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Twitter Journal Club is (as the name may suggest) a Twitter-based journal club. We meet fortnightly on Sunday nights at 8pm UK time (7pm GMT) to discuss & critique a variety of medical papers.
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1. This study uses an unorthodox set of methods to arrive at its conclusions. Is the methodology sound enough to give us adequately robust results?
2. This study is limited to one country; how applicable are the results to other countries and cultures?
3. Do the results of this study indicate a greater need for education amongst journalists, and more stringent guidelines on reporting suicides?
4. What might be the reasons behind the protective effect of articles about suicidal ideation where suicide was not attempted? Does this indicate a potential role for the media in public education on this matter?
5. In what way do the results of this study have implications for other forms of media?
This study by Niederkrotenthaler at al., published in the British Journal of Psychiatry, examines the role media content on suicide has in suicidal behaviour in the public, both increase and decrease in suicide rates, and the effect of different types of article.
The current evidence suggests that the media does play a role, with an increase in suicides reported following reports in the media, showing a dose-response relationship between the quantity of reporting and subsequent suicides. Furthermore, the increase in suicide rate is greatest in areas where a higher proportion of the population is exposed to such media reports. This copy-cat behaviour is referred to as the Werther effect, and while not as large as other psychosocial risk factors, does play a role in an individual’s likelihood of taking their own life.
The study looked at 497 suicide reports in the Austrian media in the first half of 2005, and looked for associations between specific characteristics of reports, and subsequent short-term changes in suicide rates. (In addition to the Werther effect, the team refer to any post-reporting reduction in suicide rates as the “Papageno” effect, in reference to Mozart’s The Magic Flute.)
I won’t go into great detail here about the different characteristics of reports that were used, since these can all be found in the methods section of the paper. Briefly, however, they assessed the content of the articles, the extent of the reporting, and the article’s prominence, and coded these semi-quantitatively by noting the absence or presence of a number of attributes. The characteristics of the article’s content (such as “describing the suicide method in the headline”) were generated using guidelines for media reporting of suicide produced by the WHO and a number of other national agencies.
The authors found that suicide rates increased with quantity of reporting, though prominence of the articles was not associated with more suicides. Where the reported method of suicide was jumping, this correlated with an increase in suicide rates (r=0.15, P=0.001), but there was no significant relationship for other methods (NB: suicides by jumping are more likely to be reported by the print media than any other method). Furthermore, dichotomous thinking in the report, reference to multiple suicides and/or a suicide ‘epidemic’, and reporting on myths that surround suicide, were all associated with an increase in suicides in the population. Articles which discussed increasing societal problems as a cause of suicide were also more likely to result in increased suicide rates.
The only characteristic to be associated with reduced suicide rates was that of articles focusing on suicidal ideation (e.g. an aborted suicide; considering suicide but not going through with it). Yet articles which focused on suicide research, reported on expert opinion, or gave contact details for support services (e.g. Samaritans) seemed to cause an increase in suicides, although the authors found that these attributes were likely to be found in media reports that contained unfavourable, sensationalist comments.
The idea that certain types of reporting raise suicide rates does not seem surprising to me. The concept of triggering is well known, and as I understand it, is a bit like the straw that broke the camels back. People who are vulnerable, show suicidal ideation and suicidal urges, may read an article about suicide and be strongly influenced by it. In some instances, it may trigger an individual to attempt suicide. Another example of this is self-help forums on the internet that discuss either suicide or self-harm (by which I mean self-destructive behaviours without suicidal intent). These are full of posts with “**trigger**” in the title, to alert users to potentially upsetting, or “triggering”, content. (Just Google “suicide triggering” to see what I mean.)
But why does reporting instances of suicidal ideation reduce suicide rates? The authors suggest that such articles highlight the reported outcome as “going on living”. I would add that such articles perhaps point out to individuals with suicidal ideation that they are not alone, and that the subsequent reduction in feelings of isolation may play a role. Articles that raise awareness of mental illness can also be beneficial, as discussed in the middle paragraphs of this article (yes, I like cricket and I am biased!).
The key limitations of the study that I could identify (and most of which the authors also identlfied) are as follows:
- Only print media was analysed. Although a large proportion of the population is exposed to the print media, this research fails to take into account influences from e.g. film / television and the Internet.
- Limited geographic area.
- I’m not an expert on stats, but some of their methods seem very complicated to me. Can anyone who knows a bit more explain whether the methods used are solid and reliable or not? There do seem to be a fair few attempts at validation, and the authors report “high intersubjective analytic consensus”.
