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Background Obsessive compulsive disorder (OCD) is a chronic anxiety disorder associated with significant morbidity, social impairment and lower quality of life. Psychological treatments are a frequently used approach for OCD. Objectives To perform a systematic review of randomised trials of psychological treatments for obsessive compulsive disorder in comparison with treatment as usual. Search methods We conducted an electronic search of CCDANCTR-Studies (31/10/2006), and other databases. We searched reference lists, and contacted experts in the field. Selection criteria Published and unpublished randomised trials of psychological treatments versus treatment as usual for adults with a diagnosis of OCD Data collection and analysis Two review authors worked independently throughout the selection of trials and data extraction. Findings were compared and disagreements were discussed with a third review author. Full data extraction, using a standardised data extraction sheet, was performed on all studies included in the review. Results were synthesised using Review Manager software. For dichotomous data, odds ratios were calculated. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated. Fixed and random effects models were used to pool the data. Reasons for heterogeneity in studies were explored and sensitivity analyses were performed by excluding trials of lower quality. Main results Eight studies (11 study comparisons) were identified, all of which compared cognitive and/or behavioural treatments versus treatment as usual control groups. Seven studies (ten comparisons) had usable data for meta-analyses. These studies demonstrated that patients receiving any variant of cognitive behavioural treatment exhibited significantly fewer symptoms post-treatment than those receiving treatment as usual (SMD -1.24, 95% CI -1.61 to -0.87, I² test for heterogeneity 33.4%). Different types of cognitive and/or behavioural treatments showed similar differences in effect when compared with treatment as usual. The overall treatment effect appeared to be influenced by differences in baseline severity. Authors' conclusions The findings of this review suggest that psychological treatments derived from cognitive behavioural models are an effective treatment for adult patients with obsessive compulsive disorder. Larger high quality randomised controlled trials involving longer follow up periods are needed, to further test cognitive behavioural treatments, and other psychological approaches, in comparison to each other and control conditions. Future trials should examine the predictors of response to each treatment, and also conduct cost-effectiveness evaluations.

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the efficacy of venlafaxine in comparison with other anti-depressive agents in alleviating the acute symptoms of major depressive disorder.To review acceptability of treatment with venlafaxine in comparison with other anti-depressive agents.To investigate the adverse effects of venlafaxine in comparison with other anti-depressive agents.

Background Generalised anxiety disorder (GAD) is a highly prevalent condition, characterised by excessive worry or anxiety about everyday events and problems. The effectiveness and comparative effectiveness of psychological therapies as a group has not yet been evaluated in the treatment of GAD. Objectives To examine the efficacy and acceptability of psychological therapies, categorised as cognitive behavioural therapy (CBT), psychodynamic therapy and supportive therapy, compared with treatment as usual/waiting list (TAU/WL) and compared with one another, for patients with GAD. Search methods We searched the Cochrane Depression, Anxiety & Neurosis Group (CCDAN) Controlled Trials Register and conducted supplementary searches of MEDLINE, PsycInfo, EMBASE, LILACS and controlledtrials.com in February 2006. We searched reference lists of retrieved articles, and contacted trial authors and experts in the field for information on ongoing/completed trials. Selection criteria Randomised and quasi-randomised controlled trials conducted in non-inpatient settings, involving adults aged 18-75 years with a primary diagnosis of GAD, assigned to a psychological therapy condition compared with TAU/WL or another psychological therapy. Data collection and analysis Data on patients, interventions and outcomes were extracted by two review authors independently, and the methodological quality of each study was assessed. The primary outcome was anxiety reduction, based on a dichotomous measure of clinical response, using relative risk (RR), and on a continuous measure of symptom reduction, using the standardised mean difference (SMD), with 95% confidence intervals. Main results Twenty five studies (1305 participants) were included in the review, of which 22 studies (1060 participants) contributed data to meta-analyses. Based on thirteen studies, psychological therapies, all using a CBT approach, were more effective than TAU/WL in achieving clinical response at post-treatment (RR 0.64, 95%CI 0.55 to 0.74), and also in reducing anxiety, worry and depression symptoms. No studies conducted longer-term assessments of CBT against TAU/WL. Six studies compared CBT against supportive therapy (non-directive therapy and attention-placebo conditions). No significant difference in clinical response was indicated between CBT and supportive therapy at post-treatment (RR 0.86, 95%CI 0.70 to 1.06), however, significant heterogeneity was indicated, which was partly explained by the number of therapy sessions. Authors' conclusions Psychological therapy based on CBT principles is effective in reducing anxiety symptoms for short-term treatment of GAD. The body of evidence comparing CBT with other psychological therapies is small and heterogeneous, which precludes drawing conclusions about which psychological therapy is more effective. Further studies examining non-CBT models are required to inform health care policy on the most appropriate forms of psychological therapy in treating GAD.

