Interventions to improve management of anxiety disorders in general practice: a systematic review.
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ABSTRACT: Background
Anxiety disorders are common in general practice and are associated with several problems regarding recognition and management.Aim
To systematically evaluate the effectiveness of interventions aimed at improving recognition, diagnosis, and management of patients with anxiety disorders.Design of study
Systematic review.Method
MEDLINE, EMBASE, PsychINFO, and the Cochrane Clinical Trials' Register were searched up until 2003. Randomised controlled trials, controlled before/after trials, and interrupted time series for professional, organisational, financial, and regulatory interventions were eligible. Primary effect measures consisted of anxiety outcomes, diagnosis, prescription, and referral. Two reviewers independently made eligibility judgments: eight out of 563 articles were found to be eligible. Two reviewers participated independently in the quality assessment and data extraction process using a standardised form based on the Effective Practice and Organisation of Care checklist. Relative risks or standardised mean differences were calculated when possible.Results
Four professional interventions and three organisational interventions were examined. In general, the professional interventions seemed to increase recognition, referral, and prescription as well as improving anxiety outcomes. Two out of three organisational interventions showed a positive effect on anxiety outcomes. The one study that took prescription into account showed no effect.Conclusions
The quality of care for patients with anxiety can be improved. A combination of professional and organisational interventions in which an external expert is introduced seems to be most promising. Additional research is nevertheless necessary to determine the exact effects of such interventions using patient effect measures, economic evaluations, and feasibility studies.
SUBMITTER: Heideman J
PROVIDER: S-EPMC1570770 | biostudies-literature | 2005 Nov
REPOSITORIES: biostudies-literature
Publications
Interventions to improve management of anxiety disorders in general practice: a systematic review.
Heideman Jantien J van Rijswijk Eric E van Lin Nieke N de Loos Sandra S Laurant Miranda M Wensing Michel M van de Lisdonk Eloy E Grol Richard R
The British journal of general practice : the journal of the Royal College of General Practitioners 20051101 520
<h4>Background</h4>Anxiety disorders are common in general practice and are associated with several problems regarding recognition and management.<h4>Aim</h4>To systematically evaluate the effectiveness of interventions aimed at improving recognition, diagnosis, and management of patients with anxiety disorders.<h4>Design of study</h4>Systematic review.<h4>Method</h4>MEDLINE, EMBASE, PsychINFO, and the Cochrane Clinical Trials' Register were searched up until 2003. Randomised controlled trials, ...[more]
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| S-EPMC3464688 | biostudies-literature
Project description:BackgroundAsthma is a chronic disease requiring effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how and to what extent psychological theory has been applied to the development of digital interventions, or how using theory impacts outcomes.ObjectiveThe study aimed to examine the use and application of theory in the development of digital interventions to enhance asthma self-management and to evaluate the effectiveness of theory-based interventions in improving adherence, self-management, and clinical outcomes.MethodsElectronic databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched systematically using predetermined terms. Additional studies were identified by scanning references within relevant studies. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Full-text review was undertaken for relevant studies. Those meeting inclusion criteria were assessed for risk of bias using the Cochrane Collaboration tool. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study outcomes were classified as medication adherence, self-management, asthma control, clinical markers of health, quality of life, other quality of life outcomes, and health care utilization. Effectiveness was calculated as an average outcome score based on the study's reported significance. The Theory Coding Scheme (TCS) was used to establish the extent to which each intervention had applied theory and which theoretical constructs or behavioral determinants were addressed. Associations between TCS scores and asthma outcomes were described within a narrative synthesis.ResultsFourteen studies evaluating 14 different digital interventions were included in this review. The most commonly cited theories were Social Cognitive Theory, Health Belief Model, and Self-Efficacy Theory. A greater use of theory in the development of interventions was correlated with effective outcomes (r=.657; P=.01): only the 3 studies that met >60% of the different uses of theory assessed by the TCS were effective on all behavioral and clinical outcomes measured. None of the 11 studies that met ≤60% of the TCS criteria were fully effective; however, 3 interventions were partially effective (ie, the intervention had a significant impact on some, but not all, of the outcomes measured). Most studies lacked detail on the theoretical constructs and how they were applied to the development and application of the intervention.ConclusionsThese findings suggest that greater use of theory in the development and application of digital self-management interventions for asthma may increase their effectiveness. The application of theory alone may not be enough to yield a successful intervention, and other factors (eg, the context in which the intervention is used) should be considered. A systematic approach to the use of theory to guide the design, selection, and application of intervention techniques is needed.
