Abstract 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.
Apps targeted at health and wellbeing sit in a rapidly growing industry associated with widespread optimism about their potential to deliver accessible and cost-effective healthcare. App developers ...might not be aware of all the regulatory requirements and best practice principles are emergent. Health apps are regulated in order to minimise their potential for harm due to, for example, loss of personal health privacy, financial costs, and health harms from delayed or unnecessary diagnosis, monitoring and treatment. We aimed to produce a comprehensive guide to assist app developers in producing health apps that are legally compliant and in keeping with high professional standards of user protection.
We conducted a case study analysis of the Australian and related international policy environment for mental health apps to identify relevant sectors, policy actors, and policy solutions.
We identified 29 policies produced by governments and non-government organisations that provide oversight of health apps. In consultation with stakeholders, we developed an interactive tool targeted at app developers, summarising key features of the policy environment and highlighting legislative, industry and professional standards around seven relevant domains: privacy, security, content, promotion and advertising, consumer finances, medical device efficacy and safety, and professional ethics. We annotated this developer guidance tool with information about: the relevance of each domain; existing legislative and non-legislative guidance; critiques of existing policy; recommendations for developers; and suggestions for other key stakeholders.
We anticipate that mental health apps developed in accordance with this tool will be more likely to conform to regulatory requirements, protect consumer privacy, protect consumer finances, and deliver health benefit; and less likely to attract regulatory penalties, offend consumers and communities, mislead consumers, or deliver health harms. We encourage government, industry and consumer organisations to use and publicise the tool.
Domestic violence (DV) against women during pregnancy affects many women and unborn infants worldwide. Pregnancy presents a window of opportunity for health care providers to identify DV and provide ...appropriate intervention. The aim of this systematic review was to appraise the effectiveness of DV screening and interventions for women identified for DV through screening in pregnancy. The Cochrane Library, EMBASE, MEDLINE, and PsycINFO were searched from January 1995 to November 2009 to identify potentially relevant studies. Studies using any comparative methodology from both national and international arenas were included but had to be in the English language. Nine studies (13 references) met the inclusion criteria, five for screening and four for interventions. Of the five screening studies, the identification of DV was significantly higher compared to studies that used a nonstandardized screen or no screen at all. There was also evidence that recurrent screening throughout the pregnancy further increased identification rates. There was some evidence that interventions for pregnant women who had experienced DV reduced the amount of violence experienced by these women, but the evidence is very limited by the small number of randomized studies with small participant numbers. Further research is required to establish the most effective interventions for women who are identified at risk of DV during pregnancy.
Transportation of critically ill patients within the hospital poses important risks. We sought to identify causes, outcomes and contributing factors associated with intra-hospital transport.
...Cross-sectional case review.
Incident reports submitted to the Australian Incident Monitoring Study in Intensive Care (AIMS-ICU).
Between 1993 and 1999, 176 reports were submitted describing 191 incidents. Seventy-five reports (39%) identified equipment problems, relating prominently to battery/power supply, transport ventilator and monitor function, access to patient elevators and intubation equipment. Hundred sixteen reports (61%) identified patient/staff management issues including poor communication, inadequate monitoring, incorrect set-up of equipment, artificial airway malpositioning and incorrect positioning of patients. Serious adverse outcomes occurred in 55 reports (31%) including major physiological derangement (15%), patient/relative dissatisfaction (7%), prolonged hospital stay (4%), physical/psychological injury (3%) and death (2%). Of 900 contributing factors identified, 46% were system-based and 54% human-based. Communication problems, inadequate protocols, in-servicing/training and equipment were prominent equipment-related incidents. Errors of problem recognition and judgement, failure to follow protocols, inadequate patient preparation, haste and inattention were common management-related incidents. Rechecking the patient and equipment, skilled assistance and prior experience were important factors limiting harm.
Intra-hospital transport poses an important risk to ICU patients. The adequate provision of highly qualified staff, specially designed and well maintained equipment, as well as continuous monitoring are essential to avoid/mitigate these incidents. Professional societies and local units should adopt guidelines/protocols for intra-hospital transportation. Monitoring of incidents should aid in the continuous improvement in patient safety.
