Monday 27 January 2014

Implementation of treatment guidelines in mental health care

During the past few decades, a wide range of therapies and interventions for mental health have been developed that have been supported by research and randomised evidence. This includes research evidence on the effectiveness of pharmacological treatments (such as antipsychotic drugs) and psychological therapies (such as cognitive behavioural therapy, family therapy and psychoeducation). However, research evidence is not easily translated into practice and the everyday working of healthcare services. A huge gap exists between the production of research evidence (what is known) and its uptake in healthcare settings (what is done). Better uptake of research evidence can be achieved by increasing awareness that such evidence exists.

One method of encouraging better uptake is the use of treatment guidelines based on assessments of research evidence. Treatment guidelines are now commonly employed in healthcare settings, including those providing treatment for schizophrenia. It remains unclear, however, whether treatment guidelines have any positive impact on the performance of mental health services or whether they improve outcomes for patients (such as better quality of life, improved mental state, employment and fewer admissions to hospital).

This review is based on a search carried out in March 2012 and includes five studies. The review examines the effectiveness of guideline implementation strategies in improving healthcare services and outcomes for people with mental illness. However, with such a small number of studies, and with all main results graded by review authors as providing very low quality evidence, it is not possible to arrive at concrete and definite conclusions. Although single studies provided initial evidence that implementation of treatment guidelines may achieve small changes in mental health practice, a gap in knowledge still exists about how this might improve patient outcomes and health services. This leaves scant information for people with mental health problems, health professionals and policy makers. More large-scale, well-designed and well-conducted studies are necessary to fill this gap in knowledge.

Trifluoperazine versus placebo for schizophrenia

Trifluoperazine (trade name Stelazine) is a long‐established antipsychotic drug that has been used since the 1950s to treat schizophrenia. It is one of the first generation (typical) drugs that have proven very effective for treating the ‘positive symptoms’ of schizophrenia, such as hearing voices, seeing things and having strange beliefs. These drugs may cause side effects such as involuntary shaking, restlessness and movement disorders such as having a strange posture.

There are also more modern drugs (second generation and atypical antipsychotic drugs). These are effective with the ‘positive symptoms’ of mental illness but also help treat ‘negative symptoms’ such as apathy, weight gain and loss of emotion in people with schizophrenia. These more modern drugs are much more expensive.

This review is based on a search for trials carried out in July 2012, and includes 10 studies with 686 participants. The aim was to determine the effects of trifluoperazine for schizophrenia when compared with placebo (a ‘dummy’ treatment). As expected, people given trifluoperazine showed a significant improvement compared to placebo in both the short and medium term, reinforcing the use of this well‐established typical antipsychotic for people with schizophrenia. However, trifluoperazine can cause side effects such as confusion, agitation, having a dry mouth and blurred vision, but causes less sedation and dizzy spells, so is generally well tolerated by people with schizophrenia.

The authors of the review conclude that trifluoperazine has similar effectiveness to other common antipsychotic drugs, although it may cause more side effects. Evidence used in the review was also graded as low or very low quality. In the light of this, use of other antipsychotic drugs should be considered before starting on trifluoperazine. Most of the included studies were conducted roughly 40 years ago so new, large, comprehensive and independent research trials are needed.

Supported employment for adults with severe mental illness.

People with mental health problems experience high rates of unemployment. There are various schemes delivering support to people with mental health problems who are trying to find employment. Supported employment tries to place people into competitive jobs. People are placed quickly in normal work settings where they receive intensive support and training from ‘job coaches’.

Individual placement and support (IPS) is a more specified scheme that includes: finding local jobs; a rapid job search; customer choice in what they want from the employment service; close working between employment and mental health teams; attention to people’s preferred job, their strengths and work experience; ongoing and, if necessary, long-term individual support; and the benefits of counselling. Employment specialists act to identify people’s job interests, assist with job finding, give job support and engage other support services. IPS uses assertive outreach to deliver training, advice and vocational support in the community. Augmented supported employment is where employment support is given with other supplementary techniques, such as social skills training, motivational classes and various types of rehabilitation. Other approaches are many and varied, including: job workshops; job counselling; peer support; partnerships with business; and the Clubhouse model, which involves training, work experience, peer support and transitional employment and IPS because they do not search for immediate and competitive employment. However, all approaches involve periods of preparation, education and on-the-job training.

This review compares supported employment and IPS with other approaches for finding employment. Drawing from a total of 2259 people with mental health problems in 14 studies, the review has two main findings: 1) Supported employment increases the length and time of people’s employment; 2) People on supported employment find jobs quicker. Supported employment and IPS are better than other approaches in these two respects, but there is limited information or measurable differences on other important issues for service users.

For example, there is little information on issues such as improving quality of life, impact on people’s mental health, days in hospital and costs. Furthermore, the review built its main findings on limited statistical evidence drawn mainly from studies carried out in North America and Europe. Future studies should address a fuller range of information and outcomes. Longer studies are needed to see how long the effects of supported employment last.

Tuesday 7 January 2014

Anticholinergic medication for excessive salivation caused by use of antipsychotics other than clozapine

The first line of treatment of schizophrenia is usually antipsychotic drugs. These drugs help in the treatment of the ‘positive symptoms’ of schizophrenia, such as hearing voices, seeing things and having strange beliefs. However, these drugs often have serious side effects, such as weight gain, muscle stiffness, tiredness, apathy and lack of drive. Dribbling or drooling (hypersalivation) is another common side effect, which frequently occurs at night when asleep. This can be an embarrassing and stigmatising problem that can affect quality of life and cause people to stop their medication, which may result in relapse and going back into hospital. Dribbling and drooling can be difficult to treat; however, anticholinergic drugs can decrease production of saliva and dribbling. This review assessed the evidence for the benefit or harm of anticholinergic drugs used in treating hypersalivation caused by antipsychotic or neuroleptic medication. The review excluded the antipsychotic clozapine, as its role in causing hypersalivation has been the subject of another Cochrane review.


The search was carried out 15 November 2012 and resulted in identification of four potential studies, but none could be included. Three of these were excluded because they involved clozapine-related hypersalivation. The fourth study was excluded because it involved people with mood or other mental disorders and Chinese medicines. Dribbling or hypersalivation is an important problem that needs to be investigated via well-designed research and randomised trials. Until such time, psychiatrists and patients are likely to continue their treatment of hypersalivation on the basis of daily clinical judgement and personal experience rather than hard evidence. Treatment of hypersalivation caused by antipsychotics or neuroleptics other than clozapine does not seem to have received adequate research attention to help guide practice. The review authors conclude that using anticholinergics to treat dribbling or hypersalivation caused by antipsychotic drugs other than clozapine cannot be justified without further study.