ABSTRACT: Cannabis is the third most used psychoactive substance worldwide. The legal status of cannabis is changing in many Western countries, while we have very limited knowledge of the public health impact of cannabis-related harms. There is a need for a summary of the evidence of harms and risks attributed to cannabis use, in order to inform the definition of cannabis risky use. We have conducted a systematic review of systematic reviews, aiming to define cannabis-related harms. We included systematic reviews published until July 2018 from six different databases and following the PRISMA guidelines. To assess study quality we applied the AMSTAR 2 tool. A total of 44 systematic reviews, including 1,053 different studies, were eligible for inclusion. Harm was categorized in three dimensions: mental health, somatic harm and physical injury (including mortality). Evidence shows a clear association between cannabis use and psychosis, affective disorders, anxiety, sleep disorders, cognitive failures, respiratory adverse events, cancer, cardiovascular outcomes, and gastrointestinal disorders. Moreover, cannabis use is a risk factor for motor vehicle collision, suicidal behavior and partner and child violence. Cannabis use is a risk factor for several medical conditions and negative social consequences. There is still little data on the dose-dependency of these effects; evidence that is essential in order to define, from a public health perspective, what can be considered risky use of cannabis. This definition should be based on quantitative and qualitative criteria that informs and permits the evaluation of current approaches to a regulated cannabis market. (PsycINFO Database Record (c) 2020 APA, all rights reserved)
BACKGROUND: Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems.
OBJECTIVES: To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview.
METHODS: We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.
MAIN RESULTS: We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence).
AUTHORS' CONCLUSIONS: Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.
BACKGROUND: People with severe mental illness (SMI) have high rates of chronic disease and premature death.
AIMS: To explore the strength of evidence for interventions to reduce risk of mortality in people with SMI.
METHOD: In a meta-review of 16 systematic reviews of controlled studies, mortality was the primary outcome (8 reviews). Physiological health measures (body mass index, weight, glucose levels, lipid profiles and blood pressure) were secondary outcomes (14 reviews).
RESULTS: Antipsychotic and antidepressant medications had some protective effect on mortality, subject to treatment adherence. Integrative community care programmes may reduce physical morbidity and excess deaths, but the effective ingredients are unknown. Interventions to improve unhealthy lifestyles and risky behaviours can improve risk factor profiles, but longer follow-up is needed. Preventive interventions and improved medical care for comorbid chronic disease may reduce excess mortality, but data are lacking.
CONCLUSIONS: Improved adherence to pharmacological and physical health management guidelines is indicated.
BACKGROUND: Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.
METHODS: We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.
FINDINGS: We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.
INTERPRETATION: In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.
FUNDING: The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.
BACKGROUND AND AIM: The Danish Health and Medicines Authority assembled a group of experts to develop a national clinical guideline for patients with schizophrenia and complex mental health needs. Within this context, ten explicit review questions were formulated, covering several identified key issues.
METHODS: Systematic literature searches were performed stepwise for each review question to identify relevant guidelines, systematic reviews/meta-analyses, and randomized controlled trials. The quality of the body of evidence for each review question was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Clinical recommendations were developed on the basis of the evidence, assessment of the risk-benefit ratio, and perceived patient preferences.
RESULTS: Based on the identified evidence, a guideline development group (GDG) recommended that the following interventions should be offered routinely: antipsychotic maintenance therapy, family intervention and assertive community treatment. The following interventions should be considered: long-acting injectable antipsychotics, neurocognitive training, social cognitive training, cognitive behavioural therapy for persistent positive and/or negative symptoms, and the combination of cognitive behavioural therapy and motivational interviewing for cannabis and/or central stimulant abuse. SSRI or SNRI add-on treatment for persistent negative symptoms should be used only cautiously. Where no evidence was available, the GDG agreed on a good practice recommendation.
CONCLUSIONS: The implementation of this guideline in daily clinical practice can facilitate good treatment outcomes within the population of patients with schizophrenia and complex mental health needs. The guideline does not cover all available interventions and should be used in conjunction with other relevant guidelines.