Background People with depression often experience interpersonal problems. Family therapy for depression is a widely used intervention, but it is unclear whether this is an effective therapy for the treatment of depression. Objectives To assess the efficacy of family therapy for depression. Search methods The following electronic databases were searched using a specific search strategy: CCDANCTR-Studies and CCDANCTR-References searched on 21/10/2005, The Cochrane Central Register of Controlled Trials, Medline (1966 to January 2005), EMBASE (1980 to January 2005), Psycinfo (1974 to January 2005). Reference lists of articles were also searched. Handsearches of relevant journals and bibliographies were conducted and first authors of included studies and experts in the field were contacted for further information. Selection criteria Included studies were randomised controlled and controlled clinical trials comparing family therapy with no intervention or an alternative intervention in which depression symptomatology was a main outcome measure. Data collection and analysis Methodological quality was independently assessed by two review authors using the Maastricht-Amsterdam Criteria List. The qualitative and quantitative characteristics of the selected trials were independently extracted by three review authors using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. It was not possible to perform meta-analyses because of the heterogeneity of the selected studies. Main results Three high-quality and three low-quality studies, involving 519 people with depression, were identified. The studies were very heterogeneous in terms of interventions, participants, and measuring instruments. Despite fairly good methodological quality and positive findings of some studies, evidence for the effectiveness of family therapy for depression did not exceed level 3 (limited or conflicting evidence), except for moderate evidence (level 2), based on the non-combined findings from three studies, indicating that family therapy is more effective than no treatment or waiting list condition on decreasing depression, and on increasing family functioning. Authors' conclusions The current evidence base is too heterogeneous and sparse to draw conclusions on the overall effectiveness of family therapy in the treatment of depression. At this point, use of psychological interventions for the treatment of depression for which there is already an evidence-base would seem to be preferable to family therapy. Further high quality trials examining the effectiveness and comparative effectiveness of explicitly defined forms of family therapy are required.

Objective: Clinical guidelines recommend that antidepressant treatment should be continued for a minimum of 6 months following response in depression and anxiety disorders. However, adherence to antidepressants is low. This prospective cohort study investigated the influence of patients' antidepressant concerns, treatment preferences, and illness perceptions on adherence to antidepressants over a 6-month period. Method: A cohort of 178 patients aged 18 to 74 years and newly issued with a prescription for antidepressants to treat any condition was followed up prospectively at 5 primary care practices in Southeast England. Adherence was measured through self-report and prescription refill data. Patient perceptions were quantified using validated outcome measures, the Beliefs about Medicine Questionnaire and the Illness Perception Questionnaire, at 4 timepoints. Patient treatment preferences were recorded using a specially designed questionnaire. Data collection took place between September 2000 and May 2002. Results: Of 147 participants (83%) who completed the study, 19% persisted with antidepressants in accordance with guideline recommendations throughout the 6-month period. Specific concern about antidepressant side effects (OR = 3.30, 95% CI = 2.20 to 4.97) and general worry about taking antidepressants (OR = 1.65, 95% CI = 1.13 to 2.40) were independent predictors of antidepressant nonuse. Preference for different treatment/uncertainty about preferred treatment was also a strong predictor (OR = 3.82, 95% CI = 1.35 to 10.77). However, illness perceptions were not associated with adherence. Conclusions: Concerns about antidepressants and a mismatch between patients' preferred and prescribed treatment act as significant barriers to sustained adherence. This study highlights the central role of the patient-physician partnership in exploring antidepressant concerns, working with treatment preferences, and providing supportive continued management. The findings may inform the development of interventions within primary care programs to enhance commitment to treatment for common mental disorders. © Copyright 2007 Physicians Postgraduate Press, Inc.

Objectives Several MRI studies have investigated the anterior cingulate in schizophrenia, as this is a key region for emotional processing and higher executive performances. A systematic review of structural MRI studies and a meta-analysis were conducted to explore whether anterior cingulate volumes are abnormal in patients with schizophrenia. Method A systematic search strategy was used to identify eligible MRI studies. Thereafter, a meta-analysis was carried out by using a random effect model. Also, a meta-regression analysis was used to assess the influence of age, gender and slice thickness on effect sizes. Results The meta-analysis was performed on seven studies. These results showed that the anterior cingulate volumes were significantly reduced in patients compared to healthy controls. Significant heterogeneity between these studies was observed. The meta-regression demonstrated that the effect size was significantly related only to slice thickness. Conclusions Our work confirmed the presence of abnormally reduced anterior cingulate volumes in schizophrenia. However, several methodological issues limited the interpretation of these findings. Among these were different MR acquisition parameters and the small size of the sample, which was mostly composed of chronic patients. Future MRI studies should be planned to better understand the functional expression of anterior cingulate structural abnormalities.

BACKGROUND: Selective serotonin reuptake inhibitors are thought to have better discontinuation rates (i.e. less people dropping out) than tricyclic and heterocyclic antidepressant drugs. It is important to quantify the drop-out rates of different antidepressant drugs in order to have a better understanding of the relative tolerability of these drugs. OBJECTIVES: To assess the comparative tolerability of selective serotonin reuptake inhibitors and tricyclic/heterocyclic antidepressant drugs. SEARCH STRATEGY: We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (1997 to 1999), MEDLINE (1966 to 1999), EMBASE (1974 to 1999) We also searched specialist journals, the reference lists of relevant papers and previous systematic reviews, conference abstracts and government documents. Representatives of the pharmaceutical industry were contacted. SELECTION CRITERIA: Parallel group randomised controlled trials comparing selective serotonin reuptake inhibitors with tricyclic or heterocyclic antidepressants in people with depression. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and a third reviewer checked any cases of disagreement. MAIN RESULTS: We included 136 trials. The selective serotonin reuptake inhibitors showed less participants dropping out compared to the tricyclic/heterocyclic group (odds ratio 1.21, 95% confidence interval 1.12 to 1.30). A statistically significant difference was found in total drop-outs between the selective serotonin reuptake inhibitors and the old tricyclics as well as the newer tricyclics. When the selective serotonin reuptake inhibitors were compared to the heterocyclic antidepressants, there was a non significant difference favouring the selective serotonin reuptake inhibitors. The poor tolerability profile of the old tricyclics was explained by differences in drop-outs for side-effects, but not for inefficacy. AUTHORS' CONCLUSIONS: Whilst selective serotonin reuptake inhibitors do appear to show an advantage over tricyclic drugs in terms of total drop-outs, this advantage is relatively modest. This has implications for pharmaco-economic models, some of which may have overestimated the difference of drop-out rates between selective serotonin reuptake inhibitors and tricyclic antidepressants. These results are based on short-term randomised controlled trials, and may not generalise into clinical practice.

