Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general Practice

Cost-effectiveness acceptability curves (CEACs) have been widely adopted as a method to quantify and graphically represent uncertainty in economic evaluation studies of health-care technologies. However, there remain some common fallacies regarding the nature and shape of CEACs that largely result from the ‘textbook’ illustration of the CEAC. This ‘textbook’ CEAC shows a smooth curve starting at probability 0, with an asymptote to 1 for higher money values of the health outcome (λ). But this familiar ‘ogive’ shape which makes the ‘textbook’ CEAC look like a cumulative distribution function is just one special case of the CEAC. The reality is that the CEAC can take many shapes and turns because it is a graphic transformation from the cost-effectiveness plane, where the joint density of incremental costs and effects may ‘straddle’ quadrants with attendant discontinuities and asymptotes. In fact CEACs: (i) do not have to cut the y-axis at 0; (ii) do not have to asymptote to 1; (iii) are not always monotonically increasing in λ; and (iv) do not represent cumulative distribution functions (cdfs). Within this paper we present a ‘gallery’ of CEACs in order to identify the fallacies and illustrate the facts surrounding the CEAC. The aim of the paper is to serve as a reference tool to accompany the increased use of CEACs within major medical journals. Copyright © 2004 John Wiley & Sons, Ltd.

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Cost‐effectiveness acceptability curves – facts, fallacies and frequently asked questions

http://spers.ca/wp-content/uploads/2013/08/Response-and-remission-for-major-depression.pdf

Report by the ACNP Task Force on Response and Remission in Major Depressive Disorder

OBJECTIVE Evidence-based practice involves the consideration of efficacy and effectiveness, clinical expertise, and patient preference in treatment selection. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders. DATA SOURCES A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration library through August 2011 for studies written in English that assessed adult patient preferences for the treatment of psychiatric disorders. The following search terms and subject headings were used in combination: patient preference, consumer preference, therapeutics, psychotherapy, drug therapy, mental disorders, depression, anxiety, insomnia, bipolar disorder, schizophrenia, substance-related disorder, eating disorder, and personality disorder. In addition, the reference sections of identified articles were examined to locate any additional articles not captured by this search. STUDY SELECTION Studies that assessed preferred type of treatment and included at least 1 psychological treatment and 1 pharmacologic treatment were included. Of the 644 articles identified, 34 met criteria for inclusion. DATA EXTRACTION Authors extracted relevant data including the proportion of participants reporting preference for psychological or pharmacologic treatment. RESULTS The proportion of adult patients preferring psychological treatment was 0.75 (95% CI, 0.69-0.80), which was significantly higher than equivalent preference (ie, higher than 0.50; P < .001). Sensitivity analyses suggested that younger patients (P = .05) and women (P < .01) were significantly more likely to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected (ie, non-treatment-seeking) samples (P < .001 for both) but was somewhat stronger for unselected samples. CONCLUSIONS Aggregation of patient preferences across diverse settings yielded a significant 3-fold preference for psychological treatment. Given evidence for enhanced outcomes among those receiving their preferred psychiatric treatment and the trends for decreasing utilization of psychotherapy, strategies to maximize the linkage of patients to preferred care are needed.

Patient Preference for Psychological vs Pharmacologic Treatment of Psychiatric Disorders: A Meta-Analytic Review

https://medschool.lsuhsc.edu/internal_medicine/residency/docs/jc 2015-03 gold standard or golden calf_nesh.pdf

The double-blind, randomized, placebo-controlled trial: Gold standard or golden calf?

Objectives: To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference. Design: Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes. Setting: 31 general practices in Trent region. Participants: Patients aged 18–70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms. Main outcome measures: Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria. Results: At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval −2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist9s overall assessment of outcome between any of the groups. 221/265 (83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months v 3 months). 33/221 (15%) patients had a relapse. Conclusions: Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment. What is already known on this topic Antidepressants and specific psychological interventions are effective in major depression. Generic counselling has not previously been compared with antidepressants in primary care What this study adds 12 months after starting treatment, generic counselling is as effective as antidepressants Patients treated with antidepressants may recover more quickly Given a choice, more patients opt for counselling Patients who choose counselling may benefit more than those with no strong preference

https://www.bmj.com/content/bmj/322/7289/772.full.pdf

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

Background There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor.

Aims To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response.

Method A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms.

Results There were 103 randomised and 220 preference patients in the trial. We found: no differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome.

Conclusions These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting.

/pdf/assessing-effectiveness-of-treatment-of-depression-in-1xaegkqub9.pdf

Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial.

We performed a cross-sectional survey of general practice attenders to determine their preferences regarding treatment for depression and characteristics associated with such preferences. Counselling was more popular than drug therapy (antidepressants), particularly among women, those who believed antidepressants are addictive, and those who had received such treatment in the past.

Treating depression in general practice: factors affecting patients' treatment preferences.

Gold standard or fool's gold?

Randomised controlled trials are a widely accepted means of applying experimental methods to a clinical setting and have been advocated as the gold standard for comparing and evaluating different treatments.1 2 General practice has been promoted as an appropriate arena for evaluating interventions ranging from drug treatment to developments in services3 4: nine out of 10 health service consultations take place here; it is the point of first contact for most medical conditions; and existing population registers and computer systems allow potential access to large amounts of clinical data. An increasing number of randomised controlled trials are being performed in this setting to contribute to the culture of evidence based medicine.5 But despite the theoretical attractions, applying experimental methods in clinical practice presents problems that, if not properly addressed or acknowledged, may invalidate the findings.6 The particular problems of recruitment and randomisation merit consideration with respect to primary care. …

Randomised controlled trials in general practice

This paper examines how primary care can improve for teenagers who are experiencing mental or emotional turmoil. This is an important health issue because at least 15% of teenagers experience mental health problems at any one time, there are indications that this proportion is rising, and there is evidence that suicide rates are rising in young people. The paper discusses how troubled teenagers can be identified, cared for and managed by primary care providers within the UK, although some of the information presented is from other countries. It identifies inter-relationships with other health behaviours and risk factors. The GP's role in assessing a troubled teenager is discussed, as well as a consideration of individual and contextual issues to frame a "triple" diagnosis, i.e. a diagnosis simultaneously in biomedical, individual and contextual terms. A review of present knowledge of management is presented. The paper concludes that there are several deficiencies at present, namely a lack of identification of teenage distress, a lack of training for GPs in teenage health, a lack of a research base, a lack of resources and finally a lack of information provided by any teenagers who have experienced turmoil and could give useful insights into their experience.

/pdf/tackling-teenage-turmoil-primary-care-recognition-and-2pqlbox15y.pdf

Richard Churchill

Papers

Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arms

Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial.

Treating depression in general practice: factors affecting patients' treatment preferences.

Randomised controlled trials in general practice

Tackling teenage turmoil: primary care recognition and management of mental ill health during adolescence.