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Systematic reviews are supposed to help answer clinical questions but more often than not they just seem to raise more questions. This is largely a result of the poor quality of the primary studies: garbage in, garbage out. The Cochrane reviewers have been scouring the archives, looking for evidence to support the use of benzodiazepines and supportive therapy in schizophrenia. It will come as no surprise to hear that benzodiazepines have a sedative effect that may be helpful in calming agitated patients (Cochrane Database Syst Rev 2007;1:CD006391). The effectiveness of supportive therapy is an important question given that, according to the reviewers, it’s the most commonly practiced intervention in mental health (Cochrane Database Syst Rev 2007;1:CD004716). I was bemused by their comparison of supportive therapy with standard care, having thought that they were one and the same. That is, until I came across this definition of supportive therapy: a dyadic treatment characterised by the use of direct means to ameliorate symptoms and to maintain, restore, or improve self-esteem, adaptive skills and ego function. A bit more sophisticated than checking compliance and passing comment on the weather. Once again, most of the studies reviewed were short and small, but one finding was striking: the lack of any significant difference between supportive therapy and other psychological therapies such as CBT, which flies in the face of recent guidelines exhorting their use in schizophrenia.
What CATIE did next: another report from the landmark NIMH study comparing the effectiveness of a range of antipsychotics in “real world” settings (Am J Psychiatry 2007;164:415–27). Patients who gave up on the older antipsychotic perphenazine were randomised to one of the atypicals to see which they would stick to longest—time to discontinuation being considered a marker of effectiveness. This time around quetiapine is the winner, followed by olanzapine, and then risperidone, possibly because the side effect profile of risperidone is closer to that of perphenazine than the others. What the CATIE studies do, apart from showing that people don’t stick with any particular drug for very long, is demonstrate the variability of individual responses to antipsychotic medication. A “one size fits all” approach to prescribing is clearly misguided.
Where does shyness stop and social phobia start? Social phobia has often been held up as an exemplar of the creeping medicalisation of everyday experience. It’s certainly the case that this disorder presented a new opportunity for the marketing of antidepressants, which makes the publication of this Canadian study curious (J Clin Psychiatry 2007;68:288–95). Curious in two ways: firstly it’s a drug company-sponsored study with a negative outcome, and secondly the antidepressant is nefazodone, a drug that was withdrawn from the US and European markets in 2003 due to safety concerns. As with many anxiety disorders there is mounting evidence that psychological treatments will have more enduring benefit, but for the majority of patients a merry-go-round of SSRIs or even MAOIs remains the norm.
Post-traumatic stress disorder (PTSD) is another diagnosis that attracts controversy. Now that it has been established that psychological debriefing does not work, and in fact probably makes you worse, the traumatologists have shifted focus towards screening tools. The Trauma Screening Questionnaire is a 10-item checklist that was effective in identifying those at increased risk of PTSD in a large, almost exclusively male, sample of assault victims attending an emergency department (Psychol Med 2007;37:143–50). However, a low positive predictive value meant that only one in three of those at risk would have PTSD at six months. Prolonged exposure works for PTSD, and this large pragmatic trial from the USA shows that it works in female military veterans (JAMA 2007;297:820–30). What is striking about this study however is that the most frequent reason for seeking treatment was not exposure to death, serious injury or disaster, but sexual trauma with over 70% of the sample reporting coercive sexual experiences while serving in the military.
“Happiness consists in activity. It is a running stream, not a stagnant pool.” So said the esteemed 19th century physician, Oliver Wendell Holmes. He would have been an advocate of activity scheduling, a behavioural treatment for depression in which patients monitor their activities and mood to demonstrate the connection between the two. They then learn to increase the number of enjoyable activities, which (hopefully) leads to an improvement in mood. Deceptively simple, it is a key feature of most of the self-help packages for depression but as a specific treatment has received little attention. This meta-analysis suggests that it is as effective as other psychological treatments for depression (Clin Psychol Rev 2007;27:318–26).
Deliberate self-harm (DSH) is responsible for around 85 000 hospital admissions each year in England and Wales, making it one of the most common reasons for an emergency medical admission. Despite a recent series of large trials it seems we are still in the dark when it comes to a treatment that will reduce the risk of repetition (see Evid Based Ment Health 2007;10:37–9). Although the evidence in support of any particular intervention is limited, there is a broad consensus that the least that patients should be offered is a psychosocial assessment by someone alert to the issue of risk, especially as those who leave without being seen are at greater risk of repetition. The problem however, as demonstrated in this observational study of nearly 10 000 DSH episodes (J Affect Disord 2007;98:227–37), is that the peak times for patients presenting with self-harm (72% of all presentations) are at night and the weekend. The authors call for specialist services to be available at all times, but an alternative would be to ensure that all staff involved in the management of self-harm are trained in its assessment.
Side effects of SSRIs too troublesome? CBT diary too tiring? Well don’t panic! Psychodynamic psychotherapy works for panic disorder according to this small randomised controlled trial from New York (Am J Psychiatry 2007;164:265–72). The psychotherapy was twice weekly and focused on the unconscious conflicts leading to panic. However, I’m not sure that Freud would have approved of the use of a treatment manual.
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