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Project description:BackgroundAnxiety disorders are highly prevalent and cause significant distress, disability, and cost. Medication adverse effects and interactions increase in mid-life and late-life, highlighting the need for effective non-pharmacological interventions.ObjectivesWe aimed to evaluate the extent of evidence supporting exercise interventions for anxiety and subthreshold anxiety disorders in mid-life and late-life.DesignSystematic review.Data sources and methodsWe searched MEDLINE, PsycINFO, Embase, Emcare, Ovid Nursing, CINAHL Plus, Cochrane Library, Health Collection, Humanities & Social Sciences Collection, and https://clinicaltrials.gov databases for trials published January 1994-May 2019. Randomised controlled trials of exercise interventions involving aerobic exercise or resistance training for adults aged 40 years and above with anxiety or subthreshold anxiety disorders in residential or health settings were identified. The primary outcome was change in anxiety. We excluded trials including participants aged below 40 years, participants with diagnosis of separation anxiety, selective mutism, obsessive-compulsive disorder, acute stress disorder and post-traumatic stress disorder, and head-to-head comparisons of interventions. Trial quality was assessed using the Cochrane Risk of Bias Tool and evidence synthesised in narrative form.ResultsFour trials totalling 132 participants met inclusion criteria, although some had methodological limitations. Interventions included a home-based resistance training intervention, supervised group-based aerobic intervention, Tai Chi intervention, and supervised group-based aerobic and strength intervention. Three trials included late-life participants and the fourth mid-life. Three trials demonstrated greater reductions in anxiety in the intervention group compared with control. The fourth trial showed pre-post reductions in anxiety in both groups, with between-group difference not reaching statistical significance.ConclusionThere is limited supportive evidence suggesting that exercise interventions have potential to be effective, feasible and safe non-pharmacological interventions for anxiety and subthreshold anxiety disorders in mid-life and late-life. The heterogeneity, limited number and high risk of bias of some trials meant that we were not able to conduct a meta-analysis. Tailoring of interventions may improve uptake and reduce dropout. The paucity of research in this area with only four included trials demonstrates the urgent need for future and larger trials to provide proof of concept, data about effective types and doses of exercise interventions, and guidance to community, clinical, and public health services.
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Project description:Most atopic dermatitis (AD) patients are managed by primary care providers (PCPs). PCP discomfort diagnosing and managing AD leads to suboptimal patient outcomes. In order to determine the efficacy of interventions aimed at improving PCP management of AD, a systematic literature review was performed for interventions to improve primary care management of AD. PubMed, MEDLINE, Embase, Scopus, LILACS, Cochrane, GREAT, and CINAHL were searched from database origin to February 24, 2020. Two reviewers independently performed the title/abstract and full-text review, and data extraction. Overall, 3009 non-duplicate articles were screened; 145 full-text articles were assessed. Thirteen studies met inclusion criteria, including 8 randomized controlled trials, 2 cohorts, 2 qualitative studies, and 1 unspecified design. Seven interventions (53.8%) significantly improved PCP knowledge/ability and/or a patient outcome, including patients consulting with a dermatology-trained nurse, pairing clinical education with expert consultation, pairing trainees with clinical mentors, giving clinicians a treatment guide, pairing clinical education with a treatment guide, and providing an eczema action plan. Studies had moderate-high risk-of-bias, moderate quality, and heterogeneous designs. There are few studies published and little evidence supporting the efficacy of interventions aimed at improving primary care management of AD. Further research is required to develop and implement effective interventions to improve primary care management of AD.
