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There has been recent debate regarding the efficacy of electroconvulsive therapy in the treatment of depression. This has been based on narrative reviews that contradict existing systematic reviews and meta-analyses. In this special article, we highlight the mistakes that occur when interpreting evidence using narrative reviews, as opposed to conventional systematic reviews and meta-analyses.
Recent evidence has questioned modern psychiatric clinical practice, specifically the prescribing of “atypical” antipsychotics. Our Pan-European Research Group wished to ascertain clinical practice amongst European trainees, which treatments trainees would desire for themselves, and factors influencing this.
A semi-structured survey was constructed from prior literature, piloted, and a homogenous sample size of at least 50 was agreed upon from each country, with 50% minimum response rate. It was distributed via web-link, with questions on preference of antipsychotic for patients in given scenarios, and factors influencing choice. Physicians were asked for their preference should they develop psychosis.
i) Treatment choice of antipsychotic for patients
93% (n=600) of respondents chose to prescribe “atypical” antipsychotics (excluding Clozapine), 6% (n=42) choosing “typical” antipsychotics, 1% (n=6) choosing Clozapine as first-line therapy.
ii) Treatment choice if trainees developed psychosis
89% (n=530) of responders chose to prescribe “atypical” antipsychotics (excluding Clozapine), 7% (n=40) choosing “typical” antipsychotics, 4% (n=23) choosing Clozapine as first-line therapy.
iii) Factors influencing choice
These mapped onto three domains: cost, efficacy and side-effect profile (less than 5% other reasons). 79% (n=458) of those who responded felt efficacy most important, 46% (n=270) felt side-effect profile most important and 3% (n=16) considered cost of paramount importance.
38% (n=272) of those who responded to the survey stated that the CATIE trial had influenced their decision-making.
Psychiatry trainees’ choice of antipsychotic medication for both patients and themselves is based on perceived benefits, as opposed to evidence base and recent literature.
Guidelines produced for management of Bipolar Disorder illustrate change in evidence-base for treatment of acute and maintenance phases of illness. Our Pan-European Research Group assessed clinical practice and desired treatments amongst amongst Psychiatry trainees.
A semi-structured survey was piloted, and homogenous sample size (at least 50) agreed upon from each country, with 50% minimum response rate. It was distributed via web-link, questioning preference of mood stabiliser for patients, trainees themselves and factors influencing choice.
Tables 1 summarise choices.
Lithium and Sodium Valproate
2nd Generation Atypical antipsychotics
[Choice of mood stabiliser for patient/themselves]
Factors influencing decision-making mapped onto cost, efficacy and side-effect profile (less than 4% other reasons). 66% (n=538) of respondents felt efficacy most important, 25% (n=202) felt side-effect profile most important and 3% (n=24) considered cost of most importance.
No clear difference exists in choice of mood stabiliser for European trainees and their patients, and decisions based on perceived efficacy are generally in keeping with established guidelines.
The European Federation of Psychiatric Trainees (EFPT), a trainee-led organisation, encompassing official representatives from 24 countries, set up a research group to foster trainee-led collaborative research, emphasising training and clinical practice.
The first survey of the group assessed trainees’ treatment choices for patients and themselves, across psychiatric disorders, in addition to factors influencing decision-making and guideline use.
A web-based survey was piloted, and distributed to 16 European countries. For validity, a 50% response rate from a homogenous sample, with sample size 50 or more was required,
12 countries met inclusion criteria.
(a) Antipsychotic choice and factors influencing decision-making
93% (n=600) of respondents chose to prescribe 2nd Generation atypical antipsychotics for patients, and 89% (n=530) chose this treatment for themselves. 79% (n=458) of respondents felt efficacy was the most important factor influencing decision-making.
(b) Mood stabiliser choice and factors influencing decision-making 41% (n=263) of trainees chose to prescribe lithium to patients, with 35% (n=224) stating they would wish to receive this themselves. 66% (n=538) of respondents felt perceived efficacy was the most important factor influencing decision-making.