- No causality, only correlation, and consequently large potential for confounding factors.
- Study only looked at 6 months of print media, while suicide rates are known to differ seasonally.
The role of the media in all things medical is important, but this example of suicide rates is, I feel, particularly worthy of discussion, since the outcomes are so evident and tragic. I look forward to this week’s #TwitJC on Sunday evening (8pm UK time; 7pm GMT) and hope it will be both interesting and thought provoking.
Samaritans UK guidelines on reporting suicide.
Media Wise link to an extensive selection of articles and reports on suicide reporting.
This Wired blog looks at copycat suicides, and how the increased prevalence of a new method put first responders at risk.
Press Complaints Commission – Editors’ Code of Practice (See section 5.ii) for mention of suicide)
Mind guidelines on reporting on mental health and suicide.
Finally, if you, or someone you know, is feeling suicidal, do talk to someone; either someone you know and trust, your GP, or Samaritans on 08457 909090. (Although strictly speaking, based on what I’ve just written, I probably shouldn’t have included that sentence.)
EDIT: Added link to PCC Code of Practice and Mind guidelines.
The paper for this Sunday’s Twitter Journal Club (21st August 2011):
Cohen et al., (2011) Prevention of HIV-1 Infection with Early Antiretroviral Therapy, NEJM - Link here
Welcome to the new Twitter Journal Club website!
All of the pre-existing content has been kept (all the posts and comments have been transferred), and we’ve kept the structure of the site largely the same. The main differences are that we have our own URL and it looks a bit more shiny.
However, since we are now running on wordpress.org rather than wordpress.com, it gives us a fair bit more flexibility with what we can do with the site. As such, it would be great if people could suggest features that they would like to see for the site, and if possible, we will try and implement them where possible. (Feel free to add your suggestions as comments to this post).
Also, if you haven’t yet, please could you complete this survey so we have an idea of which areas of medicine people are most interested in.
Finally, a massive thanks to everyone who has supported #TwitJC over the last couple of months: proof-reading posts, suggesting papers, offering ideas for improvements, and taking part in discussions. We really do appreciate it.
Anyone who enjoyed the discussion on Rose’s Prevention Paradox back in June may find Barton et al’s paper in the BMJ this week interesting. The study aimed to model the cost-effectiveness of population-wide risk-reduction strategies in preventing cardiovascular disease (CVD). Currently, CVD costs the NHS around £30bn each year and this study has been devised to inform the Department of Health via NICE.
While previous studies have already shown that anti-smoking and anti-salt campaigns are cost effective in reducing CVD incidence, this new studies also looked at the effect of other dietary approaches such as trans-fats and saturated fats. Outcomes were measured using mortality figures, life years and QALYs, though the emphasis was on cost savings to the NHS from cases prevented or postponed. A key limitation was the assumption that interventions would result in equal benefit across age groups and socioeconomic groups, and while consideration was made for changes in risk of CVD following the patient’s first event, none was made for subsequent events. The model also did not consider individuals over the age of eighty.
As we would expect from Rose’s theory, a small change in individuals was found to result in a large financial saving to the NHS as well as improved health in the population. This model found that a 1% reduction in the risk of cardiovascular events would save the NHS £30m each year and prevent 25,000 cases of CVD. Furthermore, a reduction in cholesterol concentrations or blood pressure levels of 5% was modelled as saving the NHS between £80m and £100m a year, while lowering mean salt intake from 8.5g to 5.5g would result in around 30,000 fewer cardiovascular events, with savings worth at least £40m a year. The authors also argue that the nature of their model means the calculations are conservative, and the true savings may be worth even more.
The points for this evening are as follows:
- Does the single-centre design mean that there are too few physicians being surveyed? Does it limit the range of viewpoints and practices that are examined?
- If most patients spoke to their doctor for at least five minutes about PCI, why did 88% still believe it would reduce their risk of MI?
- Why would 43% of cardiologists who identified no benefit in PCI in a hypothetical scenario proceed with it anyway?
- What can doctors do differently to communicate the benefits of treatment with their patients?
- With regards to the consent form, does this paper raise questions about the nature of informed consent?
Percutaneous Coronary Intervention (PCI) is a surgery in which obstruction in a stenotic coronary artery is cleared either by balloon angioplasty or stenting. It is a very common procedure, with a 2006 American Heart Association report estimating 1.2 million procedures in 2003 in the US.