Objectives The comorbidity between psychosis and substance use has attracted wide attention over the years, and a vast literature is now available for meta-analytic treatment. In the field, a majority of authors assume that cannabis smoking is a risk factor for psychosis, that substance abuse is highly prevalent in schizophrenia, that substance abuse worsens the prognosis of schizophrenia, and that integrated treatments have greater efficacy than treatment-as-usual for this complex population. The objective of the current article is to review the meta-analyses that have been published in the comorbidity field in order to determine if the above-mentioned assumptions are substantiated by evidence or not. Methods A search of the literature was performed using PubMed, PsycINFO and EMBASE. The literature search retrieved a total of 25 systematic quantitative reviews, addressing the following issues: etiology, age at onset, prevalence rates, cognition, treatment, as well as psychiatric, neurologic and functional outcomes. Results Evidence shows that the prevalence of tobacco smoking, cannabis smoking and alcohol use is elevated in psychosis. However, this prevalence is likely to be over-estimated since studies have been performed in clinical settings rather than the general population. Reliable evidence also suggests that cannabis smoking is a risk factor for psychosis outcomes. However, the association is rather small and it remains difficult to draw an unequivocal public health message from this literature. In the same vein, evidence suggests that cannabis smoking is associated with an earlier age at onset of psychosis. However, this observation is derived from cross-sectional studies, not longitudinal ones; thus, no undisputable claims on causality can be made from them. On clinical grounds, some evidence also suggests that substance use is associated with self-harm, increased positive and depressive symptoms in psychosis patients, but this evidence is derived from cross-sectional studies, not longitudinal ones. Cocaine may exacerbate antipsychotic-induced extrapyramidal symptoms in schizophrenia, but this observation is based on a small number of studies. In the case of violence, the aggregation of studies involving very large samples of patients has shown a strong association with substance abuse in psychosis patients. However, this association is based on statistics that are not adjusted for potential confounds, and the role of cluster-B personality disorders in the substance abuse-violence association has yet to be determined from an evidence-based perspective. The effects of psychoactive substances on cognition in psychosis patients are inconsistent and contradictory. In terms of treatment, evidence shows that bupropion and varenicline increase tobacco smoking cessation rates in psychosis. However, this observation is based on a small number of studies. Finally, there is no evidence that integrated psychosocial interventions are superior to treatment as usual in this population. This lack of efficacy may due to a real lack of efficacy or to methodological problems making the comparison of intervention studies difficult. Discussion The evidence supporting the main assumptions of the comorbidity field is not as strong as it may seem. Moreover, important gaps in our understanding of the psychosis-addiction comorbidity remain. Due to lack of interest or lack of data, no meta-analysis has been performed, in the dual-diagnosis population, on injectable antipsychotics, subjective reasons for use, treatment compliance, medical comorbidities, the social context of use, the neurobiological links between substance use and psychosis, as well as the comparative efficacy of nicotine replacement therapy.
WHAT DO WE WANT TO KNOW?: Delayed diagnosis results in serious consequences for patients and healthcare professionals and can incur substantial financial costs. While research focusing upon cancer suggests that late diagnosis leads to increased morbidity and mortality, the evidence for other conditions is less clear. This systematic rapid evidence assessment (SREA) identifies the nature and extent of the literature on late diagnosis across a range of conditions. We wanted to know:
1. What is the prevalence of late diagnosis?
2. What are the determinants of late diagnosis?
3. What are the outcomes of late diagnosis?
4. What are the cost implications of late diagnosis?
5. Which interventions reduce delays in diagnosis?
WHO WANTS TO KNOW?: Policy makers, clinicians, general practitioners and patients. WHAT DID WE FIND?: • Late diagnosis is of most concern for those with chronic obstructive pulmonary disease (COPD), dementia, human immunodeficiency virus (HIV) and type 1 Diabetes.
• COPD has a high prevalence of late diagnosis, with an estimated 80% of cases remaining undiagnosed. Many of these cases are patients in the milder stages of the disease.
• Early dementia is harder to detect, with doctors acknowledging their difficulties in distinguishing between dementia and ‘normal ageing’.
• The evidence suggested that a substantial proportion (16–51%) of children experience delayed diagnosis in type I diabetes.
• Those engaging in high-risk behaviours were more likely to avoid HIV testing due to fear of a positive diagnosis, with worrying implications regarding onward transmission. Data from the Health Protection Agency indicates that 50% of new diagnoses are late in the UK.
• Broadly, late diagnosis affects vulnerable groups such as older people or those living in poverty.
• Patients delayed seeking help from clinicians for a number of conditions including chronic kidney disease, dementia, HIV, stroke, myocardial infarction, epilepsy and tuberculosis. Late presentation was linked to symptom misinterpretation and lack of knowledge.
• Inadequate knowledge and training of doctors were barriers to prompt diagnosis for chronic kidney disease, COPD, dementia and tuberculosis.
• Restricted access, insufficient consultation time and resource constraints hindered diagnosis.
• There was very little material about the cost implications of delayed diagnosis. WHAT ARE THE IMPLICATIONS?: The training of doctors in the early diagnosis of COPD, dementia and tuberculosis has improved detection. Media campaigns to alert the public to the symptoms of stroke, heart attack and psychosis have had mixed results. Overall, public recognition has increased, but this may not have contributed to shortening patient delay.
This study includes information from health care systems outside the UK. However, policy makers may find future reviews of UK primary research into the late diagnosis of these conditions useful to understand the nature of the problem in a UK context. HOW DID WE GET THESE RESULTS?: We examined evidence from 43 systematic reviews for: chronic kidney disease, dementia, depression, type I diabetes, epilepsy, HIV, myocardial infarction, psychosis, stroke and tuberculosis.
