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Press releases Saturday 21 July 2007

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(1) New analysis puts cot death under scrutiny once again

(2) New study challenges NICE guidelines on adolescent depression

(3) Is GP boycott of e-health records justified?

(1) New analysis puts cot death under scrutiny once again
(Uncertainty in classification of repeat sudden unexpected infant deaths in Care of the Next Infant Programme)
http://www.bmj.com/cgi/content/short/335/7611/129

An analysis published in this week's BMJ is set to re-open the debate over sudden unexpected infant death (cot death).

The Lancet recently published a study on repeat infant deaths in 46 families, which suggested that almost 90% of second deaths in the same family are natural.

These findings contrasted with earlier studies, which found a much higher proportion of repeat cot deaths were probably homicide. Yet the Lancet study has proved very influential, being accepted by bodies such as the American Academy of Pediatrics.

In December 2006, the BMJ questioned the way these deaths were classified in the study.

Today the BMJ publishes a re-analysis of the data by two senior (now retired) paediatricians, Christopher Bacon and Edmund Hey. They reviewed the 46 second deaths in the original study to see how many might reasonably be regarded as undetermined.

They suggest that, in the three families in the original study in which both deaths were attributed to specific natural causes, one death should be regarded as undetermined.

In 18 families in the original study, both deaths were attributed to sudden infant death syndrome. The authors stated that all these families were at high risk of cot death and that the second deaths exhibited many untoward features, such as violent family relationships, pathology findings suggestive of asphyxia, and parental mental health problems.

Although Bacon and Hey do not suggest that violence in the family, for example, necessarily implies that a baby's death was unnatural, they believe that when a family has two unexplained deaths this possibility at least has to be considered and may sometimes be true. They therefore estimate that a third of these deaths might be classed as undetermined.

For 13 families in the study, information on the second death was incomplete. The original authors classified all these cases as natural, though they acknowledged that the information was insufficient to enable them to distinguish between sudden infant death syndrome and a specific natural cause.

But Bacon and Hey argue that it seems illogical to exclude covert homicide when there is not enough information to exclude a specific natural cause. They categorise all 13 cases as undetermined.

There were six further cases that could not be reviewed because the Lancet paper gave no details about them.

Overall, the re-analysis of these second deaths categorises 13% as probably unnatural, 43% as probably natural (although this includes the six cases they could not review) and 43% as undetermined. This contrasts with the original study that 87% of the deaths were natural, but is closer to the findings of previous studies that suggested about two fifths of repeat deaths probably resulted from homicide.

Bacon and Hey stress that their purpose is not to second guess the original authors, but they argue that using a dichotomy of natural or unnatural is unhelpful and more likely to be erroneous. They acknowledge the paper's value in helping to avert unjustified suspicion of parents, but they are concerned that it may also lead to mistakes in child protection.

Uncertainty may be uncomfortable, they add, but it is truer to reality, more conducive to scientific inquiry, and safer for children than a dogmatic stance at either pole.

"We would encourage professionals to keep an open mind in assessing unexplained infant deaths, to be aware of the difficulties in diagnosis, and to try to keep a balance between the need to support parents and the need to protect children," they conclude.

Contacts:
Contact: Christopher Bacon, retired paediatrician, North Yorkshire, UK
Email: Chrisjbacon@googlemail.com  

(2) New study challenges NICE guidelines on adolescent depression
(Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial)
http://www.bmj.com/cgi/content/short/335/7611/142
(Editorial: Depression in adolescents)
http://www.bmj.com/cgi/content/short/335/7611/106

Should adolescents with depression be prescribed antidepressants, and if so, should they be given only with a psychological therapy, as advocated by the National Institute for Health and Clinical Excellence (NICE)?

A study published on bmj.com last month found that adding cognitive behaviour therapy (CBT) to selective serotonin reuptake inhibitor (SSRI) treatment is unlikely to improve outcomes for adolescents with moderate to severe depression.

These findings challenge current NICE guidelines that recommend SSRIs be prescribed only in conjunction with psychological therapies.

In an editorial in this week's BMJ, a child psychiatry expert reviews the evidence and explains what this means for clinicians managing adolescents with depression.

This is the fourth study to assess the combination of SSRI and cognitive behaviour therapy over monotherapy for depression in adolescents, writes Professor Philip Hazell from the University of Sydney.

A US study published in 2004 found that the combination of fluoxetine and cognitive behaviour therapy was better than fluoxetine or behaviour therapy alone in reducing depressive symptoms.

However, a more recent trial in 2006 found no advantage of sertraline plus cognitive behaviour therapy over monotherapy. A third trial published in 2005 also found that the addition of cognitive behaviour therapy to SSRIs had no significant effect on symptoms of depression.

The results of the BMJ trial suggest a further trend away from the positive findings of the US trial, says Professor Hazell. Differences in the dose and duration of treatment may have contributed to some variation, but the data suggest that combining cognitive behaviour therapy with an SSRI has only a modest advantage over an SSRI alone.

Combining cognitive behaviour therapy with and SSRI may have other advantages, such as reducing suicidal thoughts and prolonging the benefit of treatment, he says, but evidence for this across the four trials is equivocal.

So what does this mean for clinicians managing adolescents with depression, he asks?

Contrary to NICE guidelines, evidence suggests that monotherapy with an SSRI is a reasonable treatment option for moderate to severe depression in adolescents, particularly if access to cognitive behaviour therapy may be delayed, he writes.

He adds that trial participants received a high level of clinical care, with frequent clinical reviews and rigorous monitoring of the benefit of treatment and adverse events. The implication for clinical practice is that good quality drug treatment involves more than simply writing the prescription, he concludes.

Contact:
Philip Hazell, Conjoint professor of child and adolescent psychiatry, University of Sydney, Thomas Walker Hospital, NSW, Australia
Email: Philip.Hazell@sswahs.nsw.gov.au  

(3) Is GP boycott of e-health records justified?
(Personal View: For patients' sake, don't boycott e-health records)
http://www.bmj.com/cgi/content/short/335/7611/158

An article in this week's BMJ questions the boycott of summary care records by GPs.

The NHS information and technology programme is the largest civilian IT programme in the world. One of its main features is a nationally accessible summary of patients' records.

Marlene Winfield, National Patient Lead at NHS Connecting for Health (the agency responsible for delivering the programme) argues that, as a patient, she wants to be able to see her own records and asks: are the risks of the summary care record great enough to justify a wholesale boycott by GPs acting on my behalf?

The new record has two main purposes: to provide the NHS with crucial patient information when none is available from other sources, and to give people themselves access to a good summary of their health records whenever they need it.

For me as a patient this means that anyone I ask to help me at evenings and weekends will know basic information about me, she says. This is particularly important now that GPs no longer provide their own out of hours cover.

She appreciates that GPs may be worried about confidentiality, but she also expects, as other patients do, that important information will be shared with others who need it to give care. And she points out that patients will have a range of options, from participating fully to not at all, and can change their minds at any time.

All of medicine is a balance of risks, she says, and risk needs to be weighed against the known risks to patients of poor information sharing.

GPs worry, too, about information being shared that is not accurate, but she argues that the best way to prevent inaccuracy is by giving patients access to the information so that they can check it.

"I don't want my doctors taking all the responsibility for my healthcare and keeping all the information to themselves," she writes.

Research also shows that true collaboration produces better outcomes for both patients and the NHS than paternalism. "It is precisely why I went to work for NHS Connecting for Health, she concludes."

Contact:
Marlene Winfield, National Patient Lead, NHS Connecting for Health, London, UK
Email: marlene.winfield@nhs.net  

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