The extent of disagreement between large and smaller randomized, controlled trials on mental health issues is unknown. The authors aimed to compare the results of large versus smaller trials on mental health-related interventions.The authors screened 161 Cochrane and 254 Database of Abstracts of Reviews of Effectiveness systematic reviews on mental health-related interventions. They identified 16 meta-analyses with at least one "large" randomized trial with sample size800 and at least one "smaller" trial. Effect sizes were calculated separately for large and smaller trials. Heterogeneity was assessed between all studies, within each group (large and smaller studies), and between large and smaller studies.Significant between-study heterogeneity was seen in five meta-analyses. By random-effects calculations, the results of large and smaller trials differed beyond chance in four meta-analyses (25%). In three of these disagreements (effect of day care on IQ, discontinuation of antidepressants, risperidone versus typical antipsychotics for schizophrenia), the smaller trials showed greater effect sizes than the large trials. The inverse was seen in one case (olanzapine versus typical antipsychotics for schizophrenia). With fixed-effects models, disagreements beyond chance occurred in five cases (31%). In four meta-analyses, the effect size differed over twofold between large and smaller trials. Various quality and design parameters were identified as potential explanations for some disagreements.Large trials are uncommon in mental health. Their results are usually comparable with the results of smaller studies, but major disagreements do occur. Both large and smaller trials should be scrutinized as they offer a continuum of randomized evidence.

Meta-analyses of randomized trials may incorporate new evidence, and estimated treatment effects changeover time. We evaluated whether the certainty and estimates of efficacy and tolerability of mental health interventions change over time, as more trials appear on the same topics.One hundred meta-analyses (1,024 trial entries; 99,303 participants) with an outcome of death, relapse, failure or dropout and with five or more trials published in three or more different years were examined with cumulative meta-analysis and recursive cumulative meta-analysis.Eight meta-analyses reached formal statistical significance (P.05) at some point, but lost this significance eventually when more trials were published; typically large effect sizes in early trials were dissipated with further evidence. With 500 randomized subjects,95% of the time, subsequent changes in odds ratio might be up to 1.5-fold. For death, relapse, and failure outcomes, a decrease in effect size was somewhat more common than an increase, when more data became available (157 vs. 125, P = .06). This was most clear for comparisons of pharmacotherapies versus placebo (79 vs. 51, P = .009).Evidence based on a small number of randomized subjects should be interpreted cautiously. Early treatment efficacy of pharmacotherapies is occasionally overestimated.

Critical appraisal skills are essential for interpreting studies and performing research. Each study design is susceptible to its own problems, and this chapter has summarized some of these areas of weakness, so that, for example, when reading a case–control study the immediate consideration should be whether there is recall or selection bias. However the essential characteristic of good research which has been well reported is that the reader is able to understand each stage of the process from setting out the aims of the study to reporting its conclusions.

Background : Dysfunctional attitudes may predispose to episodes of depression, although the evidence for this is poor. Most previous studies have been cross-sectional, or have followed up clinical samples. The aim of the study was to test the hypothesis that dysfunctional attitudes are associated with the onset and repeat prevalence of episodes of the common mental disorders among primary care attenders. Methods : A 12-month prospective cohort study of 305 consecutive primary care attenders at a health centre in south London. Results : Linear associations were found between (high) score on the Dysfunctional Attitude Scale (DAS) and both the onset and repeat prevalence of episodes of the common mental disorders over 12 months (unadjusted OR for episode onset 1.05, 95% CI 1.01–1.09) ( P =0.009). The association with episode onset, but not with repeat prevalence, remained statistically significant after adjusting for CIS-R score at baseline (OR 1.05, 95% CI 1.00–1.09) ( P =0.03). Limitations : This study was based in a single general practice, and had limited power to detect statistically significant interactions between DAS score and socio-economic adversity. Conclusions : Dysfunctional attitudes may be a risk factor for the onset (but not the outcome) of episodes of moderately severe, typically comorbid, anxiety and depression found in primary care settings.