PCI is not generally effective in reducing numbers of myocardial infarctions (MI) or mortality in patients with chronic stable angina, but rather only improves quality of life. (This is according to a number of randomised trials and meta-analyses, most notably the highly-publicised COURAGE trial.) Conversely, PCI can be effective in reducing morbidity and mortality in unstable angina.
This study looked at 153 patients who were undergoing diagnostic cardiac catheterisation, but who had also signed consent form for PCI to be performed if it was deemed to be necessary by the interventional cardiologist. They were asked about demographic characteristics, history of angina, whether they felt they were adequately informed about the procedure, and what their expectations of its benefits were.
The study also looked at physicians’ responses to a similar survey. Ten interventional cardiologists and 17 referring cardiologists were asked about their beliefs on the benefits of PCI, and expected outcomes for various hypothetical patients. With interventional cardiologists, the authors also asked about beliefs for study patients undergoing surgery. From my perspective, the numbers here are strikingly small, though since this is a single-centre survey, this probably placed limits on the number of cardiologists who could be asked. It does, however, mean that some of the n numbers in the results section are very small.
The key finding of the paper is that, among patients, 88% believed PCI would reduce their risk of MI, and 82% believed it would reduce their risk of fatal MI; however, among physicians, only 17% believed PCI would reduce the risk of MI and 15% believed it would reduce fatal MI. Furthermore, there was little agreement between individual patients’ and their cardiologists’ responses.
Despite this disparity, most patients reported their doctor spending at least 5 minutes explaining the procedure to them, and over half received some written information on the matter. Furthermore, 96% believed they knew why they might undergo PCI, and more than half felt they had been actively involved in decision making. With patients on whom PCI was carried out, physicians were more likely than patients to believe that the patient had been involved in decision making (78% v 94%). Also of note: patients felt they were at greater risk of MI than their cardiologists did (according to a 5 point Likert scale). Perhaps bizarrely, patients who thought they knew why there were getting PCI were more likely to hold the inaccurate belief that PCI prevented MI though this did not reach significance (Odds ratio = 5.3, CI 0.82-34.53).
The physician responses to hypothetical scenarios also generated some interesting results, perhaps most significantly:
In the first 2 scenarios, 70% of cardiologists did not identify any bnefit associated with PCI, yet 43% of these indicated that they would proceed to PCI anyway
I can’t help but question why a doctor would go ahead with a procedure from which they could foresee no benefit. In addition, this recent study also showed that for non-acute indications, 12% of PCIs were classified as inappropriate. The majority of these procedures performed in patients with little to no angina or with low-risk ischemia on stress testing.
Patients overestimating the benefits of drugs is not limited to PCI and cardiology, but why is it that patients perceive benefit when there is none? Given that most patients in this study had a discussion with their cardiologist, why were they not better informed about the potential outcomes of PCI? Is it a failure to adequately distinguish between unstable and stable angina? It does follow logically that alleviating the symptoms of cardiovascular disease would alter some underlying mechanisms to reduce the risk of MI, but shouldn’t cardiologists be making it clear to patients that this is not the case? What can doctors do differently to communicate effectively with their patients?
If you have any other comments on the paper, please do raise them this evening. As usual, a bit before 8 o’clock this evening (UK time, so 7pm GMT) I’ll post the key points for discussion.
Please see the introduction for a summary of the paper itself.
Beta blockers are widely prescribed for a range of conditions and are now widely used in the management of cardiovascular disease. There has been concerns regarding the prescription β-blockers in patients with COPD due to worries about the effect it may have on their respiratory function, particularly inhibition of the bronchodilator response to beta agonists.
This BMJ paper examined the use of β-blockers in patients with COPD to assess the effect on mortality, hospital admissions and exacerbations when used in combination with established therapy for COPD.
This was a retrospective cohort study: it identified cases from a disease-specific database in Tayside which is used by GPs and secondary care respiratory physicians. During the discussion, some concerns were raised over the observational nature of the study, and it was felt that while observational studies can be very useful, we need to be aware of their limitations.
@alasdairforrest also commented on the practicality of such a study versus a prospective study:
The Regional Ethics Committee may have preferred a retrospective study to a therapeutic trial. Or 1/5 paperwork?
The key issue was the balance between simplicity, reduced costs and increased patient numbers usually associated with an observational study, and the difficult with being as “controlled” as a prospective study. @silv24 also added that observational studies take less time to carry out.
