independently extracted data and, for dichotomous data, calculated the
relative risk (RR), its 95% confidence interval (CI) on an intention to
treat basis. Wepresent continuous data using the weighted mean
difference statistic.
Main results
We
included one trial with relevant and available data (n=56, duration 2
years) comparing compliance therapy with non-specific counseling. The
primary outcome‘non-compliance with treatment’ showed no significant
difference between compliance therapy and nonspecific counseling (n=56,
RR 1.23 CI 0.74 to 2.05). The compliance therapy did not substantially
effect attitudes to treatment (n=50, WMD DAI score -2.10 CI -6.11 to
1.91). Very few people (˜10%) left the study by one year (n=56, RR 0.5
CI 0.1 to 2.51). Mental state seemed unaffected by the therapy (n=50,
WMD PANSS score 6.1 CI -4.54 to 16.74) as was insight (n=50, WMD SAI
-0.5 CI -2.43 to 1.43), global functioning (n=50, WMD GAF - 4.20 CI
-16.42 to 8.02) and quality of life (n=50, WMD QLS -3.40 CI -16.25 to
9.45). At both one and two years the average number of days in hospital
was non-significantly reduced for those allocated to the compliance
therapy
Authors’ conclusions
There
is no clear evidence to suggest that compliance therapy is beneficial
for people with schizophrenia and related syndromes but more randomized
studies are justified and needed in order for this intervention to be
fully examined.
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
MULTIPLE SESSION EARLY PSYCHOLOGICAL INTERVENTIONS FOR THE
PREVENTION OF POSTTRAUMATIC STRESS DISORDER
Neil P Roberts, Neil J Kitchiner, Justin Kenardy, Jonathan Bisson
ABSTRACT
Background: The
prevention of long-term psychological distress following traumatic
events is a major concern. Systematic reviews have suggested that
individual Psychological Debriefing is not an effective intervention at
preventing post traumatic stress disorder (PTSD). Recently other forms
of intervention have been developed with the aim of preventing PTSD.
Objectives To
examine the efficacy of multiple session early psychological
interventions commenced within three months of a traumatic event aimed
at preventing PTSD. Single session individual/group psychological
interventions were excluded.
Search strategy
Computerised databases were searched systematically, the most recent
search was conducted in August 2008. The Journal of Traumatic Stress and
the Journal of Consulting and Clinical Psychology were handsearched for
the last two years. Personal communication was undertaken with key
experts in the field.
Selection criteria
Randomised
controlled trials of any multiple session early psychological
intervention or treatment (two or more sessions) designed to prevent
symptoms of PTSD.
Data collection and analysis
Data
were entered using Review Manager software. The methodological quality
of included studies was assessed individually by two review authors.
Data were analysed for summary effects using Review Manager 4.2. Mean
difference was used for meta-analysis of continuous outcomes and
relative risk for dichotomous outcomes.
Main results
Eleven
studies with a total of 941 participants were found to have evaluated
brief psychological interventions aimed at preventing PTSD in
individuals exposed to a specific traumatic event, examining a
heterogeneous range of interventions. Eight studies were entered into
meta-analysis. There was no observable difference between treatment and
control conditions on primary outcome measures for these interventions
at initial outcome (k=5, n=479; RR 0.84; 95% CI 0.60 to 1.17). There was
a trend for increased self-report of PTSD symptoms at 3 to 6 month
follow-up in those who received an intervention (k=4, n=292; SMD 0.23;
95% CI 0.00 to 0.46). Two studies compared a memory structuring
intervention against supportive listening. There was no evidence
supporting the efficacy of this intervention.
Authors’ conclusions
The
results suggest that no psychological intervention can be recommended
for routine use following traumatic events and that multiple session
interventions, like single session interventions, may have an adverse
effect on some individuals. The clear practice implication of this is
that, at present, multiple session interventions aimed at all
individuals exposed to traumatic events should not be used. Further,
better designed studies that explore new approaches to early
intervention are now required.
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.