Abstract Purpose Many who seek primary health care advice about mental health may be using mobile applications (apps) claiming to improve well-being or relieve symptoms. We aimed to identify how ...prominent mental health apps frame mental health, including who has problems and how they should be managed. Methods We conducted a qualitative content analysis of advertising material for mental health apps found online in the United States, the United Kingdom, Canada, and Australia during late 2016. Apps were included if they explicitly referenced mental health diagnoses or symptoms and offered diagnosis and guidance, or made health claims. Two independent coders analyzed app store descriptions and linked websites using a structured, open-ended instrument. We conducted interpretive analysis to identify key themes and the range of messages. Results We identified 61 mental health apps: 34 addressed predominantly anxiety, panic, and stress (56%), 16 addressed mood disorders (26%), and 11 addressed well-being or other mental health issues (18%). Apps described mental health problems as being psychological symptoms, a risk state, or lack of life achievements. Mental health problems were framed as present in everyone, but everyone was represented as employed, white, and in a family. Explanations about mental health focused on abnormal responses to mild triggers, with minimal acknowledgment of external stressors. Therapeutic strategies included relaxation, cognitive guidance, and self-monitoring. Apps encouraged frequent use and promoted personal responsibility for improvement. Conclusions Mental health apps may promote medicalization of normal mental states and imply individual responsibility for mental well-being. Within the health care clinician-patient relationship, such messages should be challenged, where appropriate, to prevent overdiagnosis and ensure supportive health care where needed.
Background
Post‐traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. Although a wide range of ...psychological therapies have been used in the treatment of PTSD there are no systematic reviews of these therapies in children and adolescents.
Objectives
To examine the effectiveness of psychological therapies in treating children and adolescents who have been diagnosed with PTSD.
Search methods
We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to December 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 ‐), MEDLINE (1950 ‐) and PsycINFO (1967 ‐). We also checked reference lists of relevant studies and reviews. We applied no date or language restrictions.
Selection criteria
All randomised controlled trials of psychological therapies compared to a control, pharmacological therapy or other treatments in children or adolescents exposed to a traumatic event or diagnosed with PTSD.
Data collection and analysis
Two members of the review group independently extracted data. If differences were identified, they were resolved by consensus, or referral to the review team.
We calculated the odds ratio (OR) for binary outcomes, the standardised mean difference (SMD) for continuous outcomes, and 95% confidence intervals (CI) for both, using a fixed‐effect model. If heterogeneity was found we used a random‐effects model.
Main results
Fourteen studies including 758 participants were included in this review. The types of trauma participants had been exposed to included sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma‐related support service.
The psychological therapies used in these studies were cognitive behavioural therapy (CBT), exposure‐based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most compared a psychological therapy to a control group. No study compared psychological therapies to pharmacological therapies alone or as an adjunct to a psychological therapy.
Across all psychological therapies, improvement was significantly better (three studies, n = 80, OR 4.21, 95% CI 1.12 to 15.85) and symptoms of PTSD (seven studies, n = 271, SMD ‐0.90, 95% CI ‐1.24 to ‐0.42), anxiety (three studies, n = 91, SMD ‐0.57, 95% CI ‐1.00 to ‐0.13) and depression (five studies, n = 156, SMD ‐0.74, 95% CI ‐1.11 to ‐0.36) were significantly lower within a month of completing psychological therapy compared to a control group.
The psychological therapy for which there was the best evidence of effectiveness was CBT. Improvement was significantly better for up to a year following treatment (up to one month: two studies, n = 49, OR 8.64, 95% CI 2.01 to 37.14; up to one year: one study, n = 25, OR 8.00, 95% CI 1.21 to 52.69). PTSD symptom scores were also significantly lower for up to one year (up to one month: three studies, n = 98, SMD ‐1.34, 95% CI ‐1.79 to ‐0.89; up to one year: one study, n = 36, SMD ‐0.73, 95% CI ‐1.44 to ‐0.01), and depression scores were lower for up to a month (three studies, n = 98, SMD ‐0.80, 95% CI ‐1.47 to ‐0.13) in the CBT group compared to a control. No adverse effects were identified.
No study was rated as a high risk for selection or detection bias but a minority were rated as a high risk for attrition, reporting and other bias. Most included studies were rated as an unclear risk for selection, detection and attrition bias.
Authors' conclusions
There is evidence for the effectiveness of psychological therapies, particularly CBT, for treating PTSD in children and adolescents for up to a month following treatment. At this stage, there is no clear evidence for the effectiveness of one psychological therapy compared to others. There is also not enough evidence to conclude that children and adolescents with particular types of trauma are more or less likely to respond to psychological therapies than others.