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Project description:BACKGROUND: Over the past several decades, complementary and alternative medications have increasingly become a part of everyday treatment. With the rising cost of prescription medications and their production of unwanted side effects, patients are exploring herbal and other natural remedies for the management and treatment of psychological conditions. Psychological disorders are one of the most frequent conditions seen by clinicians, and often require a long-term regimen of prescription medications. Approximately 6.8 million Americans suffer from generalized anxiety disorder. Many also suffer from the spectrum of behavioural and physical side effects that often accompany its treatment. It is not surprising that there is universal interest in finding effective natural anxiolytic (anti-anxiety) treatments with a lower risk of adverse effects or withdrawal. METHODS: An electronic and manual search was performed through MEDLINE/PubMed and EBSCO. Articles were not discriminated by date of publication. Available clinical studies published in English that used human participants and examined the anxiolytic potential of dietary and herbal supplements were included. Data were extracted and compiled into tables that included the study design, sample population, intervention, control, length of treatment, outcomes, direction of evidence, and reported adverse events. RESULTS: A total of 24 studies that investigated five different CAM monotherapies and eight different combination treatments and involved 2619 participants met the inclusion criteria and were analyzed. There were 21 randomized controlled trials and three open-label, uncontrolled observational studies. Most studies involved patients who had been diagnosed with either an anxiety disorder or depression (n = 1786). However, eight studies used healthy volunteers (n = 877) who had normal levels of anxiety, were undergoing surgery, tested at the upper limit of the normal range of a trait anxiety scale, had adverse premenstrual symptoms or were peri-menopausal, reported anxiety and insomnia, or had one month or more of elevated generalized anxiety. Heterogeneity and the small number of studies for each supplement or combination therapy prevented a formal meta-analysis. Of the randomized controlled trials reviewed, 71% (15 out of 21) showed a positive direction of evidence. Any reported side effects were mild to moderate. CONCLUSIONS: Based on the available evidence, it appears that nutritional and herbal supplementation is an effective method for treating anxiety and anxiety-related conditions without the risk of serious side effects. There is the possibility that any positive effects seen could be due to a placebo effect, which may have a significant psychological impact on participants with mental disorders. However, based on this systematic review, strong evidence exists for the use of herbal supplements containing extracts of passionflower or kava and combinations of L-lysine and L-arginine as treatments for anxiety symptoms and disorders. Magnesium-containing supplements and other herbal combinations may hold promise, but more research is needed before these products can be recommended to patients. St. John's wort monotherapy has insufficient evidence for use as an effective anxiolytic treatment.
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Project description:BackgroundIn patients with immune-mediated inflammatory disorders, poor adherence to medication is associated with increased healthcare costs, decreased patient satisfaction, reduced quality of life and unfavorable treatment outcomes.ObjectiveTo determine the impact of different interventions on medication adherence in patients with immune-mediated inflammatory disorders.DesignSystematic review.Data sourcesMEDLINE, EMBASE and Cochrane Library.Study eligibility criteria for selecting studiesIncluded studies were clinical trials and observational studies in adult outpatients treated for psoriasis, Crohn's disease, ulcerative colitis, rheumatoid arthritis, spondyloarthritis, psoriatic arthritis or multiple sclerosis.Study appraisal and synthesis methodsIntervention approaches were classified into four categories: educational, behavioral, cognitive behavioral, and multicomponent interventions. The risk of bias/study limitations of each study was assessed using the GRADE system.ResultsFifteen studies (14 clinical trials and one observational study) met eligibility criteria and enrolled a total of 1958 patients. Forty percent of the studies (6/15) was conducted in patients with inflammatory bowel disease, half (7/15) in rheumatoid arthritis patients, one in psoriasis patients and one in multiple sclerosis patients. Seven out of 15 interventions were classified as multicomponent, four as educational, two as behavioral and two as cognitive behavioral. Nine studies, of which five were multicomponent interventions, had no serious limitations according to GRADE criteria. Nine out of 15 interventions showed an improvement of adherence: three multicomponent interventions in inflammatory bowel disease; one intervention of each category in rheumatoid arthritis; one multicomponent in psoriasis and one multicomponent in multiple sclerosis.ConclusionThe assessment of interventions designed for increasing medication adherence in IMID is rare in the literature and their methodological quality may be improved in upcoming studies. Nonetheless, multicomponent interventions showed the strongest evidence for promoting adherence in patients with IMID.