Background Panic disorder can be treated with pharmacotherapy, psychotherapy or in combination, but the relative merits of combined therapy have not been well established. Objectives To review evidence concerning short- and long-term advantages and disadvantages of combined psychotherapy plus antidepressant treatment for panic disorder with or without agoraphobia, in comparison with either therapy alone. Search methods The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 11/10/2005, together with a complementary search of the Cochrane Central Register of Controlled Trials and MEDLINE, using the keywords antidepressant and panic. A reference search, SciSearch and personal contact with experts were carried out. Selection criteria Two independent review authors identified randomised controlled trials comparing the combined therapy against either of the monotherapies among adult patients with panic disorder with or without agoraphobia. Data collection and analysis Two independent review authors extracted data using predefined data formats, including study quality indicators. The primary outcome was relative risk (RR) of "response" i.e. substantial overall improvement from baseline as defined by the original investigators. Secondary outcomes included standardised weighted mean differences in global severity, panic attack frequency, phobic avoidance, general anxiety, depression and social functioning and relative risks of overall dropouts and dropouts due to side effects. Main results We identified 23 randomised comparisons (representing 21 trials, 1709 patients), 21 of which involved behaviour or cognitive-behaviour therapies. In the acute phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR 1.24, 95% confidence interval (CI) 1.02 to 1.52) or psychotherapy (RR 1.17, 95% CI 1.05 to 1.31). The combined therapy produced more dropouts due to side effects than psychotherapy (number needed to harm (NNH) around 26). After the acute phase treatment, as long as the drug was continued, the superiority of the combination over either monotherapy appeared to persist. After termination of the acute phase and continuation treatment, the combined therapy was more effective than pharmacotherapy alone (RR 1.61, 95% CI 1.23 to 2.11) and was as effective as psychotherapy (RR 0.96, 95% CI 0.79 to 1.16). Authors' conclusions Either combined therapy or psychotherapy alone may be chosen as first line treatment for panic disorder with or without agoraphobia, depending on patient preference.

Greenhalgh and colleagues’ commentary on the state of evidence informed healthcare is timely.1 However, labelling this as a “crisis” and the plea for a “return” to a mythical golden past are misguided. The solution does not involve looking backwards, and headings such as “Return to real evidence based medicine” are unhelpful. The world has moved on. Evidence is continually evolving to reflect the needs …

Background The aim of this presentation is to summarize the results of the published systematic reviews / meta-analyses of the randomized controlled trials that have investigated the effectiveness of medications for the treatment of obsessive compulsive disorder (OCD) in children/adolescents and adults and to present preliminary results from a new review study using network meta-analytical techniques Methods Medline, Cochrane database, and the register of controlled trials maintained by the Cochrane Collaboration Depression, Anxiety & Neurosis Group (CCDAN) were searched for relevant trials, systematic reviews and/or meta-analyses. Results Regarding the new review study we were able to extract 103 pharmacological arms (preliminary results: 9 for Fluoxetine, 16 for Fluvoxamine, 11 for Paroxetine, 10 for Sertraline, 16 for Clomipramine, 7 for Citalopram / escitalopram, 2 for Venlafaxine, and 32 for Placebo) with a total number of 6572 patients randomized. The previous meta-analyses have confirmed the efficacy for all SSRIs and Clomipramine in all age groups while for other drugs further evidence is required. In the context of this presentation preliminary results of the relative efficacy of each drug, using network meta-analysis techniques will also be reported. Conclusions Several antidepressants have established their efficacy and acceptability for the management of non-resistant OCD. The major weakness of the literature so far is that head to head comparisons between antidepressants are few and therefore it is difficult to establish a clear hierarchy of the efficacy and acceptability of the various agents. This gap in the present literature will be filled by the present review.

BACKGROUND: Over approximately the last fifteen years, early psychological interventions, such as psychological 'debriefing', have been increasingly used following psychological trauma. Whilst this intervention has become popular and its use has spread to several settings, empirical evidence for its efficacy is noticeably lacking. This is the third update of a review of single session psychological "debriefing", first having been undertaken in 1997. OBJECTIVES: To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder. SEARCH METHODS: Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health,SOCIOFILE, CINAHL, PSYCINFO, PSYNDEX, SIGLE, LILACS, CCTR, CINAHL, NRR, Hand search of Journal of Traumatic Stress. Contact with leading researchers. SELECTION CRITERIA: The focus of RCTs was on persons recently (one month or less) exposed to a traumatic event. The intervention consisted of a single session only, and involved some form of emotional processing/ventilation, by encouraging recollection/reworking of the traumatic event, accompanied by normalisation of emotional reaction to the event. DATA COLLECTION AND ANALYSIS: 15 trials fulfilled the inclusion criteria. Methodological quality was variable, but the majority of trials scored poorly. Data from 6 trials could not be included the meta‐analyses. These trials are summarised in the text. MAIN RESULTS: Single session individual debriefing did not prevent the onset of post traumatic stress disorder (PTSD) nor reduce psychological distress, compared to control. At one year, one trial reported a significantly increased risk of PTSD in those receiving debriefing (OR 2.51 (95% CI 1.24 to 5.09). Those receiving the intervention reported no reduction in PTSD severity at 1‐4 months (SMD 0.11 (95%CI 0.10 to 0.32)), 6‐13 months (SMD 0.26 (95%CI 0.01 to 0.50)), or 3 years (SMD 0.17 (95%CI ‐0.34 to 0.67)). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety, or that it was superior to an educational intervention. AUTHORS' CONCLUSIONS: There is no evidence that single session individual psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease. A more appropriate response could involve a 'screen and treat' model (NICE 2005).