The findings of this review are limited by the potential for methodological biases, and the small number and generally small size of identified studies. In addition, there was evidence of substantial heterogeneity in some analyses which could not be explained by subgroup or sensitivity analyses.
More evidence is required for the effectiveness of all psychological therapies more than one month after treatment. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies or the effectiveness of psychological therapies compared to other treatments. More details are required in future trials in regards to the types of trauma that preceded the diagnosis of PTSD and whether the traumas are single event or ongoing. Future studies should also aim to identify the most valid and reliable measures of PTSD symptoms and ensure that all scores, total and sub‐scores, are consistently reported.
Plain Language Summary
Psychological therapies for the treatment of post‐traumatic stress disorder in children and adolescents
Post‐traumatic stress disorder (PTSD) is highly prevalent in children and adolescents who have experienced trauma and has high personal and health costs. The aim of this review was to examine the effectiveness of all psychological therapies for the treatment of PTSD in children and adolescents.
We searched for all randomised controlled trials comparing psychological therapies to a control, other psychological therapies or other therapies for the treatment of PTSD in children and adolescents aged 3 to 18 years. We identified 14 studies with a total of 758 participants. The types of trauma related to the PTSD were sexual abuse, civil violence, natural disaster, domestic violence and motor vehicle accidents. Most participants were clients of a trauma‐related support service.
The psychological therapies used in the included studies were cognitive behavioural therapy (CBT), exposure‐based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR). Most included studies compared a psychological therapy to a control group. No study compared psychological therapies to medications or medications in combination with a psychological therapy.
There was fair evidence for the effectiveness of psychological therapies, particularly CBT, for the treatment of PTSD in children and adolescents for up to a month following treatment. More evidence is required for the effectiveness of psychological therapies in the longer term and to be able to compare the effectiveness of one psychological therapy to another.
The findings of this review are limited by the potential for bias in the included studies, possible differences between studies which could not be identified, the small number of identified studies and the low number of participants in most studies.
To study in more depth the relationship between type, dose, or duration of methylphenidate offered to children and adolescents with attention deficit hyperactivity disorder and their risks of ...gastrointestinal adverse events based on our Cochrane systematic review.
We use data from our review including 185 randomised clinical trials. Randomised parallel-group trials and cross-over trials reporting gastrointestinal adverse events associated with methylphenidate were included. Data were extracted and quality assessed according to Cochrane guidelines. Data were summarised as risk ratios (RR) with 95% confidence intervals (CI) using the inverse variance method. Bias risks were assessed according to domains. Trial Sequential Analysis (TSA) was used to control random errors. Eighteen parallel group trials and 43 cross-over trials reported gastrointestinal adverse events. All trials were at high risk of bias. In parallel group trials, methylphenidate decreased appetite (RR 3.66, 95% CI 2.56 to 5.23) and weight (RR 3.89, 95% CI 1.43 to 10.59). In cross-over trials, methylphenidate increased abdominal pain (RR 1.61, 95% CI 1.27 to 2.04). We found no significant differences in the risk according to type, dose, or duration of administration. The required information size was achieved in three out of four outcomes.
Methylphenidate increases the risks of decreased appetite, weight loss, and abdominal pain in children and adolescents with attention deficit hyperactivity disorder. No differences in the risks of gastrointestinal adverse events according to type, dose, or duration of administration were found.
Health apps are a booming, yet under-regulated market, with potential consumer harms in privacy and health safety. Regulation of the health app market tends to be siloed, with no single sector ...holding comprehensive oversight. We sought to explore this phenomenon by critically analysing how the problem of health app regulation is being presented and addressed in the policy arena.
We conducted a critical, qualitative case study of regulation of the Australian mental health app market. We purposively sampled influential policies from government, industry and non-profit organisations that provided oversight of app development, distribution or selection for use. We used Bacchi's critical, theoretical approach to policy analysis, analysing policy solutions in relation to the ways the underlying problem was presented and discussed. We analysed the ways that policies characterised key stakeholder groups and the rationale policy authors provided for various mechanisms of health app oversight.
We identified and analysed 29 policies from Australia and beyond, spanning 5 sectors: medical device, privacy, advertising, finance, and digital content. Policy authors predominantly framed the problem as potential loss of commercial reputations and profits, rather than consumer protection. Policy solutions assigned main responsibility for app oversight to the public, with a heavy onus on consumers to select safe and high-quality apps. Commercial actors, including powerful app distributors and commercial third parties were rarely subjects of policy initiatives, despite having considerable power to affect app user outcomes.
