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Smoking cessation interventions for patients with depression: a systematic review and meta-analysis |
Gierisch JM, Bastian LA, Calhoun PS, McDuffie JR, Williams JW |
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CRD summary The authors concluded that there were several promising interventions, but the evidence was from small subgroup analyses. Patients with depression could stop smoking and should be offered behavioural mood management and nicotine replacement therapy. The authors' tentative conclusion reflects the evidence presented and seems to be reliable. Authors' objectives To evaluate the effects on abstinence rates, and the adverse events, of smoking cessation interventions for patients with depression, or a history of depression. Searching MEDLINE, EMBASE, PsycINFO, and The Cochrane Library were searched, to March 2010, for published studies in English. Search terms, including a filter for study design, were reported. The bibliographies of included studies were scanned for further articles. Study selection Eligible for inclusion were randomised controlled trials (RCTs), or secondary analyses of RCTs, that compared two or more patient-level smoking cessation interventions (alone or with co-treatments), or compared an intervention with usual care or placebo, in an out-patient setting. Co-treatments were defined as any smoking cessation intervention. Eligible patients were those aged 18 or older, with a history of depression, ongoing depression, or current significant depressive symptoms (diagnosed by a validated diagnostic tool). Trials of pregnant women were excluded. The outcomes of interest were smoking abstinence (point prevalence in the last seven days, or extended abstinence, since quit date), at least three months after randomisation, and the adverse effects associated with the intervention. All the included trials were conducted in the USA. There was little information on the included patients. The interventions varied, and included nicotine replacement therapy; antidepressants; behavioural mood management therapy; and behavioural counselling. Most included trials did not state current or recent depression as an inclusion criterion. Two reviewers independently selected the studies for inclusion. Assessment of study quality Trial quality was assessed using Agency for Healthcare Research and Quality criteria, covering adequacy of randomisation, allocation concealment, baseline comparability of groups, blinding, completeness of follow-up, differential loss to follow-up, treatment of incomplete data, and validity of outcome measures. Trials were rated as good, fair or poor quality. Two reviewers independently assessed quality. Disagreements were resolved by consensus, with the involvement of a third reviewer if necessary. Data extraction Data were extracted, where possible, to enable the calculation of risk ratios and 95% confidence intervals. It appears that one reviewer extracted the data, and the results were checked by a second reviewer. Disagreements were resolved by consensus, with the involvement of a third reviewer if necessary. Methods of synthesis Where possible, risk ratios were pooled in a random-effects (Mantel-Haenszel) meta-analysis. A narrative synthesis of the other results was presented. The results were grouped by intervention type. Statistical heterogeneity was assessed using Cochran's Q and Ι². Subgroup analyses were conducted to explore the differential effect of interventions, by depression status, gender, and whether treatments were delivered concurrently or sequentially. Results of the review Sixteen RCTs, with 3,553 patients (range 60 to 615) were included in the review. Ten trials were considered to be good quality. Six trials were conducted with depression status as an inclusion criterion; the other 10 were subgroups of trials, and these analyses were considered to be underpowered to detect clinically important treatment effects. Behavioural mood management plus co-treatment had significant favourable effects on smoking abstinence, compared with active control (RR 1.41, 95% CI 1.01 to 1.96; five RCTs; Ι²=0). The pooled risk ratio for antidepressants plus co-treatments, versus placebo plus co-treatments, did not show any statistically significant difference between groups (three RCTs; Ι²=0). The remaining trials were summarised in a narrative. Three of four nicotine replacement therapy trials showed positive effects on clinically significant abstinence (two were statistically significant). One trial of naltrexone and behavioural counselling showed improvements in cessation at six months, compared with placebo plus behavioural counselling; another trial showed no effect from exercise counselling to promote smoking cessation. Adverse effects were reported in five RCTs, three of which provided sufficient detail for antidepressants with co-treatments, and one for nicotine gum. Details were given in the full report. There was insufficient data to explore the moderating effects of depression status, gender, or intervention delivery sequencing. Authors' conclusions There were several promising interventions, but the evidence was from small subgroup analyses. Patients with depression could stop smoking and should be offered behavioural mood management and nicotine replacement therapy. CRD commentary The review question was broad, but the inclusion criteria were sufficiently detailed to enable replication. A range of relevant data sources were accessed, but restrictions in the search mean that trials might have been missed and publication and language bias cannot be ruled out. Steps were taken throughout the review process to minimise error and bias, and relevant quality assessment criteria were applied to the included trials. Trial details were presented, but these lacked patient characteristics, making the generalisability of the results uncertain. The two methods of synthesis seemed appropriate, based on the levels of heterogeneity. The authors drew attention to the limitations of their review, including its reliance on a few trials (some with small samples), most of which were subgroup analyses for patients with depressive symptoms or remote histories of depressive disorders. The authors' tentative conclusion reflects the evidence presented and seems to be reliable. Implications of the review for practice and research Practice: The authors stated that health care providers should encourage smokers with depression to accept smoking cessation services that include nicotine replacement therapy and behavioural mood management. Research: The authors stated that research should focus on direct comparisons of interventions likely to be effective, such as combinations with nicotine replacement therapy, specifically in patients with current depression. Trials should attempt to distinguish the elements of multi-component interventions that are effective, and assess the adverse effects of treatments. Funding Funding received from the Department of Veterans Affairs, USA. Bibliographic details Gierisch JM, Bastian LA, Calhoun PS, McDuffie JR, Williams JW. Smoking cessation interventions for patients with depression: a systematic review and meta-analysis. Journal of General Internal Medicine 2012; 27(3): 351-360 Other publications of related interest Gierisch JM, Bastian LA, Calhoun PS, McDuffie JR, Williams JW. Comparative effectiveness of smoking cessation treatments for patients with depression: a systematic review and meta-analysis of the evidence. Washington, DC, USA: Department of Veterans Affairs, Health Services Research and Development Service. Evidence-based Synthesis Program; 09-010. 2010. Indexing Status Subject indexing assigned by NLM MeSH Counseling; Depression /epidemiology; Health Promotion; Humans; Incidence; Smoking /adverse effects; Smoking Cessation /methods; United States /epidemiology AccessionNumber 12012024238 Date bibliographic record published 19/07/2012 Date abstract record published 16/02/2013 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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