Recent eLetters
Displaying 1-10 letters out of 15 published
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Response to Dr Goy's commentary
Submit responseDear Editor,
We thank Dr Goy for her interpretation of our systematic review. She has touched on an important issue in the meta-analysis of complex interventions, which is to keep the right balance between enough power to detect any effect, and combining sometimes heterogeneous trials. We appreciate her comments on the combination of broad psychological outcomes and we would like to take the opportunity to clarify the rationale behind our approach. Separating the different psychological outcomes according to their exact component had indeed been considered in our analysis but was not performed because i) for such interventions many subgroups could be investigated (different outcomes, difference between interventions, different time points); in order to keep the meta-analysis as informative and clear as possible, we separated by subgroup only by major category of heterogeneity, such as direct or indirect intervention, ii) if we had taken a narrower view on what we included in a meta-analysis, the analysis may have lacked sufficient power to detect any effects , iii) on the advice of specialist reviewers within the Cochrane Collaboration, we therefore followed a pre-specified analysis plan, in which we decided a priori which components of psychological outcomes should be combined. In our results the absence of heterogeneity across the trials did not challenge this approach.
We also would like to nuance her conclusion for practitioners to focus on identifying hopelessness and anxiety symptoms, as our review did not show evidence to support this statement. It is true that the combined mean effect size was marginally higher for measures of hopelessness than of depression, however the confidence intervals were wide and mostly overlapping. Also, the only study measuring anxiety actually found a mean effect size smaller than the mean effect on depression outcomes, but with once again confidence intervals too wide to draw any firm conclusions. Our findings therefore suggest that supportive interventions aimed to alleviate carer suffering may help buffer against psychological distress, including depression.
Conflict of Interest:
none
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Brief advice good enough
Submit responseThe review by Havard and colleagues [1] does not take into account the fact that brief advice, either oral or written, is good enough to bring about behavioral change. To have such a group as the control group is self-defeating. In fact, in an emergency department (ED) setting, where both emotions and tension run high, it would be futile to try and attempt other time-consuming interventions such as motivational interviewing and pharmacological treatment. An ideal form of treatment is therefore the Brief advice. As the commentary [2] observes, brief interventions are sufficient to reduce the negative health consequences, such as alcohol related injuries in this group. I believe that such patients may also be amenable to further behavioral changes in order to prevent development of alcohol dependence by proper identification of "at-risk" individuals. This can be done by enquiring for craving, tolerance and loss of control [3] which can prove beneficial to these problem and pre-dependent drinkers [4].
References
1)Havard A, Shakeshaft A, Sanson-Fisher R. Systematic review and meta -analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries. Addiction 2008;103:368–76.
2)Crawford MJ. Review: Screening and intervention for alcohol misuse in emergency rooms reduces alcohol-related injuries. Evid. Based Ment. Health 2008;11;88
3)Manjunatha N, Saddichha S, Sinha BNP et al. Chronology of alcohol dependence: Implications in prevention.Ind J Com Med 2008; 33: 228-32.
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ADHD behaviour
Submit responseDear Editor
The only method of improving the behaviour of ADHD children is to make them teachable. To become teachable the medical treatment needs to be titrated to an optimal dose, given every day without exception and monitored with an effective rating scale on a monthly basis.
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Differing titration times leaves us none the wiser
Submit responseDear Editor
The authors of the reviewed article state that for some of the tested drugs titration to full dose took "one to two weeks". One would assume that quetiapine would have been amongst the drugs that required the longest time to achieve therapeutic doses. A two week titration leaves only one week on an adequate dose of drug before the three week period, when lack of effectiveness is judged, ends. Other drugs, such as haloperidol, olanzapine and risperidone would have been titrated up to and beyond the manufacturers recommended doses within days. A fair trial would have started once all the drugs were at therapeutic doses and would have used therapeutic doses for all the drugs on trial. A curious finding in this trial was the requirement for an anticholinergic with quetiapine use when this drugs affinity for D2 receptors is in the region of six times less than that for olanzapine, though it appears that additional haloperidol was used more frequently in the quetiapine group. In light of these quirks the study findings must be viewed with great caution.
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Antidepressants in Children-To give or not to give?
Submit responseDear Editor
I read the review "antidepressant use increases the risk of suicidal behaviour and ideation in children" ,Evid Based Ment Health 2007; 10: 20 with interest.For clinicians like me who are faced with dilemma about prescribing antidepressant medications for children and adolescents,this systematic review is a welcome addition to the list of good quality studies available on risk-benefit ratio of these drugs in this population.
Clinicians with responsibility for children and adolescents with depressive disorder seeking evidence based approaches in their management should also consider the following.Depressed youngsters have more pronounced mood lability and anhedonia when compared to adult population. Many other factors influence the treatment outcome including co-morbidity,genetic factors,age and illness course.Clinical studies used in meta-analysis in future should include those that have looked at the link between "suicidality and antidepressants", clinical dimensions like anhedonia,hopelessness,impulsive trait,borderline personality,past history of suicide attempts,familial dysfunction,substance abuse,life events,open access of arms and biological indices if we really want to add to the robustness of the study.