BACKGROUND: Selective serotonin reuptake inhibitors are thought to have better discontinuation rates (i.e. less people dropping out) than tricyclic and heterocyclic antidepressant drugs. It is important to quantify the drop-out rates of different antidepressant drugs in order to have a better understanding of the relative tolerability of these drugs. OBJECTIVES: To assess the comparative tolerability of selective serotonin reuptake inhibitors and tricyclic/heterocyclic antidepressant drugs. SEARCH STRATEGY: We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (1997 to 1999), MEDLINE (1966 to 1999), EMBASE (1974 to 1999) We also searched specialist journals, the reference lists of relevant papers and previous systematic reviews, conference abstracts and government documents. Representatives of the pharmaceutical industry were contacted. SELECTION CRITERIA: Parallel group randomised controlled trials comparing selective serotonin reuptake inhibitors with tricyclic or heterocyclic antidepressants in people with depression. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and a third reviewer checked any cases of disagreement. MAIN RESULTS: We included 136 trials. The selective serotonin reuptake inhibitors showed less participants dropping out compared to the tricyclic/heterocyclic group (odds ratio 1.21, 95% confidence interval 1.12 to 1.30). A statistically significant difference was found in total drop-outs between the selective serotonin reuptake inhibitors and the old tricyclics as well as the newer tricyclics. When the selective serotonin reuptake inhibitors were compared to the heterocyclic antidepressants, there was a non significant difference favouring the selective serotonin reuptake inhibitors. The poor tolerability profile of the old tricyclics was explained by differences in drop-outs for side-effects, but not for inefficacy. REVIEWER'S CONCLUSIONS: Whilst selective serotonin reuptake inhibitors do appear to show an advantage over tricyclic drugs in terms of total drop-outs, this advantage is relatively modest. This has implications for pharmaco-economic models, some of which may have overestimated the difference of drop-out rates between selective serotonin reuptake inhibitors and tricyclic antdepressants. These results are based on short-term randomised controlled trials, and may not generalise into clinical practice.

A recent systematic review by the Cochrane Airways Group showed that adding multiple doses of anticholinergics to β2 agonists is safe and effective in improving lung function and avoiding hospital admission for school aged children and adolescents attending casualty departments with severe acute asthma.1 The estimated reduction in the risk of admission was 9.4% (0.4% to 18.4%). This intervention presumably improves bronchodilatation until systemic corticosteroids take effect. Evidence of cost effectiveness, however, is lacking. To clarify whether scarce healthresources should be spent on this intervention we conducted an economic evaluation. We used various assumptions to estimate the financial implications of treatment (see table on the BMJ 's website). The costs of drug administration were not included, as anticholinergics are always given with β2 agonists and involvelittle additional manipulation. The cost of nebulisers, other drugs, and the casualty attendance were also excluded. No consideration was given to possible changes in length of stay in casualty. …

STUDY OBJECTIVE: To compare the potential impact of high risk and population based approaches to the prevention of psychiatric disorder, using a representative sample of general practice attenders as the target population. DESIGN: This was a prospective cohort study. SETTING: A health centre in south London. PARTICIPANTS: Three hundred and seven consecutive attenders aged 16-65, recruited at randomly selected general practice surgeries. MAIN RESULTS: A linear association was found between the number of different types of socioeconomic adversity reported at recruitment (T1) and the prevalence of psychiatric disorder one year later (T2). The population attributable fraction (PAF) for socioeconomic adversity at T1 was 37.4%. In theory, social interventions for high risk individuals at T1 would reduce the prevalence of psychiatric disorder at T2 by 9% at most, compared with a reduction of 18% if just one item of socioeconomic adversity were eliminated among those with any socioeconomic risk factors. CONCLUSIONS: Social interventions targeted at individuals at highest risk of the most common mental disorders are likely to be extremely limited in their capacity to reduce the prevalence of these conditions. A population based risk reduction strategy, modified according to individual risk, represents a potentially feasible and effective alternative.

Swanson et al ([2000][1]) reanalysed the results of the North Carolina trial ([Swartz et al , 1999][2]) and their findings are becoming increasingly influential in current debates about mental health legislation in the UK. Our recent systematic review ([Churchill et al , 2007][3]), which included

Background: In the UK, Black and minority ethnic (BME) patients have been reported to be disproportionately detained under the Mental Health Act. Aims: Systematic review of all UK literature on ethnicity and detention with meta-analysis of detention rates for BME patients, to determine range of explanatory hypotheses and examine the evidence for these hypotheses Methods: Electronic data bases searched for all date-based studies (1984-2005). Meta-analyses performed where data available. Explanations offered for any excess categorised and evidence examined. Results: 49 studies identified, 19 included in meta-analyses. Compared with White patients, Blacks were 3.83 times, BME patients 3.35 times and Asians 2.06 times more likely to be detained. Racial stereotyping and discrimination against BME patients was the most often cited explanation (53% studies); followed by alienation and mistrust of psychiatric services (28%); higher rates of psychosis (22%); delay in help seeking (18%); and misdiagnosis/ under recognition of illness (16%). There was no primary evidence provided by any study to confirm any of these explanations, while some papers presented data that contradicted these explanations. Conclusions: BME patients experience higher rates of detention under the MHA than White patients. Available explanations offered for this excess are largely unsupported. Explanations such as ‘institutional racism’ in psychiatry neither accurately account for the excess, nor help find ways of reducing detention rates.