(c) Antidepressant choice and factors influencing decision-making 75% (n-461) of trainees would prescribe SSRIs to patients with a moderate depressive episode, 78% (n=438) wishing to receive SSRIs themselves. 67% (n=523) of respondents felt efficacy to be the most important determining facor.
Trainees are able to provide clinically-relevant research through trainee networks, and a number of decisions governing treatment do not appear to be based on current evidence.
Alcoholism has a high prevalence and impacts on morbidity, mortality, life quality, and the economy. Heritability estimates of alcohol dependence are 50-61%. Putative psychological, cultural, and genetic susceptibilities to alcoholism have been identified but understanding of the genetic components is still underdeveloped.
Identify genetic vulnerabilities predisposing individuals to alcoholism and co-morbid psychiatric disorders in the largest study of its kind.
12 centres including 10 trainees are currently collecting blood and clinical samples. Nearly 1700 of 2000 cases of ICD-10/DSM-IV alcohol dependence have been collected; 500 with standardized assessments of alcohol use and comorbdity; and 2000 ancestrally-matched supernormal controls from UCL/collaborators. Genomic DNA will be isolated following standard procedures. Genotyping will be performed using the Affymetrix Gene Chip Human Mapping 1M Array to type up to 1 million single nucleotide polymorphism (SNP) and copy number variant (CNV) markers. Chi-square analysis of allelic association for the alcoholic sample versus controls will occur.
n=65; 57% male; mean age 45years; mean age onset harmful alcohol use 19years; mean age onset withdrawals 32y; mean alcohol intake 21 units; primary depression 27%; secondary depression 49%; antisocial personality disorder 14%. The candidate gene approach in this sample has shown that the GABA receptor B1 (GABRB1) and the tachykinin receptor 1 (TACR1) are involved in genetic susceptibility to alcoholism. The D2 dopamine receptor is next.
Preliminary data suggests high psychiatric comorbidity in a clinical alcohol dependence sample and implicated candidate genes. Next is genomewide analysis of markers, sequencing and biological pathway/systems alterations.
There is growing concern about the influence of the pharmaceutical industry on psychiatric teaching and psychiatric professionalism as a whole. As a consequence, several national and international medical and psychiatric associations have issued guidelines to regulate the interactions between physicians and industry.
The EFPT-PRIRS study aims to provide the lacking data on the extent and nature of these interactions among psychiatric trainees across Europe.
Study objectives were determined by the EFPT research group (EFPT-RG), after discussion with national and international experts. A survey was then devised compiling previously published questionnaires extending them by questions with specific relevance to psychiatric trainees. The resulting questionnaire was piloted amongst members of the EFPT-RG, modified accordingly and subsequently distributed to the national study coordinators. All 24 EFPT member countries were invited to participate in the study and data collection is currently ongoing.
Preliminary analysis reveals the vast differences in industry - trainee relationships across European countries as well as major differences in personal attitudes towards these interactions.
EFPT-PRIRS will potentially have an impact on the regulation of the interactions between the pharmaceutical industry and psychiatric trainees.
Despite recent recent evidence and subsequent guidelines that have suggested factors such as side-effect profile and cost should be taken into account when prescribing antidepressant medication, relatively little evidence exists on decision-making in clinical practice.
Our Pan-European Research Group looked at clinical practice regarding antidepressants amongst Psychiatry trainees, treatments trainees would desire themselves, and factors influencing decision-making.
A semi-structured survey was constructed from recent literature, was piloted, and a homogenous sample size of at least 50 agreed upon from each country, with 50% the minimum response rate. It was distributed via web-link, questioning preference of antidepressant for patients, and factors influencing choice. Trainees were asked for their preference should they develop a moderate to severe depressive episode, and require medication.