Declaration of interest-none
References
1.Goldney R D et al "Depressed youth,suicidality and antidepressants" ,The Medical Journal of Australia 2005;183(5):275-276
2.Hamrin V,Scahill L et al "Selective Serotonin reuptake inhibitors for children and adolescents with major depresion:current controversies and recommendations",Issues Ment Health Nurs.2005 May;26(4)433-50
Author Dr.L.Ramasubramanian.MRCPsych Willis House 5 Boroughs Partnership NHS Trust Merseyside,UK email: gautamprabha@aol.com telephone:0151-4265885 fax:0151-2922595
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Response to commentary
Submit responseDear Editor,
Peters discusses some limitations in relation to our systematic review of the prevelance of substance abuse and dependence in prisoners. Peters states that we have not disaggregated findings obtained from sentenced and unsentenced prisoners. In fact, in Table 3, we do present the findings of sentenced and remand prisoners separately by gender, and by type of substance (alcohol and drug).
Peters also states that we have reported the findings from his study inaccurately. This depends on how the data are extracted. The Peters study involved diagnostic interviews with 400 inmates consecutively admitted to a state prison. Peters states that the prevalence of "drug use" was 36.8% and "alcohol use" was 34.5% - and this uses denominators of 307 and 380 prisoners, respectively. However, we extracted the data for "dependence disorder" rather than "use" - again, this is in order to be consistent with the other included studies (where studies provided both data on prevalences for "dependence" and "abuse or dependence", we used the former). Further, we decided to use 400 inmates as the denominator. This is based on an assumption that those who did not complete the protocols were not substance dependent, which we believe is reasonable. Even if it is not, as we did not meta-analyse the data, this does not alter our main findings, and the alternative estimates from the Peters study fall within the range of prevalences already given in our review. The alternative prevalences for drug dependence would be 28.0% rather than 25.0%, and for alcohol 26.3% rather than 21.5%.
Finally, Peters states that with changes in the types of drugs used in the community, it is unclear whether the range of prevelances for drug dependence would still be applicable. By eyeballing the figures in our review, there does not appear to be any time trend for the prevalence estimates in the included studies (1988-1998 in the men; 1996-2001 in the women), periods when it is also likely for there to have been changes in the types of drugs used in the community.
The summary notes in EBMH rightly state that the inclusion criterion for sample size was not clearly reported in our review of reception studies. In fact, we chose not to have a sample size criterion and all studies - of any size - were included that met the other criteria.
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Statement link missing
Submit responseDear Editor,
It would have been utterly helpful if you had included a citation for the APA-NAMI-NMHA-statement in your article - or the following hypertext- link: http://www.nmha.org/newsroom/system/news.vw.cfm?do=vw&rid=662.
Kind regards,
Th. Schumann
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Protection at home or risks away
Submit responseDear Editor,
Is it not just as plausible to postulate a relative protection from schizophrenia in less developed countries that is inversely proportional to their degree of development. In this scenario the schizophrenia genotypes would be more prevalent in these countries and only become more liable to expression upon migration. This of course would be particularly so for those in the high risk years which a number of first generation migrants would have traversed. This argument would be supported by the well documented improved outcomes with schizophrenias in the less developed world.
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Risperidone improves tardive dyskinesia- are the benefits maintained in the longer term?
Submit responseDear Editor,
It would be interesting to know what proportion of the sample that had the initial positive response maintain the improvement in the longer term. This is important as tardive dyskinesia characteristically occurs after prolonged neuroleptic therapy. There are several case reports of long-term risperidone therapy causing tardive dyskinesia [1-5]. Recently a child in my clinic developed tardive dyskinesia after being on risperidone for 18 months. Risperidone was used in this case to control the behavioural symptoms of autism.
References:
1. Mullen A. Risperidone and tardive dyskinesia: a case of blepharospasm. [Case Reports. Letter] Australian & New Zealand Journal of Psychiatry. 34(5):879-80, 2000 Oct
2. Ipekci S. Birsoz S. Tardive dyskinesia caused by the atypical antipsychotic risperidone and cured by the use of another drug of the same class, olanzapine. [Case Reports. Letter] European Psychiatry: the Journal of the Association of European Psychiatrists. 16(4):259-60, 2001 Jun.
3. Suzuki E. Obata M. Yoshida Y. Miyaoka H. Tardive dyskinesia with risperidone and anticholinergics. [Case Reports. Letter] American Journal of Psychiatry. 159(11):1948, 2002 Nov.
4. Karama S. Lal S. Tardive dyskinesia following brief exposure to risperidone--a case study. [Case Reports. Letter] European Psychiatry: the Journal of the Association of European Psychiatrists. 19(6):391-2, 2004 Sep
5. Kwon H. Tardive dyskinesia in an autistic patient treated with risperidone. [Case Reports. Letter] American Journal of Psychiatry. 161(4):757-8, 2004 Apr
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Buprenorphine is not a "symptomatic" treatment
Submit responseDear Editor
The title and content of this article give the impression that buprenorphine is akin to symptomatic treatments like clonidine, lofexidine and the various cocktails of drugs added to these drugs during detoxification.
We have been using buprenorphine detoxification for over a year with good results. However, it should be recognized that buprenorphine is a drug of abuse and more like methadone or other opiates in its effects, and in patient expectations of effects. In fact buprenorphine is used in some cases as a maintainence therapy. There is a basic difference between symptomatic treatment and replacement therapy with buprenophine falling into the latter camp.
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