The consensus reached was that while observational studies have their limitations, such as the need to consider randomisation problems and confounding factors, they “can also lead to more definitive questions and enable better RCTs in the future” (@mgtmccartney).
As for whether observational studies can be used to change clinical practice, again the responses were mixed. Some agreed that they could be used, but that it was dependent on the strength of the evidence. Alternatively, observational studies could act as a good starting point for other research. Others felt that observational studies alone were inadequate, but that they can add the evidence in favour of a particular practice. As @drgandalf52 pointed out, “to convince the bulk of GPs [we] need to convince NICE”.
An important issue raised with the paper was the lack of information on the patient:
- “we don’t actually know why any of these patients were on beta blockers for one thing!” (@silv24)
- “Although database sounds comprehensive, past history of patients is unknown and no record of indication for starting BBs” (@northern_doctor)
- “the biggest bias might have been that beta blockers were only prescribed to less seriously ill [patients] in [the] first place” (@amcunningham)
The discussion then moved onto whether the end-points used in the study were robust enough to show that beta blockers are safe in COPD in this patient population. @alasdairforrest felt that “hazard ratio for emergency steroids is a good endpoint”, and @northern_doctor pointed out that this shows there was no adverse effect of beta-blockers on airway. Furthermore, @silv24 “found the data on reductions in hospital admissions and emergency oral corticosteroid use very interesting”.
I think @northern_doctor neatly summed the issue up:
I think authors were very thorough with statistical and subgroup analysis to anticipate possible limitations - Couldn’t have done more with data that was available
The paper only considers one geographical area, so did this affect the application of the results to other populations? There was a bit of debate over whether the population studied was representative of the wider population in the UK, but @citylivindundee, first author of the paper, clarified that:
database covers tayside, population >200,000. we believe it to be typical of general population
We discussed the possibility of a nationwide database for patient details, either specific for a study, or as a general NHS database. @northern_doctor pointed out the pre-existing SITS-MOST data for stroke thrombolysis, which perhaps shows the idea would be feasible for a study such as this, although there would need to be a reason for collating this data (for example a study) due to costs.Some felt that the paper, on its own, did not provide adequate evidence for using beta blockers in COPD patients, and that further studies, such as RCTs, would be necessary to confirm the findings. However others felt that since this paper contributed to a pre-existing body of research into the safety of beta-blockers in COPD (such as this Cochrane Review via @mgtmccartney), it may not be ethical to conduct an RCT.
Overall, it was felt that while this paper has its flaws and needs to be considered in context, it provides further evidence towards the idea that all patients with cardiovascular disease can be prescribed beta-blockers, regardless of co-existing COPD.
We would like to thank Phil Short (@citylivindundee), first author of the paper, for contributing to the discussion.
There were mixed responses over which format people preferred, so we will be continuing with both for the time being.
For our second paper we discussed Rose’s Prevention Paradox. For an introduction to this paper, please see here. I feel confident saying there was no issue with finding relevance in this paper to current practice. There was initially some concern about the choice of paper and whether the usual criteria for critiquing a paper applied, but the general consensus, both at the beginning and after the session, was that it was an interesting and important paper to discuss. I hope everyone would agree that the discussion raised some very interesting points about the nature of preventing disease, including preventive medication and public health initiatives. As with last week, we’ve picked some key points to focus on:
Impact on Clinical Practice
We began by discussing how the paper might affect clinical practice, with @petermbenglish tweeting:
This was a bright shiny new idea when the paper was published. Has it become tarnished in the mean time?
A few people commented that this will always be an important paper, and consensus was that this is a paper relevant to many areas of clinical practice. Soon, the issue of balancing individual interests against the population’s interests came to the forefront of the discussion. @silv24 pointed out:
[We] need to examine the risks as well as the benefits when giving preventative treatment, that has to apply to every individual
Should we be aiming for improvement in the patient sat in front of us or the population as a whole?
Fundamentally, this aspect of the discussion boiled down to balancing the interests of the individual patient against the interests of the population as a whole. Most agreed that there was too much focus on high-risk patients, with @davecurtis314 suggesting this might be because they don’t understand Rose, (although in fact this can end up being in the best interests of the patient). The issue of engaging with patients to promote adherence to any medication regime was raised on a few occasions, with concerns also raised about how to encourage low-risk patients to agree to and adhere to treatment, especially in the context of treating a non-event. However, as @GarethEnticott highlighted, there need not be a dichotomy between addressing the needs of the population versus the individual:
Trouble with rose is people think it is an either/or choice. Rose concludes both strategies have to be used.
