Evidence Based Mental Health最新文献

Background: Task-sharing treatment approaches offer a pragmatic approach to treating common mental disorders in low-income and middle-income countries (LMICs). The Friendship Bench (FB), developed in Zimbabwe with increasing adoption in other LMICs, is one example of this type of treatment model using lay health workers (LHWs) to deliver treatment.

Objective: To consider the level of treatment coverage required for a recent scale-up of the FB in Zimbabwe to be considered cost-effective.

Methods: A modelling-based deterministic threshold analysis conducted within a 'cost-utility' framework using a recommended cost-effectiveness threshold.

Findings: The FB would need to treat an additional 3413 service users (10 per active LHW per year) for its scale-up to be considered cost-effective. This assumes a level of treatment effect observed under clinical trial conditions. The associated incremental cost-effectiveness ratio was $191 per year lived with disability avoided, assuming treatment coverage levels reported during 2020. The required treatment coverage for a cost-effective outcome is within the level of treatment coverage observed during 2020 and remained so even when assuming significantly compromised levels of treatment effect.

Conclusions: The economic case for a scaled-up delivery of the FB appears convincing in principle and its adoption at scale in LMIC settings should be given serious consideration.

Clinical implications: Further evidence on the types of scale-up strategies that are likely to offer an effective and cost-effective means of sustaining required levels of treatment coverage will help focus efforts on approaches to scale-up that optimise resources invested in task-sharing programmes.

Background: Adjunctive metformin is the most well-studied intervention in the pharmacological management of antipsychotic-induced weight gain (AIWG). Although a relatively unaddressed area, among guidelines recommending consideration of metformin, prescribing information that would facilitate its applied use by clinicians, for example, provision of a dose titration schedule is absent. Moreover, recommendations differ regarding metformin's place in the hierarchy of management options. Both represent significant barriers to the applied, evidence-based use of metformin for this indication.

Objective: To produce a guideline solely dedicated to the optimised use of metformin in AIWG management, using internationally endorsed guideline methodology.

Methods: A list of guideline key health questions (KHQs) was produced. It was agreed that individual recommendations would be 'adopted or adapted' from current guidelines and/or developed de novo, in the case of unanswered questions. A systematic literature review (2008-2020) was undertaken to identify published guidelines and supporting (or more recent) research evidence. Quality appraisal was undertaken using the Appraisal of Guidelines Research and Evaluation II tool, A Measurement Tool to Assess Systematic Reviews (AMSTAR) assessment,and the Cochrane Risk of Bias 2 tool, where appropriate. Assessment of evidence certainty and recommendation development was undertaken using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

Findings: We confirmed that no published guideline-of appropriate quality, solely dedicated to the use of metformin to manage AIWG was available. Recommendations located within other guidelines inadequately addressed our KHQs.

Conclusion: All 11 recommendations and 7 supporting good practice developed here were formulated de novo.

Clinical implications: These recommendations build on the number and quality of recommendations in this area, and facilitate the optimised use of metformin when managing AIWG.

Background: A relationship between caesarean section and offspring cognitive ability has been described, but data are limited, and a large-scale study is needed.

Objective: To determine the relationship between mode of delivery and general cognitive ability.

Methods: A cohort of 579 244 singleton males, born between 1973 and 1987 who conscripted before 2006, were identified using the Swedish population-based registries. Their mode of delivery was obtained from the Swedish Medical Birth registry. The outcome measure was a normalised general cognitive test battery (mean 100, SD 15) performed at military conscription at around age 18.

Findings: Males born by caesarean section performed poorer compared with those born vaginally (mean score 99.3 vs 100.1; adjusted mean difference -0.84; 95% CI -0.97 to -0.72; p<0.001). Both those born by elective (99.3 vs 100.2; -0.92; 95% CI -1.24 to -0.60; p<0.001) and non-elective caesarean section (99.2 vs 100.2; -1.03; 95% CI -1.34 to -0.72; p=0.001), performed poorer than those born vaginally. In sibling analyses, the association was attenuated to the null (100.9 vs 100.8; 0.07; 95% CI -0.31 to 0.45; p=0.712). Similarly, neither elective nor non-elective caesarean section were associated with general cognitive ability in sibling analyses.

Conclusion: Birth by caesarean section is weakly associated with a lower general cognitive ability in young adult males. However, the magnitude of this association is not clinically relevant and seems to be largely explained by familial factors shared between siblings.

Clinical implication: Clinicians and gravidas ought not to be concerned that the choice of mode of delivery will impact offspring cognitive ability.

Question: Suicide is a global public and mental health problem. The effectiveness of social support interventions has not been widely demonstrated in the prevention of suicide. We aimed to describe the methods of social support interventions in preventing suicide and examine the efficacy of them.

Study selection and analysis: We searched literature databases and conducted clinical trials. The inclusion criteria for the summary of intervention methods were as follows: (1) studies aimed at preventing suicide through method(s) that directly provide social support; (2) use of one or more method(s) to directly provide social support. The additional inclusion criteria for meta-analysis on the efficacy of these interventions included: (1) suicide, suicide attempt or social support-related outcome was measured; (2) randomised controlled trial design and (3) using social support intervention as the main/only method.