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Project description:BackgroundInternet-based interventions show clinical effectiveness for treating anxiety disorders and depression and could make mental healthcare more affordable.MethodsWe searched databases including PubMed; EMBASE; Cochrane Central; PsychINFO; CINAHL; EconLit; and Web of Science from January 1, 2000 to August 21, 2020. Inclusion criteria were: 1) pertained to the treatment or prevention of anxiety disorders or depression; 2) evaluated the use of an internet-delivered psychological intervention; 3) recruited participants; and 4) reported costs or cost-effectiveness.ResultsOf the 6,069 articles identified, 33 targeted anxiety (N=13) and depression (n=20) and met final inclusion criteria. All studies were from high-income countries. The control conditions and cost components included were heterogeneous. Only eight studies reported costs of developing the intervention. Of 27 studies that made a conclusion about cost-effectiveness, 81% of interventions were cost-effective. The quality of studies included was high based on a quality assessment checklist of economic evaluations, although many studies did not include definitions of cost components or differentiate between patient-side and system-level costs.LimitationsStudies varied in methodology, making conclusions about cost-effectiveness difficult. The generalizability of these results is unclear as studies were clustered in a small number of high-income countries and costs vary over time and between regions.ConclusionsInternet-delivered interventions appeared to be cost-effective although control conditions and cost component reporting were variable. We propose a checklist of cost components for future cost analyses to better compare intervention costs. More research is needed to describe development costs, cost-effectiveness in low-resource settings, and cost-effectiveness of newer technologies.
| S-EPMC8008508 | biostudies-literature
Project description:BackgroundAnxiety disorders are common, yet treatment options in general practice are often limited to medication or CBT. There is a lack of evidence for the effectiveness of exercise in the treatment of anxiety in patients who present to general practice and also about the intensity of exercise required to lead to improvement. The aim of this systematic review was to assess the use of exercise versus waiting list control groups in the treatment of anxiety and also to assess the benefit of high intensity exercise vs low intensity exercise. Long term follow up scores were also analysed. We included patients who met diagnostic criteria for anxiety disorders or had clinically raised anxiety levels on a validated rating scale and performed a subgroup analysis of the outcomes between the two groups. The intervention was any aerobic exercise programme carried out for at least two weeks, or exercise carried out at high intensity for at least two weeks. The comparison groups were either a waiting list control group or low intensity exercise.MethodSystematic review of randomised controlled trials. Three databases were searched; CENTRAL, Medline and Embase. Outcome assessment was based on validated anxiety rating scales. The quality of the studies was appraised according to the Cochrane Risk of Bias tool. Effect sizes were calculated using the standardised mean difference.ResultsFifteen studies were identified with a total of 675 patients. Nine trials had participants with diagnosed anxiety disorders and six trials had participants with raised anxiety on a validated rating scale. Aerobic exercise was effective in the treatment of raised anxiety compared to waiting list control groups (effect size - 0.41, 95% CI = - 0.70 to - 0.12). High intensity exercise programmes showed greater effects than low intensity programmes. There was no significant difference in outcomes between groups of patients with diagnosed anxiety disorders and patients who had raised anxiety on a rating scale. Conclusions were limited by the small number of studies and wide variation in the delivery of exercise interventions.ConclusionExercise programmes are a viable treatment option for the treatment of anxiety. High intensity exercise regimens were found to be more effective than low intensity regimens. The results have implications for the use of exercise schemes in General Practice.
