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Complementary and alternative treatments for late-life depression, anxiety, and sleep disturbance: a review of randomized controlled trials |
Meeks T W, Wetherell J L, Irwin M R, Redwine L S, Jeste D V |
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CRD summary The review concluded that some well-conducted studies suggested potential effectiveness for certain complementary and alternative medicine interventions for sleep disturbance and anxiety in non-demented older adults . However, owing to substantial methodological limitations, more rigorous research is required. Consequently, the authors' cautious conclusions correctly reflect the poor-quality studies on this topic. Authors' objectives To evaluate complementary and alternative medicine (CAM) interventions for the treatment of depression, anxiety and sleep disturbance in non-demented older adults. Searching PubMed (from 1966) and PsycINFO (from 1984) were searched to September 2006; the search terms were reported. The bibliographies of retrieved articles were also screened for relevant studies. Only studies reported in English were eligible for inclusion. Study selection Randomised controlled trials (RCTs) comparing CAM with a control group were eligible for inclusion. To be included, studies had to have a sample size of 30 or more, with participants aged over 60 years with no dementia or cognitive disorder, and a duration of 2 or more weeks. They also had to have at least one primary outcome that assessed mood, depression, anxiety, sleep, or a combination of these. Studies of cognitive-behavioural therapy and repetitive transcranial magnetic stimulation were excluded. Studies assessing participants who were classified as 'healthy' or 'normal' (e.g. prevention trials) were also excluded. The most common CAM interventions in the included studies were categorised as mind-body, biologically-based, energy-based and body-based/manipulative treatments; they were compared with a wide variety of comparators. The duration of the studies ranged from 2 to 52 weeks (mean 9.5). The mean age of the participants was 70.5 years (range: 61 to 82). The outcomes in the included studies were assessed by a wide variety of standard instruments.
The authors did not state how the papers were selected for the review, or how many reviewers performed the selection. Assessment of study quality Validity was assessed using a modified version of the Scale for Assessing Scientific Quality of Investigations (SASQI) , with a maximum possible score of 20. The scale evaluated research design, experimental treatment condition, participants and measures, statistical analysis and discussion.
One author assessed all studies for validity, while a second author evaluated a random selection of 10 studies, blinded to the first author's ratings. Data extraction CAM treatments were categorised on the basis of the National Center for Complementary and Alternative Medicine's organisational scheme. The studies were rated as 'positive' or 'negative' for CAM therapy outcomes. 'Positive' was defined as CAM therapy being significantly more effective (p<0.05) than an inactive or active control group on at least one outcome related to sleep, depression or anxiety.
The authors did not state how many reviewers performed the data extraction. Methods of synthesis The studies were combined in a narrative, with further data being reported in the tables. The studies were grouped by CAM treatment category, symptoms assessed, country where study conducted, sample size, treatment duration and mean sample age. Results of the review Thirty-three RCTs (n=2,210) were included in the review.
The SASQI-CAM mean score was 10.3 (indicating modest methodological quality) and scores ranged from 5 to 17 points. The mean SASQI for negative studies was higher than for positive studies: 12.3 versus 9.2. Many methodological details were poorly reported.
Twenty-two RCTs (n=1,400; 67% of studies) were rated as positive. The proportion of studies reported as positive categorised according to CAM treatment varied widely: mind-body (83%, 10 out of 12 RCTs), biologically-based (44%, 4 out of 9 RCTs), energy-based (56%, 5 out of 9 RCTs) and body-based/manipulative (100%, all 3 RCTs). Seventy-seven per cent (13 out of 17 RCTs) of positive CAM studies targeted sleep disturbances and 59% (10 out of 17 RCTs) targeted depression and/or anxiety were. Studies rated as negative tended to have slightly higher sample sizes and treatment duration than positive-rated studies. Authors' conclusions Some well-conducted studies suggested potential therapeutic effectiveness for certain CAM interventions for sleep disturbance and anxiety in older non-demented adults. However, as the majority of the included studies had substantial methodological limitations, more rigorous research is required. CRD commentary Inclusion criteria were clear in terms of the intervention, participants, outcomes and study design. Only two databases were searched for studies published in English and no attempts were made to locate unpublished studies, thus raising the possibility of language and publication bias. The methods used to select the studies were not described and those used to extract the data were only partially described, so it is not known whether any efforts were made to reduce reviewer error and bias. Validity was assessed using published criteria but, since the validity assessment was only conducted in duplicate for a small selection of studies, there may be the potential for error and bias in the analysis. A narrative synthesis was appropriate given the between-study differences. The authors appropriately highlight methodological limitations and differences across the studies. Consequently, the authors' cautious conclusions correctly reflect the poor-quality studies on this topic. Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors stated that further well-conducted studies of CAM therapies among older non-demented adults with psychological problems is needed. In addition, studies should examine mediating variables including cognition and health beliefs and the use of flexible, but reproducible, protocols where individualised treatment is a core component of CAM therapy. Future research should also use systematic psychiatric diagnoses and clear symptom thresholds for inclusion criteria and have clear reporting of financial support and possible conflicts of interest. Funding National Institute of Mental Health, grant numbers MHQ19934 and MH66248; Department of Veterans Affairs, San Diego, California. Bibliographic details Meeks T W, Wetherell J L, Irwin M R, Redwine L S, Jeste D V. Complementary and alternative treatments for late-life depression, anxiety, and sleep disturbance: a review of randomized controlled trials. Journal of Clinical Psychiatry 2007; 68(10): 1461-1471 Indexing Status Subject indexing assigned by NLM MeSH Anxiety Disorders /diagnosis /psychology /therapy; Complementary Therapies /methods; Depressive Disorder, Major /diagnosis /psychology /therapy; Humans; Randomized Controlled Trials as Topic; Sleep Wake Disorders /diagnosis /psychology /therapy AccessionNumber 12007003987 Date bibliographic record published 09/08/2008 Date abstract record published 01/12/2008 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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