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(2) DOCTORS
AND PATIENTS COLLUDE TO
MAINTAIN 'FALSE
OPTIMISM' ABOUT RECOVERY
(3) SHORT
TERM PSYCHOLOGICAL THERAPY MORE
EFFECTIVE THAN
GENERAL PRACTITIONER CARE
FOR DEPRESSION
(4) SHOULD
DDT FOR MALARIA CONTROL BE
BANNED?
(1) NEW SCHIZOPHRENIA
DRUGS MAY BE NO MORE
EFFECTIVE THAN CONVENTIONAL THERAPY
(Atypical antipsychotics in the treatment
of schizophrenia:
systematic overview and meta-regression
analysis)
http://bmj.com/cgi/content/full/321/7273/1371
There is no clear evidence that new antipsychotic
drugs are
any more effective or better tolerated
than conventional drugs
for patients with schizophrenia, despite
being considered
superior, finds a study in this week's
BMJ. Conventional
drugs should be considered first unless
the patient has
previously not responded to these drugs
or has unacceptable
side effects.
Geddes and colleagues analysed 52 trials,
involving over
12,500 patients, comparing new or 'atypical'
antipsychotics
with conventional antipsychotics. They
found that, when
compared with conventional drugs at a
moderate dose,
atypical antipsychotics caused fewer side
effects but had a
similar effect on symptoms. All things
being equal,
conventional drugs should be used as the
initial treatment of
schizophrenia, although atypical drugs
are a valuable addition
to treatment options, especially when
side effects are a
problem, say the authors.
These findings emphasise the importance
of a good
relationship between doctor and patient,
add the authors. The
broader choice of drugs now available
increases the chance
of finding the most appropriate drug for
each individual
patient, encouraging the patient to adhere
to their treatment,
they conclude
Contact:
John Geddes, Senior Clinical Research Fellow
and Honorary
Consultant Psychiatrist, Department of
Psychiatry,
Warneford Hospital, Oxford, UK
Email: john.geddes@psych.ox.ac.uk
(2) DOCTORS AND
PATIENTS COLLUDE TO
MAINTAIN 'FALSE OPTIMISM' ABOUT RECOVERY
(Collusion in doctor-patient communication
about imminent
death: an ethnographic study)
http://bmj.com/cgi/content/full/321/7273/1376
Many cancer patients develop a "false optimism"
about their
recovery, as a result of collusion between
doctor and patient,
which allows them not to acknowledge the
long term
consequences of the illness, finds a study
in this week's BMJ.
Researchers in the Netherlands observed
35 patients with
untreatable small cell lung cancer, from
initial diagnosis to
their death, to explore the reasons why
virtually all these
patients showed a false optimism about
their recovery.
They found that, although doctors did not
withhold
information from patients, consultations
were almost entirely
restricted to discussing treatment activities,
such as planning
chemotherapy sessions and discussing test
results. Both
parties colluded in focusing on the short
term "treatment
calendar" and ignoring the long term prognosis,
say the
authors. This optimism helped patients
and their relatives to
endure the treatment phase but, in hindsight,
most of them
regretted this as it obstructed "saying
farewell" in time and
making necessary arrangements, add the
authors.
Breaking this cycle of collusion between
doctor and patient
requires an active, patient oriented approach
from the doctor,
say the authors. They conclude that solutions
have to be
found outside the doctor-patient relationship,
for instance by
involving "treatment brokers."
Contact:
Anne-Mei The, Institute for Research in
Extramural
Medicine, Amsterdam, Netherlands
Email: am.the.emgo@med.vu.nl
(3) SHORT TERM
PSYCHOLOGICAL THERAPY MORE
EFFECTIVE THAN GENERAL PRACTITIONER
CARE
FOR DEPRESSION
(Randomised controlled trial of non-directive
counselling,
cognitive-behaviour therapy, and
usual general practitioner
care for patients with depression.
