entire issue. - The Royal New Zealand College of General ...

More documents

Recommendations

Info

BACk TO BACk are not safer than long half-life benzodiazepines. Hip fracture risk is highest during the first two weeks after starting a benzodiazepine. Those older people that just want something in the shortterm as a result of a recent stress are at highest risk of hip fracture from your prescriptions. Even with a reasonably high NNT, hip fracture is a devastating event. Less than 50% of those with hip fracture regain pre-fracture function and 20% die within 12 months after hip fracture. In a large group of cognitively normal Canadians, the frequency of falls was 60% greater in benzodiazepine users compared to non-users. Our own Professor John Campbell successfully reduced the risk of falls to 18% (an NNT to cause a fall of 2), in an RCT of older people on benzodiazepines, by reducing the dose of benzodiazepine gradually over six months and continuing a placebo tablet. Unfortunately after unblinding, half of the older people in the intervention group returned to the GP to get their prescription successfully renewed! Systematic reviews also identified that chronic consumers of benzodiazepines are more susceptible to the appearance and progression of many acute and chronic diseases (infectious and malignant diseases). The risk of using this medication usually far outweighs the benefits and use should be restricted to those with moderate to severe anxiety disorders. Are they needed for insomnia? Benzodiazepines do improve sleep; however more patients receiving benzodiazepines reported adverse effects, especially daytime drowsiness and dizziness or light-headedness (common odds ratio 1.8, 95% CI 1.4 to 2.4) compared with other sleep treatments. Cognitive function decline including memory impairment was reported in several of the studies and Zopiclone was not found to be superior to benzodiazepines on any of the outcome measures examined. A large systematic review compared sleep pharmacotreatments. Benzodiazepines were no better than non-benzodiazepines in reducing time to sleep. All drug groups had a statistically significant higher risk of harm compared to placebo, but benzodiazepines had the highest risk difference. Non-pharmacological treatment for insomnia is very effective. When identified accurately, primary insomnia responds best to sleep restriction techniques and medications are seldom needed for those in late life. If it is not primary insomnia then an underlying disorder, such as pain, depression or restless leg syndrome should be sought and appropriate treatment started. Can we stop them? It is relatively easy to encourage stopping benzodiazepines. A simple letter to patients using these drugs may be effective in reducing useage. Recognised tapering protocols are available and reasonably successful. Older people sleep less and relaxation and sleep hygiene along with sleep restriction can be very successful in improving satisfaction with sleep. Take it slow and make sure the older person wants to stop. So don’t be persuaded by the Professor. We are currently using too many benzodiazepines in older people and exposing them to unacceptable risk associated with their use. We are definitely NOT under-prescribing benzodiazepines for older people. References 1. Kerse N. Medication use in residential care. NZ Fam Phys 2005;32:251–5. 2. Peri K, Kerse N, Kiata L, Wilkinson T, Robinson E, Parsons J, et al. Promoting independence in residential care: Successful recruitment for a randomised controlled trial. JAMDA. 2007:doi10.1016/j.jamda.2007.11.008. 3. Australian Institute of Health and Welfare. General practice activity in Australia 2004-05. Canberra: AIHW; 2005. 4. Browne MO, Wells J, Scott K. Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health; 2006. 5. Bushnell J, McLeod D, Dowell A, Salmond C, Ramage S, Collings S, et al. The treatment of common mental health problems in general practice. Fam Pract 2006;23(1):53–9. 6. Mathew VM, Dursun SM, Reveley MA. Increased aggressive, violent, and impulsive behaviour in patients during chronic-prolonged benzodiazepine use. Can J Psychiatr - Revue Canadienne de Psychiatrie 2000 Feb;45(1):89–90. 7. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Int Med 2003;163:2716–24. 8. Takkouche B, Montes-Martinez A, Gill SS, Etminan M. Psychotropic medications and the risk of fracture: a metaanalysis. Drug Safety 2007;30(2):171–84. (Further references available from: n.kerse@auckland.ac.nz) 60 VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE
Patient Oriented Evidence that Matters Psychological interventions reduce onset of depression CLiNiCAL qUEsTiON: Do behavioural interventions reduce the risk of new onset depression? BOTTOM LiNE: Behavioural interventions to prevent depression reduce the incidence of newly diagnosed depression. Most of the studies included in this report were of cognitive behavioural therapy interventions in group format for individuals at increased risk for major depression. (LOE=1a-) REfERENCE: Cuijpers P, van Straten A, Smit F, Mihalopoulos C. Beekman A. Preventing the onset of depressive distorders: A meta-analytic review of psychological interventions. Am J Psychiatry 2008;165(10):1272–1280. sTUdy dEsigN: Meta-analysis (randomised controlled trials) fUNdiNg: Unknown/not stated ALLOCATiON: Concealed sETTiNg: Various (meta-analysis) syNOPsis: This is a meta-analysis of randomised trials to prevent depression using behavioural interventions. The primary outcome was incident cases of depression. Because the length of the studies varied, the incidence rates were calculated by the authors in person-years. A total of 19 studies with 5806 participants met inclusion criteria, one of which tested three different preventive interventions, for a total of 21 comparisons. Seven studies were about preventing postpartum depression, and the rest included various other targets, such as school and primary care settings. There were three types of prevention; universal (two), selective programmes aimed at high-risk groups (11), and prevention aimed at individuals with depressive symptoms who do not meet the criteria for a diagnosis of major depression (eight). The majority of interventions were cognitive behavioural therapy (15). Group format was used in 18 comparisons. The incidence ratio of new depression per person-year was 0.78 (95% CI, 0.65–0.93), indicating a reduction of the incidence of depressive disorders by 22% in the intervention groups compared with control groups. The authors calculated the number needed to treat as 22. © 1995–2009 John Wiley & Sons Inc. All Rights Reserved. www.infopoems.com CONTiNUiNg PROfEssiONAL dEVELOPMENT CBT is effective for self-harm CLiNiCAL qUEsTiON: Is cognitive behavioural therapy an effective treatment for self-harm? BOTTOM LiNE: A brief series of cognitive behavioural therapy (CBT) sessions reduces the risk of self-harm and improves a number of other important psychological outcomes. (LOE=1b-) REfERENCE: Slee N, Garnefski N, van der Leeden R, Arensman E, Spinhoven P. Cognitive-behavioural intervention for self-harm: randomised controlled trial. Br J Psych 2008;192:202–211. sTUdy dEsigN: Randomised controlled trial (nonblinded) fUNdiNg: Government sETTiNg: Outpatient (specialty) ALLOCATiON: Concealed POEMs syNOPsis: Self-harm is a poorly studied but psychologically devastating condition. In this study, 90 patients in the Netherlands with a recent history of self-harm were randomised to either CBT or treatment as usual. Of the 48 patients assigned to CBT, only 40 began the therapy but all 40 attended all 12 sessions (the first 10 were weekly). Eight of 42 patients in the treatment-as-usual group were lost to follow-up because of suicide, severe psychological problems, or other reasons. Analysis was by modified intention to treat; the patients who did not begin the CBT were excluded. Patients were between the ages of 15 years and 35 years, and more than 90% were women. At nine months, the number of self-harm episodes in the previous three months declined more in the CBT group, from 14.4 to 1.2, compared with a decline from 11.6 to 4.6 in the usual treatment group (P < .05). Secondary outcomes (depression, anxiety, self-esteem, helplessness, problem-solving, unlovability, and poor distress tolerance) all improved significantly more in the CBT group. VOLUME 1 • NUMBER 1 • MARCH 2009 J OURNAL OF PRIMARY HEALTH CARE 61
Page 1:
OF PRIMARY HEALTH CARE ‘It is pos
Page 4 and 5:
EDITORIALs FROM THE EDiTOR Felicity
Page 6 and 7:
EDITORIALs FROM THE EDiTOR editor.
Page 8 and 9:
EDITORIALs GUEsT EDiTORiAL Barry S
Page 10 and 11:
EDITORIALs GUEsT EDiTORiAL cial int
Page 12 and 13: EDITORIALs GUEsT EDiTORiAL depressi
Page 14 and 15: ORIGINAL SCIENTIFIC PAPERS qUANTITA
Page 32 and 33: ORIGINAL SCIENTIFIC PAPERS MIXED ME
Page 38 and 39: ORIGINAL SCIENTIFIC PAPERS SYSTEMAT
Page 52 and 53: iMPROViNg PERfORMANCE 1 Harbour Hea
Page 54 and 55: iMPROViNg PERfORMANCE Figure 1. Pri
Page 56 and 57: iMPROViNg PERfORMANCE Patient comme
Page 58 and 59: iMPROViNg PERfORMANCE ACkNOwLEDgEME
Page 60 and 61: BACk TO BACk fewer/no falls? He cho
Page 64 and 65: CONTiNUiNg PROfEssiONAL dEVELOPMENT
Page 74 and 75: EtHiCs unknown, and to manage the p
Page 76 and 77: EssAYs sub-threshold mental health
Page 78 and 79: EssAYs training for psychological t
Page 80 and 81: EssAYs Resonance Imaging (MRI) anal
Page 82 and 83: LETTERS TO THE EDITOR Vignette from
Page 84 and 85: BOOK REVIEWS The Baby Business: Wha
Page 86 and 87: BOOK REVIEWS Review by Ms Helen Rid
Page 88 and 89: RESEARCH GEMS GemS Of NeW ZeAlAND p
Page 90: JOURNAL OF pRIMARy HEALTH CARE The
show all

entire issue. - The Royal New Zealand College of General ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?