Treatment choices are summarised in Table 1. 79% of trainees would prescribe similar antidepressants for themselves as for patients.
Factors influencing decision-making mapped onto three main domains: cost, efficacy and side-effect profile (5% other reasons). 86% (n = 548) of those who responded felt efficacy most important, 38% (n = 237) felt side-effect profile most important and 6% (n = 33) considered cost of most importance.
Some differences exist in choice of antidepressant for European trainees and their patients, and factors affecting choice conflict with evidence base and guideline suggestions.
There is no doubt that, in the modern era, psychiatry and the pharmaceutical industry have a relationship, though the nature of this is not universally well defined. Given that psychotropic medication is widely prescribed (ranking 3rd and 4th in US sales in 2007), and the role of the pharmaceutical industry in medical education has come under scrutiny, it is worth noting that the relationship between the industry and psychiatry trainees has not been studied in great depth.
Our Pan-European research group, composed exclusively of psychiatry trainees from at least 18 different countries, as part of the European Federation of Psychiatric Trainees (EFPT) has sought to study this in a systematic fashion. I will present preliminary findings of our survey, PRIRS (Psychiatric Residents-Industry Relationship Survey) which is currently taking place.
It is also hoped that this will facilitate a discussion amongst those attending the session, on the role of the pharmaceutical industry in psychiatric training, education and in general.
In the last decades, psychiatric training has undergone a major transformation due to the contribution of recent scientific developments in psychiatry. Nowadays, the information acquired during the Psychiatric training seems considerably variable in content and quality between different countries. However, data concerning access to information and also about the educational resources available to the trainees in Europe is very limited.
Objectives and aims
The ATIIPT survey aimed to evaluate Psychiatric trainees’ access to published, online, senior's or industry's information in Europe.
A short paper questionnaire constituted of 7 questions (Appendix 1) was created by the members of the EFPT Research Working Group and passed to each delegate of the 32 countries represented at the 19th EFPT Forum in Prague, Czech Republic, on the 2nd of July 2011.
According to the ATIIPT results, access to information among Psychiatric trainees in Europe is heterogeneous. The most available resources are books and websites, and the most preferable resource is journals. Most of the trainees find their resources sufficient, with the main obstacles being related to low availability of journals and books, lack of time and help from seniors.
Better access to information and more evidence in practice is warranted, since the introduction of novel approaches to access to information may create better psychiatrists in the future, encourage medical students to consider psychiatry as a potential career, and help reduce negative attitudes towards mental illness.
The influence of pharmaceutical industry (PI) on clinical practice and research in psychiatry has been considered a serious problem. Strict rules and guidelines were developed to regulate the interactions between doctors and PI. However, there is an ongoing debate whether these were thoroughly implemented in practice and internalized by physicians. The objective of our study was to assess the attitudes and behaviors of trainees in psychiatry and child & adolescent psychiatry toward PI across Europe. Methodologically, a validated questionnaire with additional items was administered to1444 trainees in 20 European countries. The minimum response rate was set at 60%. We found a high variation across countries in number of interactions between trainees and PI representatives; Portugal and Turkey had the highest number of interactions. The majority (59.76%) agreed that interactions with PI representatives have an impact on physicians’ prescribing behavior; whereas only 29.26% and 19.79% agreed interactions with PI representatives and gifts from PI have impact on their own prescribing behavior, respectively. Most of the gifts were considered appropriate by the majority, except tickets to vacation spot and social dinner at a restaurant. Of the sample, 70.76% think they have not been given sufficient training regarding how to interact with PI representatives. Only less than 20% indicated they have guidelines at institutional or national level. In conclusion, there is substantial interaction between trainees and PI across countries. The majority feel inadequately trained regarding professional interaction with PI, and believes they are immune to the influence of PI.