I: Clinical effectiveness)
http://bmj.com/cgi/content/full/321/7273/1383
(Randomised controlled trial of non-directive
counselling,
cognitive-behaviour therapy, and
usual general practitioner
care for patients with depression.
II: Cost effectiveness)
http://bmj.com/cgi/content/full/321/7273/1389
Two studies in this week's BMJ show that
psychological
therapy is a more clinically and cost
effective treatment for
patients with depression than usual general
practitioner care in
the short term, but that these advantages
are lost after one
year.
King and colleagues identified 464 patients
attending general
practices in London and Manchester with
depression.
Patients were randomly divided into three
treatment groups ±
usual general practitioner care, up to
12 sessions of
psychological counselling or up to 12
sessions of
cognitive-behaviour therapy. Some patients,
who expressed a
strong preference, were allowed to choose
their treatment.
At four months, patients receiving counselling
or
cognitive-behaviour therapy showed less
depressive
symptoms than those receiving usual general
practitioner care.
Psychological therapies may also be more
cost effective, as
more benefit was gained with no significant
difference in cost
between the three treatment groups. However,
this advantage
was lost 12 months into the study, suggesting
that
psychological therapies were no more clinically
or cost
effective than usual care in the long
term.
Despite some limitations of the studies,
the authors conclude
that employing practice based counsellors
or behaviour
therapists may enable patients with moderately
severe
depression to recover faster. The findings
also suggest that
factors other than outcomes and costs
- such as staff and
patient preferences or staff availability
- should be considered
when deciding on services, they add.
Contact:
Michael King, Department of Psychiatry
and Behavioural
Sciences, Royal Free and University College
Medical
School, Royal Free Campus, London, UK
Email: m.king@rfc.ucl.ac.uk
(4) SHOULD DDT
FOR MALARIA CONTROL BE
BANNED?
(Doctoring malaria, badly: the global
campaign to ban DDT)
http://bmj.com/cgi/content/full/321/7273/1403
Malaria kills more than one million people
every year, yet the
United Nations Environment Programme will
meet in
Johannesburg next week to discuss phasing
out DDT, which
is still used by many countries to control
the mosquitoes that
spread malaria. A debate in this week's
BMJ considers the
merits of such a phase-out.
DDT should not be banned, argue malaria
specialists Amir
Attaran and Rajendra Maharaj. House spraying
with DDT is
an inexpensive, highly effective practice
against malaria and
has been approved by the World Health
Organisation. The
quantities used are minimal and results
in little harmful release
to the environment, they say.
Despite extensive scrutiny, there is still
no evidence that
exposure to DDT is a risk to human health,
they say.
Alternatives to house spraying are not
always possible,
particularly in African countries where
the health ministry's
budget may be less than £3 per person,
they add. Public
health benefits of DDT amply outweigh
its health risks ± if,
indeed, such risks exist at all, say the
authors. They believe
that the campaign to ban DDT is not only
wrong but
outrageously unethical.
Richard Liroff of the World Wildlife Fund
believes that the
solution lies in promotion of alternative
approaches to malaria
control, together with a slow phasing
out of DDT. Research
suggests that exposure to DDT early in
life might cause
harmful effects, and many alternatives
to DDT have already
been successfully used for controlling
malaria, he says.
The issue of mosquito resistance to alternative
chemicals may
be a dilemma for some countries, says
the author, so the
proposed phase-out suggests a series of
challenges that must
be addressed directly. These include financial
and technical
assistance from the developed world to
enable the poorest
countries to shift from DDT and investments
in researching
and implementing alternatives to DDT.
The author believes
that a properly constructed phase out
of DDT can produce a
"win-win" situation for environmental
health - achieving
protection from both malaria and DDT.
Contacts:
Amir Attaran, Center for International
Development, Harvard
University, Cambridge, USA
Email: amir_attaran@harvard.edu
Richard Liroff, World Wildlife Fund, Washington,
USA
Email: rich.liroff@wwfus.org
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