Antidepressants do relieve depression, some more effectively than others, according to new study

The Lancet has published a systematic review and network meta-analysis comparing the efficacy and acceptability of antidepressants in treating adults with a major depressive disorder.  
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The study compares and ranks antidepressants for the acute treatment of adults with unipolar major depressive disorder. It included unpublished data in addition to information from the 522 clinical trials involving the short-term treatment of acute depression in adults. The study found all of the antidepressants  were more effective than placebos, with their efficacy ranging from being a third more effective than a placebo to more than twice as effective. 
Summary 
Background Major depressive disorder is one of the most common, burdensome, and costly psychiatric disorders worldwide in adults. Pharmacological and non-pharmacological treatments are available; however, because of inadequate resources, antidepressants are used more frequently than psychological interventions. Prescription of these agents should be informed by the best available evidence. Therefore, we aimed to update and expand our previous work to compare and rank antidepressants for the acute treatment of adults with unipolar major depressive disorder.

Methods We did a systematic review and network meta-analysis. We searched Cochrane Central Register of Controlled Trials, CINAHL, Embase, LILACS database, MEDLINE, MEDLINE In-Process, PsycINFO, the websites of regulatory agencies, and international registers for published and unpublished, double-blind, randomised
controlled trials from their inception to Jan 8, 2016. We included placebo-controlled and head-to-head trials of 21 antidepressants used for the acute treatment of adults (greater than 18 years old and of both sexes) with major depressive disorder diagnosed according to standard operationalised criteria. We excluded quasi-randomised trials and trials that were incomplete or included 20% or more of participants with bipolar disorder, psychotic depression, or treatment-resistant depression; or patients with a serious concomitant medical illness. We extracted data following a predefined hierarchy. In network meta-analysis, we used group-level data. We assessed the studies’ risk of bias in accordance to the Cochrane Handbook for Systematic Reviews of Interventions, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. Primary outcomes were efficacy (response rate) and acceptability (treatment discontinuations due to any cause). We estimated summary odds ratios (ORs) using pairwise and network meta-analysis with random effects.

Findings We identified 28 552 citations and of these included 522 trials comprising 116 477 participants. In terms of efficacy, all antidepressants were more effective than placebo, with ORs ranging between 2·13 (95% credible interval [CrI] 1·89–2·41) for amitriptyline and 1·37 (1·16–1·63) for reboxetine. For acceptability, only agomelatine (OR 0·84, 95% CrI 0·72–0·97) and fluoxetine (0·88, 0·80–0·96) were associated with fewer dropouts than placebo, whereas
clomipramine was worse than placebo (1·30, 1·01–1·68). When all trials were considered, differences in ORs between antidepressants ranged from 1·15 to 1·55 for efficacy and from 0·64 to 0·83 for acceptability, with wide CrIs on most of the comparative analyses. In head-to-head studies, agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants (range of ORs 1·19–1·96), whereas fluoxetine, fluvoxamine, reboxetine, and trazodone were the least efficacious drugs (0·51–0·84). For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were more tolerable than other antidepressants (range of ORs 0·43–0·77), whereas amitriptyline, clomipramine, duloxetine, fluvoxamine, reboxetine, trazodone, and venlafaxine had the highest dropout rates (1·30–2·32). 46 (9%) of 522 trials were rated as high risk of bias, 380 (73%) trials as moderate, and 96 (18%) as low; and the certainty of evidence was moderate to very low.

Interpretation All antidepressants were more efficacious than placebo in adults with major depressive disorder. Smaller differences between active drugs were found when placebo-controlled trials were included in the analysis, whereas there was more variability in efficacy and acceptability in head-to-head trials. These results should serve evidence-based practice and inform patients, physicians, guideline developers, and policy makers on the relative merits of the different antidepressants.

The full text article can be downloaded from The Lancet here

Full reference:  Cipriani, A. et al |Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive
disorder: a systematic review and network meta-analysis| February 2018The Lancet | Published online| doi: http://dx.doi.org/10.1016/S0140-6736(17)32802-7

In the media: The Independent: Of course antidepressants work: They’ve saved my life several times
The GuardianThe drugs do work: antidepressants are effective, study shows

BBC News: Antidepressants: Major study finds they work 

Related: Mind Mind’s response to Lancet antidepressant study 

NICE Shared learning database

There are three new examples of good practice on NICE Shared Learning: workplace-1245776_1920

Obesity and diabetes both linked to caner

Diabetes and high BMI are leading causes of death and ill health globally and are on the increase in most countries. In 2014 9% of men and 8% of women worldwide had diabetes; 38.5% of men and 39.2% of women had high Body Mass Index (BMI), a figure equivalent to approximately 2 billion adults. 

A high BMI was responsible for almost twice as many cancers as diabetes. Over 5% of cancers worldwide were attributable to diabetes or high BMI in 2012, it is estimated that this proportion may increase by 25% by 2035 as a result of the global increase in obesity. 

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For countries such as the UK, an estimated 15% to 16% of cancers could be avoided by preventing diabetes, obesity or excess weight (defined as a BMI  greater than 25). A high BMI was responsible for almost twice as many cancers as diabetes.

