Cognitive behavioural therapy for tinnitus.

BACKGROUND: This is an update of a Cochrane Review originally published in Issue 1, 2007 of The Cochrane Library.Tinnitus is an auditory perception that can be described as the experience of sound, in the ear or in the head, in the absence of external acoustic stimulation. Cognitive behavioural therapy (CBT) uses relaxation, cognitive restructuring of the thoughts and exposure to exacerbating situations in order to promote habituation and may benefit tinnitus patients, as may the treatment of associated psychological conditions. OBJECTIVES: To assess whether CBT is effective in the management of patients suffering from tinnitus. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; PsycINFO; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 6 May 2010. SELECTION CRITERIA: Randomised controlled trials in which patients with unilateral or bilateral tinnitus as their main symptom received cognitive behavioural treatment. DATA COLLECTION AND ANALYSIS: One review author (PMD) assessed every report identified by the search strategy. Three authors (PMD, AW and MT) assessed the methodological quality and applied inclusion/exclusion criteria. Two authors (PMD and RP) extracted data and conducted the meta-analysis. The four authors contributed to the final text of the review. MAIN RESULTS: Eight trials comprising 468 participants were included.For the primary outcome of subjective tinnitus loudness we found no evidence of a difference between CBT and no treatment or another intervention (yoga, education and 'minimal contact - education').In the secondary outcomes we found evidence that quality of life scores were improved in participants who had tinnitus when comparing CBT to no treatment or another intervention (education and 'minimal contact education'). We also found evidence that depression scores improved when comparing CBT to no treatment. We found no evidence of benefit in depression scores when comparing CBT to other treatments (yoga, education and 'minimal contact - education').There were no adverse/side effects reported in any trial. AUTHORS' CONCLUSIONS: In six studies we found no evidence of a significant difference in the subjective loudness of tinnitus.However, we found a significant improvement in depression score (in six studies) and quality of life (decrease of global tinnitus severity) in another five studies, suggesting that CBT has a positive effect on the management of tinnitus.

The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial.

BACKGROUND: Data from 12-week placebo-controlled trials have led to mounting concerns about increased mortality in patients with Alzheimer's disease (AD) who are prescribed antipsychotics; however, there are no mortality data from long-term placebo-controlled trials. We aimed to assess whether continued treatment with antipsychotics in people with AD is associated with an increased risk of mortality. METHODS: Between October, 2001, and December, 2004, patients with AD who resided in care facilities in the UK were enrolled into a randomised, placebo-controlled, parallel, two-group treatment discontinuation trial. Participants were randomly assigned to continue with their antipsychotic treatment (thioridazine, chlorpromazine, haloperidol, trifluoperazine, or risperidone) for 12 months or to switch their medication to an oral placebo. The primary outcome was mortality at 12 months. An additional follow-up telephone assessment was done to establish whether each participant was still alive 24 months after the enrollment of the last participant (range 24-54 months). Causes of death were obtained from death certificates. Analysis was by intention to treat (ITT) and modified intention to treat (mITT). This trial is registered with the Cochrane Central Registry of Controlled Trials/National Research Register, number ISRCTN33368770. FINDINGS: 165 patients were randomised (83 to continue antipsychotic treatment and 82 to placebo), of whom 128 (78%) started treatment (64 continued with their treatment and 64 received placebo). There was a reduction in survival in the patients who continued to receive antipsychotics compared with those who received placebo. Cumulative probability of survival during the 12 months was 70% (95% CI 58-80%) in the continue treatment group versus 77% (64-85%) in the placebo group for the mITT population. Kaplan-Meier estimates of mortality for the whole study period showed a significantly increased risk of mortality for patients who were allocated to continue antipsychotic treatment compared with those allocated to placebo (mITT log rank p=0.03; ITT p=0.02). The hazard ratio for the mITT group was 0.58 (95% CI 0.35 to 0.95) and 0.58 (0.36 to 0.92) for the ITT population. The more pronounced differences between groups during periods of follow up longer than 12 months were evident at specific timepoints (24-month survival 46%vs 71%; 36-month survival 30%vs 59%). INTERPRETATION: There is an increased long-term risk of mortality in patients with AD who are prescribed antipsychotic medication; these results further highlight the need to seek less harmful alternatives for the long-term treatment of neuropsychiatric symptoms in these patients. FUNDING: UK Alzheimer's Research Trust.