Modern technology and globalization dramatically changed our perception of how research in psychiatry should be done. On one hand, research topics in modern psychiatry considerably broadened over the years, and opportunities for collaboration as well as dissemination of results dramatically increased. On the other hand, research in psychiatry has become highly demanding, requiring the use of the most modern methodologies, large numbers of participants and fast publications of the results in highly competitive journals. Inevitably, it has become very costly in terms of time, money and human resources.
These changes brought more opportunities for research to the new generations of European early career psychiatrists. Nevertheless, they also increased the inequality in opportunities for research among them, due to relative centralization of the most “exclusive” psychiatric research sites. Indeed, the majority of European early career psychiatrists miss real opportunities to get involved in research due to a lack of mentorship, psychiatric research groups and research facilities in their countries.
Within this scenario, choosing the right kind of research for early career psychiatrists might be confusing and somewhat discouraging. To support the involvement of young colleagues in research, the Early Career Psychiatrists Committee has formed the Task Force on Research. We will present several projects run by our task force, each relying on a different approach of research in psychiatry. We think that the proposed approaches would be useful for early career psychiatrists, since they take into account both the strengths and limitations inherent to the role/position of early career psychiatrists.
Interactions between the pharmaceutical industry (PI) and psychiatrists have been under scrutiny recently, though there is little empirical evidence on the nature of the relationship and its intensity at psychiatry trainee level. We therefore studied the level of PI interactions and the underlying beliefs and attitudes in a large sample of European psychiatric trainees.
One thousand four hundred and forty-four psychiatric trainees in 20 European countries were assessed cross-sectionally, with a 62-item questionnaire.
The total number of PI interactions in the preceding two months varied between countries, with least interactions in The Netherlands (M (Mean) = 0.92, SD = 1.44, range = 0–12) and most in Portugal (M = 19.06, SD = 17.44, range = 0–100). Trainees were more likely to believe that PI interactions have no impact on their own prescribing behaviour than that of other physicians (M = 3.30, SD = 1.26 vs. M = 2.39, SD = 1.06 on a 5-point Likert scale: 1 “completely disagree” to 5 “completely agree”). Assigning an educational role to the pharmaceutical industry was associated with more interactions and higher gift value (IRR (incidence rate ratio) = 1.21, 95%CI = 1.12–1.30 and OR = 1.18, 95%CI = 1.02–1.37).
There are frequent interactions between European psychiatric trainees and the PI, with significant variation between countries. We identified several factors affecting this interaction, including attribution of an educational role to the PI. Creating alternative educational opportunities and specific training dedicated to PI interactions may therefore help to reduce the impact of the PI on psychiatric training.
The association between cigarette smoking and psychosis remains unexplained, but could relate to causal effects in both directions, confounding by socioeconomic factors, such as ethnicity, or use of other substances, including cannabis. Few studies have evaluated the association between cigarettes and psychotic experiences (PEs) in diverse, inner-city populations, or relationships with number of cigarettes consumed.
We assessed associations and dose–response relationships between cigarette smoking and PEs in a cross-sectional survey of household residents (n = 1680) in South East London, using logistic regression to adjust for cannabis use, other illicit substances, and socioeconomic factors, including ethnicity.
We found association between any PEs and daily cigarette smoking, which remained following adjustment for age, gender, ethnicity, cannabis and use of illicit stimulant drugs (fully adjusted odds ratio 1.47, 95% confidence interval 1.01–2.15). Fully adjusted estimates for the association, and with number of PEs, increased with number of cigarettes smoked daily, implying a dose–response effect (p = 0.001 and <0.001, respectively). Odds of reporting any PEs in ex-smokers were similar to never-smokers.
In this diverse epidemiological sample, association between smoking and PEs was not explained by confounders such as cannabis or illicit drugs. Daily cigarette consumption showed a dose–response relationship with the odds of reporting PEs, and of reporting a greater number of PEs. There was no difference in odds of reporting PEs between ex-smokers and never-smokers, raising the possibility that the increase in PEs associated with smoking may be reversible.