A stronger regulatory focus on app distributors and commercial partners may improve consumer privacy and safety. Policy-makers in different sectors should work together to develop an overarching regulatory framework for health apps, with a focus on consumer protection.
Care delivery for the increasing number of people presenting at hospital emergency departments (EDs) with mental illness is a challenging issue. This review aimed to synthesise the research evidence ...associated with strategies used to improve ED care delivery outcomes, experience, and performance for adults presenting with mental illness.
We systematically reviewed the evidence regarding the effects of ED-based interventions for mental illness on patient outcomes, patient experience, and system performance, using a comprehensive search strategy designed to identify published empirical studies. Systematic searches in Scopus, Ovid Embase, CINAHL, and Medline were conducted in September 2023 (from inception; review protocol was prospectively registered in Prospero CRD42023466062). Eligibility criteria were as follows: (1) primary research study, published in English; and (2) (a) reported an implemented model of care or system change within the hospital ED context, (b) focused on adult mental illness presentations, and (c) evaluated system performance, patient outcomes, patient experience, or staff experience. Pairs of reviewers independently assessed study titles, abstracts, and full texts according to pre-established inclusion criteria with discrepancies resolved by a third reviewer. Independent reviewers extracted data from the included papers using Covidence (2023), and the quality of included studies was assessed using the Joanna Briggs Institute suite of critical appraisal tools.
A narrative synthesis was performed on the included 46 studies, comprising pre-post (
= 23), quasi-experimental (
= 6), descriptive (
= 6), randomised controlled trial (RCT;
= 3), cohort (
= 2), cross-sectional (
= 2), qualitative (
= 2), realist evaluation (
= 1), and time series analysis studies (
= 1). Eleven articles focused on presentations related to substance use disorder presentation, 9 focused on suicide and deliberate self-harm presentations, and 26 reported mental illness presentations in general. Strategies reported include models of care (e.g., ED-initiated Medications for Opioid Use Disorder, ED-initiated social support, and deliberate self-harm), decision support tools, discharge and transfer refinements, case management, adjustments to liaison psychiatry services, telepsychiatry, changes to roles and rostering, environmental changes (e.g., specialised units within the ED), education, creation of multidisciplinary teams, and care standardisations. System performance measures were reported in 33 studies (72%), with fewer studies reporting measures of patient outcomes (
= 19, 41%), patient experience (
= 10, 22%), or staff experience (
= 14, 30%). Few interventions reported outcomes across all four domains. Heterogeneity in study samples, strategies, and evaluated outcomes makes adopting existing strategies challenging.
Care for mental illness is complex, particularly in the emergency setting. Strategies to provide care must align ED system goals with patient goals and staff experience.
Humidification by artificial means must be provided when the upper airway is bypassed during mechanical ventilation. Heated humidification (HH) and heat and moisture exchangers (HME) are the most ...commonly used types of artificial humidification in this situation.
To determine whether HHs or HMEs are more effective in preventing mortality and other complications in people who are mechanically ventilated.
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4) and MEDLINE, EMBASE and CINAHL (January, 2010) to identify relevant randomized controlled trials (RCTs).
We included RCTs comparing heat and moisture exchangers (HMEs) to heated humidifiers (HHs) in mechanically ventilated adults and children. We included randomized crossover studies.
We assessed the quality of each study and extracted the relevant data. Where appropriate, results from relevant studies were meta-analysed for individual outcomes.
We included 33 trials with 2833 participants, 25 studies were parallel group design (n = 2710) and eight crossover design (n = 123). Only three included studies reported data for infants or children. There was no overall effect on artificial airway occlusion, mortality, pneumonia, or respiratory complications; however, the PaCO(2) and minute ventilation were increased when HMEs were compared to HHs and body temperature was lower. The cost of HMEs was lower in all studies that reported this outcome. There was some evidence that hydrophobic HMEs may reduce the risk of pneumonia and that blockages of artificial airways may be increased with the use of HMEs in certain subgroups of patients.
There is little evidence of an overall difference between HMEs and HHs. However, hydrophobic HMEs may reduce the risk of pneumonia and the use of an HME may increase artificial airway occlusion in certain subgroups of patients. Therefore, HMEs may not be suitable for patients with limited respiratory reserve or prone to airway blockage. Further research is needed relating to hydrophobic versus hygroscopic HMEs and the use of HMEs in the paediatric and neonatal populations. As the design of HMEs evolves, evaluation of new generation HMEs will also need to be undertaken.
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