Background So-called 'third wave' cognitive and behavioural therapies represent a new generation of psychological therapies that are increasingly being used in the treatment of psychological problems. However, the effectiveness and acceptability of third-wave cognitive and behavioural therapy (CBT) approaches as treatment for acute depression remain unclear. Objectives 1. To examine the effects of all third wave CBT approaches compared with treatment as usual/waiting list/attention placebo/psychological placebo control conditions for acute depression. 2. To examine the effects of different third wave CBT approaches (ACT, compassionate mind training, functional analytic psychotherapy, dialectical behaviour therapy, MBCT, extended behavioural activation and metacognitive therapy) compared with treatment as usual/waiting list/attention placebo/psychological placebo control conditions for acute depression. 3. To examine the effects of all third wave CBT approaches compared with different types of comparators (treatment as usual, no treatment, waiting list, attention placebo, psychological placebo) for acute depression. Search methods We searched the Cochrane Depression Anxiety and Neurosis Group Trials Specialised Register (CCDANCTR to 01/01/12), which includes relevant randomised controlled trials from The Cochrane Library (all years), EMBASE, (1974-), MEDLINE (1950-) and PsycINFO (1967-). We also searched CINAHL (May 2010) and PSYNDEX (June 2010) and reference lists of the included studies and relevant reviews for additional published and unpublished studies. An updated search of CCDANCTR restricted to search terms relevant to third wave CBT therapies was conducted in March 2013 (CCDANCTR to 01/02/13). Selection criteria Randomised controlled trials that compared third wave CBT therapies with control conditions for acute depression in adults. Data collection and analysis Two review authors independently identified studies, assessed trial quality and extracted data. Study authors were contacted for additional information when required. We rated the quality of evidence using GRADE methods. Main results Four small studies (224 participants) were included in the review. Little information was provided about the process of allocating participants to groups. None of the studies used independent outcome assessors, and evidence suggested researcher allegiance towards the active treatments. The four studies examined a diversity of third wave CBT approaches (extended behavioural activation, acceptance and commitment therapy and competitive memory training) and control conditions. None of the studies conducted follow-up assessments. The results showed a significant difference in clinical response rates in favour of third wave CBT when compared with treatment as usual (TAU) conditions (three studies, 170 participants, risk ratio (RR) 0.51, 95% confidence interval (CI) 0.27 to 0.95; very low quality). No significant difference in treatment acceptability based on dropout rates was found between third wave CBT approaches and TAU (four studies, 224 participants, RR 1.01, 95% CI 0.08 to 12.30; very low quality). Both analyses showed substantial statistical heterogeneity. Authors' conclusions Very low quality evidence suggests that third wave CBT approaches appear to be more effective than treatment as usual in the treatment of acute depression. The very small number of available studies and the diverse types of interventions and control comparators, together with methodological limitations, limit the ability to draw any conclusions on their effect in the short term or over a longer term. The increasing popularity of third wave CBT approaches in clinical practice underscores the importance of completing further studies of third wave CBT approaches in the treatment of acute depression, on a short- and long-term basis, to provide evidence of their effectiveness to policy-makers, clinicians and users of services.

BACKGROUND: Although pharmacological and psychological interventions are both effective for major depression, in primary and secondary care settings antidepressant drugs remain the mainstay of treatment. Amongst antidepressants many different agents are available. Duloxetine hydrochloride is a dual reuptake inhibitor of serotonin and norepinephrine and has been licensed by the Food and Drug Administration in the US for major depressive disorder (MDD), generalised anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia and chronic musculoskeletal pain. OBJECTIVES: To assess the evidence for the efficacy, acceptability and tolerability of duloxetine in comparison with all other antidepressant agents in the acute-phase treatment of major depression. SEARCH METHODS: MEDLINE (1966 to 2012), EMBASE (1974 to 2012), the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register and the Cochrane Central Register of Controlled Trials up to March 2012. No language restriction was applied. Reference lists of relevant papers and previous systematic reviews were hand-searched. Pharmaceutical company marketing duloxetine and experts in this field were contacted for supplemental data. SELECTION CRITERIA: Randomised controlled trials allocating patients with major depression to duloxetine versus any other antidepressive agent. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and a double-entry procedure was employed. Information extracted included study characteristics, participant characteristics, intervention details and outcome measures in terms of efficacy, acceptability and tolerability. MAIN RESULTS: A total of 16 randomised controlled trials (overall 5735 participants) were included in this systematic review. Of these, three trials were unpublished. We found 11 studies (overall 3304 participants) comparing duloxetine with one selective serotonin reuptake inhibitor (SSRI) (six studies versus paroxetine, three studies versus escitalopram and two versus fluoxetine), four studies (overall 1978 participants) comparing duloxetine with a newer antidepressants (three with venlafaxine and one with desvenlafaxine, respectively) and one study (overall 453 participants) comparing duloxetine with an antipsychotic drug which is also used as an antidepressive agent, quetiapine. No studies were found comparing duloxetine with tricyclic antidepressants. The pooled confidence intervals were rather wide and there were no statistically significant differences in efficacy when comparing duloxetine with other antidepressants. However, when compared with escitalopram or venlafaxine, there was a higher rate of drop out due to any cause in the patients randomised to duloxetine (odds ratio (OR) 1.62; 95% confidence interval (CI) 1.01 to 2.62 and OR 1.56; 95% CI 1.14 to 2.15, respectively). There was also some weak evidence suggesting that patients taking duloxetine experienced more adverse events than paroxetine (OR 1.24; 95% CI 0.99 to 1.55). AUTHORS' CONCLUSIONS: Duloxetine did not seem to provide a significant advantage in efficacy over other antidepressive agents for the acute-phase treatment of major depression. No differences in terms of efficacy were found, even though duloxetine was worse than some SSRIs (most of all, escitalopram) and newer antidepressants (like venlafaxine) in terms of acceptability and tolerability. Unfortunately, we only found evidence comparing duloxetine with a handful of other active antidepressive agents and only a few trials per comparison were found (in some cases we retrieved just one trial). This limited the power of the review to detect moderate, but clinically meaningful differences between the drugs. As many statistical tests have been used in the review, the findings from this review are better thought of as hypothesis forming rather than hypothesis testing and it would be very comforting to see the conclusions replicated in future trials. Most of included studies were sponsored by the drug industry manufacturing duloxetine. As for all other new investigational compounds, the potential for overestimation of treatment effect due to sponsorship bias should be borne in mind. In the present review no trials reported economic outcomes. Given that several SSRIs and the great majority of antidepressants are now available as generic formulation (only escitalopram, desvenlafaxine and duloxetine are still on patent), more comprehensive economic estimates of antidepressant treatment effect should be considered to better inform healthcare policy.