We then discussed the difference between “normalising” interventions, such as promoting healthy eating and smoking abstinence, and interventions such as medication, which effectively increase abnormality. Related to this point was the “polypill“, which most people felt would be rejected by Rose on the basis that there currently exists insufficient safety data (since safety data takes longer to obtain than efficacy data). We spoke about the fact that Rose declared long-term mass preventive medication to be unacceptable, while suggested that interventions such as promoting healthier lifestyles would be more ethical since they are “normalising” interventions. (Though @drgrumble pointed out that it may be easier to encourage patients to take a pill every day than give up smoking and change their diet.) However, as @davecurtis314 pointed out, the “problem is that effect on individual [is] tiny, effect on population/NHS huge”.
Many people felt this was something that doctors could improve on. The difference between relative and absolute risk reductions was emphasised, and number needed to treat (NNT) was also discussed, although this paper showed that presenting NNT alone to a patient may not be appropriate. This Cochrane review suggests that natural frequencies (“50 out of 1000″ rather than “5%”) may be preferable, but does not provide conclusive results. There was also a brief discussion about the teaching of statistics at medical school. The responses were mixed: @silv24 and @DrDLittle reported receiving very little teaching, though I received a lecture series in medical statistics in my first year of medical school.
Preventive vs Therapeutic: Differences between Specialities
Psychiatry was suggested by @davecurtis314 as a speciality in which prevention and treatment overlap, although prevention is usually of relapse, rather than initial episode of illness. Paediatrics was one area identified as being very pro-active in its use of preventive intervention, in the form of vaccination. A particularly interesting suggestion was made by @danjrharvey, with respect to the use of antivirals during the H1N1 influenza outbreak not only to treat ‘flu, but also to prevent transmission. Rose highlights obstetrics and antenatal care as being largely preventive by nature, both at the individual and population level. In addition, screening is particularly widely used in women’s health, and increasingly in sexual health, which can arguably count as a form of prevention. @adriamarilla also pointed out that in Cuba, doctors are trained with a much stronger population preventive approach, perhaps indicating strong geographical differences.
Most agreed that preventive treatment was more cost-effective than cures; however, as @silv24 pointed out, this raises the issue of commercial interests of pharmaceutical companies, and also the issue of public concerns about medicalisation in light of new medications with lower limits for treatment.
The conversation they moved onto sociology: @danjrharvey felt the most powerful way of altering the behaviour of a population was through economics, and socioeconomic factors were identified as being a key predictor of health. @amcunningham tweeted:
Personally I think sociologists [are] at least as important as psychologists when thinking about what determines health behaviour.
It became apparent that social factors and lifestyle were considered very important, and @carotomes pointed out that these were both likely to be cost-effective and sustainable. There was quite a bit of discussion about whether doctors should create social pressure to effect behaviour change – is it effective? is it ethical? Social change, @amcunningham said, arose not from putting pressure on individuals, but on society as a whole, which @petermbenglish pointed out meant engaging mainstream media. No doubt doctors play a role in this too, but most agreed that this was not something they could do on their own. @aj0610, @petermbenglish and @alijmbacon raised the issue of media emphasising things that are either lacking in value, or which are wrong, with sensationalism trumping sensibility in order to appeal to what readers are interested in. However, as @anaestheticdoc pointed out:
This is presuming that society wants to change. Does everybody want good health, and go without some unhealthy lifestyle choices?
What is a Patient?
One concern with preventive treatment is that it make asymptomatic individuals assume the “sick role“. Should individuals receiving preventive treatment be considered patients? @doctorblogs quite emphatically felt “no”, and @Trisha_the_doc added that medicalising healthy people is not a good thing. Some agreed; others, such as @davecurtis314, disagreed, saying that “taking a pill every day makes you a patient”. If true, this medicalises a large proportion of the population, although as @themattmak pointed out, plenty of people take multivitamins or cod liver oil without being designated a patient. Furthermore, would we call women on the contraceptive pill “patients”?
After the end of the meeting, the conversation continued into the evening for some time with a discussion about encouraging patients to engage in fewer unhealthy and counterproductive behaviours, such as excessive alcohol consumption and smoking.
Finally, I’d like to conclude with a quote from John Gordon, tweeted by @GabrielScally, as some food for thought:
“No mass disorder afflicting mankind has ever been brought under control or eliminated by attempts at treating the individual”
Once again, please do leave comments about this second meeting, including anything you think would help improve it.