We found 606 UK primary studies on late diagnosis, of which 12 investigated COPD, 12 investigated tuberculosis and 4 investigated epilepsy. While there were systematic reviews to draw on for most conditions, this was not the case for COPD (no systematic reviews), tuberculosis (systematic reviews with limited relevance to UK healthcare system) and epilepsy (systematic reviews focused on over-diagnosis), and so we used evidence from the primary studies.
INTRODUCTION: Meta-analyses are a convenient way for clinicians and researchers to review data regarding different interventions. Meta-analyses can overcome many of the limitations of individual studies, namely the power to detect differences, and help resolve the results of inconsistent studies.
AREAS COVERED: This paper is a review of meta-analyses of oral atypical antipsychotics for the treatment of schizophrenia, located through PubMed and the Cochrane Database of Systematic Reviews. A total of 91 meta-analyses were identified that included efficacy outcome data for the 10 atypical antipsychotics available in the USA (11 focused on clozapine, 17 for risperidone, 8 for olanzapine, 5 for quetiapine, 3 for ziprasidone, 10 for aripiprazole, 5 for paliperidone, 1 for iloperidone, 0 for asenapine or lurasidone, and 31 others that were classified more broadly). These include Cochrane Reviews and other similarly executed reports, as well as pooled analyses meta-tagged in PubMed as a meta-analysis.
EXPERT OPINION: In general, there is heterogeneity among the atypical antipsychotics in terms of efficacy, with clozapine evidencing consistent superiority over typical antipsychotics, trailed behind by olanzapine and risperidone. Meta-analyses generally do not support efficacy differences between the other atypical antipsychotics compared with the older typical agents. Although this review is focused on efficacy, other considerations are also important, including the large tolerability differences among all the agents and the need to individualize medication choice based on past history of therapeutic response, past history of tolerability issues and the individual's personal values and preferences.
OBJECTIVE: To provide a comprehensive overview of the research on organizational changes aimed at improving health care for patients with severe mental illness and to learn lessons for mental health practice from the results.
METHOD: We searched for systematic literature reviews published in English during 2000 to 2007 in PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Central Register of Systematic Reviews. Three reviewers independently selected and assessed the studies' quality. Studies involving changes of who delivers health care, how care is organized, or where care is delivered were included. We categorized the studies using an existing taxonomy of 6 broad categories of strategies for organizational change.
RESULTS: A total of 21 reviews were included. Among these, 17 had reasonably good methodological quality, Almost all reviews included or intended to include randomized controlled trials (RCTs), 6 reviews did not identify studies that met eligibility criteria. Multidisciplinary teams and integrated care models had been reviewed most frequently (a total of 15 reviews). In most studies, these types of changes showed better outcomes in terms of symptom severity, functioning, employment, and housing, compared with conventional services. Different results were found on cost savings. Other types of organizational changes, such as changing professional roles or introducing quality management or knowledge management, were much less frequently reviewed. Very few reviews looked at effects of organizational changes on professional performance.
CONCLUSIONS: There is a fairly large body of evidence of the positive impact of multidisciplinary teams and integrated care changes on symptom severity, functioning, employment, and housing of people with severe mental illness, compared with conventional services. Other strategies, such as changes in professional roles, quality or knowledge management, have either not been the subject of systematic reviews or have not been evaluated in RCTs. There is still a lack of insight in the so-called black box of change processes and the impact of change on professional performance.
Cannabis is the third most used psychoactive substance worldwide. The legal status of cannabis is changing in many Western countries, while we have very limited knowledge of the public health impact of cannabis-related harms. There is a need for a summary of the evidence of harms and risks attributed to cannabis use, in order to inform the definition of cannabis risky use. We have conducted a systematic review of systematic reviews, aiming to define cannabis-related harms. We included systematic reviews published until July 2018 from six different databases and following the PRISMA guidelines. To assess study quality we applied the AMSTAR 2 tool. A total of 44 systematic reviews, including 1,053 different studies, were eligible for inclusion. Harm was categorized in three dimensions: mental health, somatic harm and physical injury (including mortality). Evidence shows a clear association between cannabis use and psychosis, affective disorders, anxiety, sleep disorders, cognitive failures, respiratory adverse events, cancer, cardiovascular outcomes, and gastrointestinal disorders. Moreover, cannabis use is a risk factor for motor vehicle collision, suicidal behavior and partner and child violence. Cannabis use is a risk factor for several medical conditions and negative social consequences. There is still little data on the dose-dependency of these effects; evidence that is essential in order to define, from a public health perspective, what can be considered risky use of cannabis. This definition should be based on quantitative and qualitative criteria that informs and permits the evaluation of current approaches to a regulated cannabis market. (PsycINFO Database Record (c) 2020 APA, all rights reserved)