A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (the DART-AD trial).

BACKGROUND: There have been increasing concerns regarding the safety and efficacy of neuroleptics in people with dementia, but there are very few long-term trials to inform clinical practice. The aim of this study was to determine the impact of long-term treatment with neuroleptic agents upon global cognitive decline and neuropsychiatric symptoms in patients with Alzheimer disease. DESIGN: Randomised, blinded, placebo-controlled parallel two-group treatment discontinuation trial. SETTING: Oxfordshire, Newcastle and Gateshead, London and Edinburgh, United Kingdom. PARTICIPANTS: Patients currently prescribed the neuroleptics thioridazine, chlorpromazine, haloperidol trifluoperazine or risperidone for behavioural or psychiatric disturbance in dementia for at least 3 mo. INTERVENTIONS: Continue neuroleptic treatment for 12 mo or switch to an identical placebo. OUTCOME MEASURES: Primary outcome was total Severe Impairment Battery (SIB) score. Neuropsychiatric symptoms were evaluated with the Neuropsychiatric Inventory (NPI). RESULTS: 165 patients were randomised (83 to continue treatment and 82 to placebo, i.e., discontinue treatment), of whom 128 (78%) commenced treatment (64 continue/64 placebo). Of those, 26 were lost to follow-up (13 per arm), resulting in 51 patients per arm analysed for the primary outcome. There was no significant difference between the continue treatment and placebo groups in the estimated mean change in SIB scores between baseline and 6 mo; estimated mean difference in deterioration (favouring placebo) -0.4 (95% confidence interval [CI] -6.4 to 5.5), adjusted for baseline value (p = 0.9). For neuropsychiatric symptoms, there was no significant difference between the continue treatment and placebo groups (n = 56 and 53, respectively) in the estimated mean change in NPI scores between baseline and 6 mo; estimated mean difference in deterioration (favouring continue treatment) -2.4 (95% CI -8.2 to 3.5), adjusted for baseline value (p = 0.4). Both results became more pronounced at 12 mo. There was some evidence to suggest that those patients with initial NPI >/= 15 benefited on neuropsychiatric symptoms from continuing treatment. CONCLUSIONS: For most patients with AD, withdrawal of neuroleptics had no overall detrimental effect on functional and cognitive status. Neuroleptics may have some value in the maintenance treatment of more severe neuropsychiatric symptoms, but this benefit must be weighed against the side effects of therapy. TRIAL REGISTRATION: Cochrane Central Registry of Controlled Trials/National Research Register (#ISRCTN33368770).

Pain and deliberate self-harm: an important association.

OBJECTIVE: The aim of this study was to establish how often pain was a factor contributing to an episode of deliberate self-harm. METHOD: Retrospective case note examination of all deliberate self-harm patients with concurrent medical problems admitted to a general hospital over 2 years. RESULTS: Pain was considered to be a contributory factor in the episode of deliberate self-harm in 75 (4%) of the total number of episodes of deliberate self-harm (1665) over the 2-year period. These patients were older and had higher suicide intent scores, but lower rates of previous psychiatric illness or alcohol or drug misuse than did the deliberate self-harm patients with medical problems but no pain. Although 60% had experienced pain for more than 6 months only, 8 (12%) were attending the local Pain Clinic at the time of the deliberate self-harm. CONCLUSION: We propose closer collaboration between general hospital services and local pain clinics for deliberate self-harm patients with painful disorders. Clinicians need to assess suicidal ideation and risk of self-harm when prescribing for this population.