| S-EPMC6048763 | biostudies-literature
Project description:Pharmacotherapy in older adults is one of the most challenging aspects of patient care. Older people are prone to drug-related problems such as adverse effects, ineffectiveness, underdosage, overdosage, and drug interactions. Anticholinergic medications are associated with poor outcomes in older patients, and there is no specific intervention strategy for reducing drug burden from anticholinergic activity medications. Little is known about the effectiveness of current interventions that may likely improve the anticholinergic prescribing practice in older adults. This review seeks to document all types of interventions aiming to reduce anticholinergic prescribing among older adults and assess the current evidence and quality of existing single and combined interventions. We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO from January 1990 to August 2021. Only studies that examined the effect of interventions in older people focused on improving compliance with anticholinergic prescribing guidelines with quantifiable data were included. The primary outcome of interest was to find the effectiveness of interventions that enhance the anticholinergic prescribing practice in older adults. We screened 3168 records and ended up in 23 studies that met the inclusion criteria. We found only single-component interventions to reduce anticholinergic prescribing errors in older people. Pharmacists implemented interventions without collaboration in nearly half of the studies (n = 11). Medication review (43%) and education provision (26%) to healthcare practitioners were the most common interventions. Sixteen studies (70%) reported significant reductions in anticholinergic prescribing errors, whereas seven studies (30%) showed no significant effect. This systematic review suggests that healthcare practitioner-oriented interventions have the potential to reduce the occurrence of anticholinergic prescribing errors in older people. Interventions were primarily effective in reducing the burden of anticholinergic medications and assisting with deprescribing anticholinergic medications in older adults.
| S-EPMC8836376 | biostudies-literature
Project description:BackgroundSupported asthma self-management improves health outcomes. However, people with limited health literacy, especially in lower-middle-income countries (LMICs), may need tailored interventions to enable them to realise the benefits. We aimed to assess the clinical effectiveness of asthma self-management interventions targeted at people with limited health literacy and to identify strategies associated with effective programmes.MethodsFollowing Cochrane methodology, we searched ten databases (January 1990 - June 2018; updated October 2019), without language restriction. We included controlled experimental studies whose interventions targeted health literacy to improve asthma self-management. Selection of papers, extraction of data and quality assessment were done independently by two reviewers. The primary outcomes were clinical (asthma control) and implementation (adoption/adherence to intervention). Analysis was narrative.ResultsWe screened 4318 titles and abstracts, reviewed 52 full-texts and included five trials. One trial was conducted in a LMIC. Risk of bias was low in one trial and high in the other four studies. Clinical outcomes were reported in two trials, both at high risk of bias: one of which reported a reduction in unscheduled care (number of visits in 6-month (SD); Intervention:0.9 (1.2) vs Control:1.8 (2.4), P?=?0.001); the other showed no effect. None reported uptake or adherence to the intervention. Behavioural change strategies typically focused on improving an individual's psychological and physical capacity to enact behaviour (eg, targeting asthma-related knowledge or comprehension). Only two interventions also targeted motivation; none sought to improve opportunity. Less than half of the interventions used specific self-management strategies (eg, written asthma action plan) with tailoring to limited health literacy status. Different approaches (eg, video-based and pictorial action plans) were used to provide education.ConclusionsThe paucity of studies and diversity of the interventions to support people with limited health literacy to self-manage their asthma meant that the impact on health outcomes remains unclear. Given the proportion of the global population who have limited health literacy skills, this is a research priority.Protocol registrationPROSPERO CRD 42018118974.
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