Findings: In total, 22 656 records and 185 clinical trials were identified. We reviewed 77 studies in terms of intervention methods, settings, support providers and support recipients. There was a total of 18 799 person-years among the ten studies measuring suicide. The number of suicides was significantly reduced in the intervention group (risk ratio (RR)=0.48, 95% CI 0.27 to 0.85). In 14 studies with a total of 14 469 person-years, there was no significant reduction of suicide attempts in the overall pooled RR of 0.88 (95% CI 0.73 to 1.07).

Conclusions: Social support interventions were recommended as a suicide prevention strategy for those with elevated suicide risk.

Question: Mental disorders typically start in childhood and persist, causing high individual and collective burdens. To inform policymaking to address children's mental health in high-income countries we aimed to identify updated data on disorder prevalence.

Methods: We identified epidemiological studies reporting mental disorder prevalence in representative samples of children aged 18 years or younger-including a range of disorders and ages and assessing impairment (searching January 1990 through February 2021). We extracted associated service-use data where studies assessed this. We conducted meta-analyses using a random effects logistic model (using R metafor package).

Findings: Fourteen studies in 11 countries met inclusion criteria, published from 2003 to 2020 with a pooled sample of 61 545 children aged 4-18 years, including eight reporting service use. (All data were collected pre-COVID-19.) Overall prevalence of any childhood mental disorder was 12.7% (95% CI 10.1% to 15.9%; I²=99.1%). Significant heterogeneity pertained to diagnostic measurement and study location. Anxiety (5.2%), attention-deficit/hyperactivity (3.7%), oppositional defiant (3.3%), substance use (2.3%), conduct (1.3%) and depressive (1.3%) disorders were the most common. Among children with mental disorders, only 44.2% (95% CI 37.6% to 50.9%) received any services for these conditions.

Conclusions: An estimated one in eight children have mental disorders at any given time, causing symptoms and impairment, therefore requiring treatment. Yet even in high-income countries, most children with mental disorders are not receiving services for these conditions. We discuss the implications, particularly the need to substantially increase public investments in effective interventions. We also discuss the policy urgency, given the emerging increases in childhood mental health problems since the onset of the COVID-19 pandemic (PROSPERO CRD42020157262).

Background: Compared with traditional screening questionnaires, computerised adaptive tests for severity of depression (CAT-DI) and computerised adaptive diagnostic modules for depression (CAD-MDD) show improved precision in screening for major depressive disorder. CAT measures have been tailored to perinatal women but have not been studied in low-income women of colour despite high rates of perinatal depression (PND).

Objective: This study aimed to examine the concordance between CAT and traditional measures of depression in a sample of primarily low-income black and Latina women.

Methods: In total, 373 women (49% black; 29% Latina) completed the Patient Health Questionnaire-9 (PHQ-9), CAD-MDD and CAT-DI at 845 visits across pregnancy and postpartum. We examined the concordance between continuous CAT-DI and PHQ-9 scores and between binary measures of PND diagnosis on CAD-MDD and the PHQ-9 (cut-off score >10). We examined cases with a positive PND diagnosis on the CAD-MDD but not on the PHQ-9 ('missed' cases) to determine whether clinic notes were consistent with CAD-MDD results.

Findings: CAT-DI and PHQ-9 scores were significantly associated (concordance correlation coefficient=0.67; 95% CI 0.58 to 0.74). CAD-MDD detected 5% more case of PND compared with PHQ-9 (p<0.001). The average per-visit rate of PND was 14.4% (14.5% in blacks, 14.9% in Latinas) on the CAD-MDD, and 9.5% (9.8% in blacks, 8.8% in Latinas) on the PHQ-9. Clinical notes were available on 60% of 'missed' cases and validated CAD-MDD PND diagnosis in 89% of cases.

Conclusions: CAD-MDD detected 5% more cases of PND in women of colour compared with traditional tests, and the majority of these cases were verified by clinician notes.

Clinical implications: Use of CAT in routine clinic care may address health disparities in PND screening.

Objective: The current practice in meta-analysis of the effects of psychopharmacological interventions ignors the administered dose or restricts the analysis in a dose range. This may introduce unnecessary uncertainty and heterogeneity. Methods have been developed to integrate the dose-effect models in meta-analysis.

Methods: We describe the two-stage and the one-stage models to conduct a dose-effect meta-analysis using common or random effects methods. We illustrate the methods on a dataset of selective serotonin reuptake inhibitor antidepressants. The dataset comprises 60 randomised controlled trials. The dose-effect is measured on an odds ratio scale and is modelled using restricted cubic splines to detect departure from linearity.

Results: The estimated summary curve indicates that the probability of response increases up to 30 mg/day of fluoxetine-equivalent which results in reaching 50% probability to respond. Beyond 40 mg/day, no further increase in the response is observed. The one-stage model includes all studies, resulting in slightly less uncertainty than the two-stage model where only part of the data is analysed.

Conclusions: The dose-effect meta-analysis enables clinicians to understand how the effect of a drug changes as a function of its dose. Such analysis should be conducted in practice using the one-stage model that incorporates evidence from all available studies.