Although the links between high BMI, diabetes and cancer have been known for some time, this study presents the first calculations of attributable risk for 175 countries. This represents the proportion of cancers that could be prevented if the risk factors were eliminated.  (The National Institute of Health Research NIHR)

The abstract is taken from NIHR

Abstract
Background
Diabetes and high body-mass index (BMI) are associated with increased risk of several cancers, and are increasing in prevalence in most countries. We estimated the cancer incidence attributable to diabetes and high BMI as individual risk factors and in combination, by country and sex.

Methods We estimated population attributable fractions for 12 cancers by age and sex for 175 countries in 2012. We defined high BMI as a BMI greater than or equal to 25 kg/m2. We used comprehensive prevalence estimates of diabetes and BMI categories in 2002, assuming a 10-year lag between exposure to diabetes or high BMI and incidence of cancer, combined with relative risks from published estimates, to quantify contribution of diabetes and high BMI to site-specific cancers, individually and combined as independent risk factors and in a conservative scenario in which we assumed full overlap of risk of diabetes and high BMI. We then used GLOBOCAN cancer incidence data to estimate the number of cancer cases attributable to the two risk factors. We also estimated the number of cancer cases in 2012 that were attributable to increases in the prevalence of diabetes and high BMI from 1980 to 2002. All analyses were done at individual country level and grouped by region for reporting.

Findings We estimated that 5·6% of all incident cancers in 2012 were attributable to the combined effects of diabetes and high BMI as independent risk factors, corresponding to 792 600 new cases. 187 600 (24·5%) of 766 000 cases of liver cancer and 121 700 (38·4%) of 317 000 cases of endometrial cancer were attributable to these risk factors. In the conservative scenario, about 4·5% (626 900 new cases) of all incident cancers assessed were attributable to diabetes and high BMI combined. Individually, high BMI (544 300 cases) was responsible for twice as many cancer cases as diabetes (280 100 cases). 26·1% of diabetes-related cancers (equating to 77 000 new cases) and 31·9% of high BMI-related cancers (174 040 new cases) were attributable to increases in the prevalence of these risk factors from 1980 to 2002.

Interpretation A substantial number of cancer cases are attributable to diabetes and high BMI. As the prevalence of these cancer risk factors increases, clinical and public health efforts should focus on identifying optimal preventive and screening measures for whole populations and individual patients.

Full reference:  Pearson-Stuttard, J. et al |Worldwide burden of cancer attributable to diabetes and high body mass index: a comparative risk assessment|The Lancet Diabetes & Endocrinology|2017

The article can downloaded from The Lancet here 

Poll of GPs reveals nearly a quarter have seen patients harmed due to the ‘winter crisis’

A  GPonline indicates that 25% of GPs have seen patients harmed by the NHS winter pressure. The survey of over 500 GPs said they were aware of at least one specific case in which a patient at their practice had come to harm because NHS services were overstretched this winter.  Respondents reported that some patients have died due to the extreme pressure on the health service. doctor-784329_1920

A third of GP partners were aware of patients registered at their practice who had come to harm because of winter pressure. More than 80% of all respondents said they were concerned that patients had been put at risk by pressure on the health service in their area this winter.

Further information and the full story is available from GPonline

Patients’ right to choose where to receive care

NHS Partners Network has issued an infographic to raise awareness of  patients’ legal rights when choosing where to receive their NHS care.

  • You have the right to choose where you receive NHS treatment.
  • The right t o be referred to a different hospital if the wait is more than 2 weeks to see a specialist for suspected cancer
  • The right to be referred to a different hospital if the wait is more than 18 weeks for non-urgent treatment.
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Image Source: NHS Confederation nhsconfed.org

 

NHS Confederation |You have the right to choose where you receive NHS treatment |February 2018

Long-term sustainability of the NHS and social care

Government response to the report on long-term sustainability of the NHS and adult social care | The Department of Health and Social Care  

This paper responds to the Lords Select Committee report stating that significant efficiencies will be needed to make the NHS and social care system sustainable for the long term.

The original report made 34 recommendations in the areas of:

  • service transformation
  • funding the NHS and adult social care
  • innovation technology and productivity
  • public health, prevention and patient responsibility
  • lasting political consensus

 

Full document: Government response to the Lords Select Committee report on Long-Term Sustainability of the NHS and Adult Social Care| The Department of Health and Social Care

 

Integrated care systems

Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England |  Chris Ham | The King’s Fund 

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NHS England has recently changed the name of accountable care systems to integrated care systems. In this updated long read, Chris Ham looks at work under way in these systems and at NHS England’s proposals for an accountable care organisation contract.

The article looks at the following:

  • Why is change needed?
  • What are integrated care and population health?
  • What’s happening with new care models?
  • What’s happening in integrated care systems?
  • What are ACOs and why are they controversial?
  • How are integrated care systems and partnerships developing?
  • What has this way of working achieved?
  • What do these developments mean for commissioning?
  • Are these developments really a way of making cuts?
  • Will these developments lead to privatisation?
  • Where next?

The author concludes that integrated care should be supported as it is the best hope for the NHS and its partners to provide services to meet the needs of the growing and ageing population.

Full article: Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England