Background: The efficacy of combined psychotherapy and benzodiazepine treatment for panic disorder is still unclear despite its widespread use. The present systematic review aims to examine its efficacy compared with either monotherapy alone. Methods: All randomised trials comparing combined psychotherapy and benzodiazepine for panic disorder with either therapy alone were identified by comprehensive electronic search on the Cochrane Registers, by checking references of relevant studies and of other reviews, and by contacting experts in the field. Two reviewers independently checked eligibility of trials, assessed quality of trials and extracted data from eligible trials using a standardized data extraction form. Our primary outcome was "response" defined by global judgement. Authors of the original trials were contacted for further unpublished data. Meta-analyses were undertaken synthesizing data from all relevant trials. Results: Only two studies, which compared the combination with behaviour (exposure) therapy, met our eligibility criteria. Both studies had a 16-week intervention. Unpublished data were retrieved for one study. The relative risk for response for the combination was 1.25 (95%CI: 0.78 to 2.03) during acute phase treatment, 0.78 (0.45 to 1.35) at the end of treatment, and 0.62 (0.36 to 1.07) at 6–12 months follow-up. Some secondary outcomes hinted at superiority of the combination during acute phase treatment. One study was identified comparing the combination to benzodiazepine. The relative risk for response was 1.57 (0.83 to 2.98), 3.39 (1.03 to 11.21, statistically significant) and 2.31 (0.79 to 6.74) respectively. The superiority of the combination was observed on secondary outcomes at all the time points. No sub-group analyses were conducted due to the limited number of included trials. Conclusion: Unlike some narrative reviews in the literature, our systematic search established the paucity of high quality evidence for or against the combined psychotherapy plus benzodiazepine therapy for panic disorder. Based on limited available published and unpublished data, however, the combined therapy is probably to be recommended over benzodiazepine alone for panic disorder with agoraphobia. The combination might be superior to behaviour therapy alone during the acute phase, but afterwards this trend may be reversed. We know little from these trials about their adverse effects.

Objective Preliminary evidence suggested that sertraline might be slightly superior to other antidepressant medications in terms of efficacy. The aim of this study was to carry out a systematic review and meta-analysis to compare sertraline with any other antidepressant in the acute phase treatment of major depression at 8 weeks. Data sources MEDLINE; EMBASE; the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register; and the Cochrane Central Register of Controlled Trials up to August 2007. No language restriction. The following search strategy was used: diagnosis = depress* or dysthymi* or adjustment disorder* or mood disorder* or affective disorder or affective symptoms, and intervention (or free text) = sertraline. Reference lists of relevant papers and previous systematic reviews were hand-searched. Pharmaceutical companies and experts in this field were contacted for supplemental data. Study selection Only randomized controlled trials allocating patients with major depression to sertraline versus any other antidepressant agent. Data extraction Three reviewers independently extracted data. A double-entry procedure was employed by 2 reviewers. To analyze data, a very conservative approach with a 99% confidence interval (CI) and a random effects model was used. Information extracted included study characteristics, participant characteristics, intervention details, and outcome measures, such as the number of patients who responded to treatment and the number of patients who failed to complete the study by any cause at 8 weeks. Data synthesis This systematic review and meta-analysis found that sertraline is statistically significantly better than fluoxetine (relative risk [RR] = 0.85, 99% CI = 0.74 to 0.98; number needed to treat [NNT] = 12) and other SSRIs as a class (RR = 0.88, 99% CI = 0.78 to 0.99; NNT = 17) and highlighted a consistent even though not statistically significant trend in favor of sertraline over many other antidepressants both in terms of efficacy and acceptability in a homogeneous and clinically relevant time frame of 8 weeks. Conclusions The results of this review suggest that sertraline may be a candidate as the initial choice of antidepressant for people with major depression.

