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In this the eleventh article of the SOCRATES series we present our synopses of reviews from the Cochrane Database of Systematic Reviews relating to counselling, psychology, and psychiatry that the working party felt were of particular relevance to emergency medicine practitioners. The methods of our review and the rationale for the forming the SOCRATES working party are as have previously been published.
BRIEF PSYCHOLOGICAL INTERVENTIONS (“DEBRIEFING”) FOR TRAUMA RELATED SYMPTOMS AND PREVENTION OF POST TRAUMATIC STRESS DISORDER
Twenty five per cent of those involved in a road traffic accident have a defined psychiatric disorder one year later, with up to 11% displaying post-traumatic stress disorder (PTSD). Debriefing involves emotional processing by encouraging recollection of the traumatic event. The objective of this review was to assess the effectiveness of a single session of debriefing in the reduction and prevention of psychological morbidity after traumatic events.
A total of 8 randomised trials were identified involving over 600 patients. The studies covered violent crime, burns, road traffic accidents, and spontaneous miscarriage. The populations were somewhat heterogeneous. Outcomes included PTSD, anxiety, and depression. Overall there was a tendency towards an adverse outcome with the intervention.
Brief psychological intervention for the prevention of trauma related psychological morbidity has not been shown to be beneficial and is potentially harmful.
PHYSICIAN ADVICE FOR SMOKING CESSATION
There is evidence from some randomised trials to suggest that advice from motivated physicians can be effective in facilitating smoking cessation. From a public health perspective, even if effectiveness is small, large numbers of physicians providing advice will have a significant net effect. In the emergency department large numbers of patients are encountered who may have no other healthcare intervention and thus present a significant opportunity for smoking cessation advice. The objective of this review was to determine the effectiveness of advice from medical practitioners in promoting smoking cessation.
A total of 31 trials involving over 26 000 smokers were included. Minimal intervention versus no advice revealed a small but significant increase in cessation rate of about 2.5%. Additional manoeuvres appear to have only a small effect. The reviewer, however, defined minimal intervention as trials where advice was provided (with or without a leaflet) during a single consultation lasting less than 20 minutes and up to one follow up visit. This will be impractical in most emergency departments.
This review failed to establish whether there is any role for brief advice on smoking cessation as part of a normal emergency department consultation.
NURSING INTERVENTIONS FOR SMOKING CESSATION
Seventy per cent of smokers visit a healthcare professional each year—the majority of these are nurse orientated. Ninety per cent of smokers want to stop smoking. There is evidence of the effectiveness of physician advice to stop smoking, but the evidence for non-physician advice is less robust. This review was undertaken to determine the effectiveness of nurse delivered smoking cessation interventions.
The review included a total of 19 studies. Of these, 15 demonstrated a significant increase in rate of smoking cessation. There was no evidence that “intensive” intervention was more effective than less intensive, however a low intensity intervention was defined as advice provided during a single consultation lasting 10 minutes or less, with up to one follow up visit.
There is evidence to show that nurse delivered smoking cessation advice can be beneficial. It is unclear whether advice of even low intensity defined in the review could be easily incorporated into current emergency department nursing practice.
PSYCHOSOCIAL AND PHARMACOLOGICAL TREATMENTS FOR DELIBERATE SELF HARM
A history of deliberate self harm (DSH) is the best predictor of eventual suicide. About 40 to 50% of people who commit suicide have previous episodes of DSH. The objective of this systematic review was to identify all randomised control trials of treatments following DSH, and to compare the effects of specific treatments and standard types of aftercare or control treatments for DSH. The main outcome measure was the rate of repeated DSH within a follow up period of two years.
Twenty three studies were identified with a total number of 3014 randomised participants and outcome data were available on 2832 with respect to repetition of DSH. In the five studies addressing problem solving therapy versus standard aftercare there was reduced repetition in the experimental groups but the summary odds ratio of 0.70 (95% CI 0.45 to 1.11) was not statistically significant. In studies of intensive intervention plus outreach versus standard aftercare there was no consistent direction of effect.
In the two studies addressing the question of emergency card (patients in the experimental group were given an emergency contact card which gave them either access to a psychiatrist 24 hours per day or the right of self admission to hospital) versus standard aftercare there was a trend towards less repetition of DSH in the experimental group but the summary odds ratio of 0.45 (95% CI 0.19 to 1.07) was not significant.
In the study of dialectical behaviour therapy (this is similar to cognitive behavioural therapy and is very intensive, involving weekly group and individual therapy for one year and 24-hour access to the therapist) versus standard aftercare there was a significantly lower rate of repetition of DSH in the experimental group (odds ratio 0.24; 95% CI 0.06 to 0.93). In studies of same therapist versus different therapist the repetition rate was significantly higher in those seeing the same person for aftercare compared to those who had a change of clinician (odds ratio 3.70; 95% CI 1.13 to 12.09). The one study relating to general hospital admission versus discharge did not indicate a beneficial effect of general hospital admission following DSH (odds ratio 0.75; 95% CI 0.16 to 3.60).
In one trial of flupentixol versus placebo there was a significant reduction of DSH in patients receiving flupentixol (odds ratio 0.09; 95% CI 0.02 to 0.50). In three studies of antidepressants (where the antidepressants used were mianserin, nomifensine, or paroxetine) compared with placebo the pooled odds ratio for the three studies indicated no apparent reduction in repetition of DSH in the experimental groups (odds ratio 0.83; 95% CI 0.47 to 1.48).
In a study of long term versus short term therapy there was no indication that long term therapy was more effective in reducing repetition of DSH (odds ratio 1.0; 95% CI 0.35 to 2.86). In the single study of home based family therapy versus standard aftercare the odds ratio did not show a beneficial effect of family therapy (odds ratio 1.02; 95% CI 0.41 to 2.51).
This systematic review reveals that there is insufficient evidence on which to make firm recommendations about the treatment of patients who engage in DSH.
In this article we have reviewed the Cochrane database of clinical reviews relating to emergency medicine with regards to counselling, psychology, and psychiatry. We hope that our synopsis of the Cochrane reviews applicable to emergency services has helped to further disseminate some of the invaluable information available in the Cochrane Database of Systematic Reviews.
We would like to thank Dr R Hardern and the staff of the Postgraduate Medical Library at the General Infirmary at Leeds for their support and technical advice in the preparation of this paper.
Competing interests: none declared