BackgroundPanic disorder can be treated with psychotherapy, pharmacotherapy or a combination of both.AimsTo summarise the evidence concerning the short- and long-term benefits and adverse effects of a combination of psychotherapy and antidepressant treatment.MethodMeta-analyses and meta-regressions were undertaken using data from all relevant randomised controlled trials identified by a comprehensive literature search. The primary outcome was relative risk (RR) of response.ResultsWe identified 23 randomised comparisons (21 trials involving a total of 1709 patients). In the acute-phase treatment, the combined therapy was superior to antidepressant pharmacotherapy (RR=1.24, 95% CI 1.02–1.52) or psychotherapy (RR=1.16, 95%CI 1.03–1.30). After termination of the acute-phase treatment, the combined therapy was more effective than pharmacotherapy alone (RR=1.61, 95% CI 1.23–2.11) and was as effective as psychotherapy (RR=0.96, 95% CI 0.79–1.16).ConclusionsEither combined therapy or psychotherapy alone may be chosen as first-line treatment for panic disorder with or without agoraphobia, depending on the patient's preferences.

BACKGROUND: Mirtazapine has a unique mechanism of antidepressive action and is one of the commonly used antidepressants in clinical practice. OBJECTIVES: The aim of the present review was to assess the evidence on the efficacy and acceptability of mirtazapine compared with other antidepressive agents in the acute-phase treatment of major depression in adults. SEARCH METHODS: We searched the Cochrane Collaboration Depression, Anxiety and Neurosis review group's specialised register (CCDANCTR), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years to April 2011), EMBASE, (1980 to July 2011) MEDLINE (1950 to July 2011) and PsycINFO (1974 to July 2011). Reference lists of the reports of relevant studies were checked and experts in the field contacted. The review was not limited to English-language articles. SELECTION CRITERIA: Randomised controlled trials (RCTs) allocating participants with major depression to mirtazapine versus any other antidepressive agent. DATA COLLECTION AND ANALYSIS: Two authors independently checked eligibility and extracted data on an intention-to-treat basis. The primary outcome was response to treatment. The secondary outcomes included dropouts and individual adverse events.Meta-analyses were conducted using the random-effects model. MAIN RESULTS: A total of 29 RCTs (n = 4974), mostly following up the participants for six weeks in outpatient clinics and inadequately reporting the risk of bias, were included. In comparison with tricyclic antidepressants (10 trials, n = 1553) there was no robust evidence to detect a difference between mirtazapine and tricyclics in terms of response at two weeks (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.64 to 1.13) or at the end of acute-phase treatment (at 6 to 12 weeks) (OR 0.89, 95% CI 0.72 to 1.10). In comparison with selective serotonin reuptake inhibitors (SSRIs) (12 trials, n = 2626) mirtazapine was significantly more effective at two weeks (OR 1.57, 95% CI 1.30 to 1.88) and at the end of acute-phase treatment (OR 1.19, 95% CI 1.01 to 1.39). Mirtazapine was significantly more effective than a serotonin-noradrenaline reuptake inhibitor (venlafaxine only, two trials, n = 415) at two weeks (OR 2.29, 95% CI 1.45 to 3.59) and at the end of acute-phase treatment (OR 1.53, 95% CI 1.03 to 2.25).In terms of dropouts, there was no robust evidence to detect a difference between mirtazapine and other antidepressants. Mirtazapine was more likely to cause weight gain or increased appetite and somnolence than SSRIs but less likely to cause nausea or vomiting and sexual dysfunction. AUTHORS' CONCLUSIONS: Some statistically significant and possibly clinically meaningful differences between mirtazapine and other antidepressive agents were found for the acute-phase treatment of major depression. Mirtazapine is likely to have a faster onset of action than SSRIs during the acute-phase treatment. Dropouts occur similarly in participants treated with mirtazapine and those treated with other antidepressants, although the adverse event profile of mirtazapine is unique.

BackgroundRandomised controlled trials (RCTs) are the most important method of evaluating new treatments and treatment policies. Despite this, there are relatively few large pragmatic RCTs in psychiatry.AimsTo explore the main advantages of large pragmatic RCTs and the obstacles to performing them in psychiatry.MethodA narrative review of literature on pragmatic RCTs with examples drawn from psychiatry and other medical specialities.ResultsObstacles to performing pragmatic RCTs in psychiatry include the complexity of psychiatric interventions, the complexity of outcomes used in psychiatry and the difficulties of blinding subjects and investigators to some psychiatric interventions.ConclusionsResearchers need to frame questions in a form that is relevant to clinicians and to convince clinicians to cooperate in simple large pragmatic trials.

The Mental Health Act 1983 provides legislation to ensure a consistent and comprehensive approach to the compulsory admission of psychiatric patients in England and Wales. Since the introduction of the act, the provision of service has changed: hospitals have closed and the care in the community programme has been introduced. Despite the reduction in the number of psychiatric beds available Department of Health data show a rise in the absolute number of compulsory admissions.1 We aimed to determine the proportion of all psychiatric admissions that these compulsory “formal” admissions represent. The Department of Health collects data from health authorities on compulsory psychiatric admissions, and these data were used to determine the proportion of all psychiatric admissions that were compulsory. Between 1984 and 1986 these data were presented for each calendar year. Since 1987 they have been presented for each financial year. Data were available from the Mental Health Enquiry from 1984 …