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The Cochrane Database of Systematic... Feb 2010Aggression is a major public health issue and is integral to several mental health disorders. Antiepileptic drugs may reduce aggression by acting on the central nervous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Aggression is a major public health issue and is integral to several mental health disorders. Antiepileptic drugs may reduce aggression by acting on the central nervous system to reduce neuronal hyper-excitability associated with aggression.
OBJECTIVES
To evaluate the efficacy of antiepileptic drugs in reducing aggression and associated impulsivity.
SEARCH STRATEGY
We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, metaRegister of Controlled Trials (mRCT) and ClinicalTrials.gov to April 2009. We also searched Cochrane Schizophrenia Group's register of trials on aggression, National Research Record and handsearched for studies.
SELECTION CRITERIA
Prospective, placebo-controlled trials of antiepileptic drugs taken regularly by individuals with recurrent aggression to reduce the frequency or intensity of aggressive outbursts.
DATA COLLECTION AND ANALYSIS
Three authors independently selected studies and two authors independently extracted data. We calculated standardised mean differences (SMDs), with odds ratios (ORs) for dichotomous data.
MAIN RESULTS
Fourteen studies with data from 672 participants met the inclusion criteria. Five different antiepileptic drugs were examined. Sodium valproate/divalproex was superior to placebo for outpatient men with recurrent impulsive aggression, for impulsively aggressive adults with cluster B personality disorders, and for youths with conduct disorder, but not for children and adolescents with pervasive developmental disorder. Carbamazepine was superior to placebo in reducing acts of self-directed aggression in women with borderline personality disorder, but not in children with conduct disorder. Oxcarbazepine was superior to placebo for verbal aggression and aggression against objects in adult outpatients. Phenytoin was superior to placebo on the frequency of aggressive acts in male prisoners and in outpatient men including those with personality disorder, but not on the frequency of 'behavioral incidents' in delinquent boys.
AUTHORS' CONCLUSIONS
The authors consider that the body of evidence summarised in this review is insufficient to allow any firm conclusion to be drawn about the use of antiepileptic medication in the treatment of aggression and associated impulsivity. Four antiepileptics (valproate/divalproex, carbamazepine, oxcarbazepine and phenytoin) were effective, compared to placebo, in reducing aggression in at least one study, although for three drugs (valproate, carbamazepine and phenytoin) at least one other study showed no statistically significant difference between treatment and control conditions. Side effects were more commonly noted for the intervention group although adverse effects were not well reported. Absence of information does not necessarily mean that the treatment is safe, nor that the potential gains from the medication necessarily balance the risk of an adverse event occurring. Further research is needed.
Topics: Adolescent; Adult; Aggression; Anger; Anticonvulsants; Antisocial Personality Disorder; Child; Disruptive, Impulse Control, and Conduct Disorders; Female; Hostility; Humans; Male; Medication Adherence; Randomized Controlled Trials as Topic
PubMed: 20166067
DOI: 10.1002/14651858.CD003499.pub3 -
The Cochrane Database of Systematic... Oct 2007Cognitive-behavioral therapy (CBT) appears to be effective in the treatment of antisocial behavior both in adolescents and adults. Treatment of antisocial behavior in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cognitive-behavioral therapy (CBT) appears to be effective in the treatment of antisocial behavior both in adolescents and adults. Treatment of antisocial behavior in youth in residential settings is a challenge since it usually involves more serious behavioral problems and takes place in a closed setting. The motivation for change is usually low and there is little possibility to address the maintenance of any behavioral changes following release.
OBJECTIVES
To investigate the effectiveness of CBT in reducing recidivism of adolescents placed in secure or non-secure residential settings. A secondary objective was to see if interventions that focus particularly on criminogenic needs are more effective than those with a more general focus on cognitions and behavior.
SEARCH STRATEGY
We searched a number of databases including: CENTRAL 2005 (Issue 2), MEDLINE 1966 to May 2005, Sociological Abstracts 1963 to May 2005, ERIC 1966 to November 2004, Dissertation Abstracts International 1960s to 2005. We contacted experts in the field concerning current research.
SELECTION CRITERIA
Both randomised controlled trials and studies with non-randomized comparison groups were included. Participants had to be young people aged 12-22 and placed in a residential setting for reasons of antisocial behavior.
DATA COLLECTION AND ANALYSIS
Two reviewers independently reviewed 93 titles and abstracts; 35 full-text reports were retrieved and data from 12 trials eligible for inclusion were extracted and entered into RevMan. Results were synthesized using a random effects model, due to the significant heterogeneity across included studies. Results are reported at 6, 12 and 24 months post-treatment, and presented in graphical (forest plots) form. Odds ratios are used throughout and intention-to-treat analyses were made with drop-outs imputed proportionally. Pooled estimates were weighted with inverse variance methods and 95% confidence intervals were used.
MAIN RESULTS
The results for 12 months follow-up show that although single studies generally show no significant effects, the results for pooled data are clearly significant in favor of CBT compared to standard treatment with an odds ratio of 0,69. The reduction in recidivism is about 10% on the average. There is no evidence of effects after 6 or 24 months or when CBT is compared to alternative treatments.
AUTHORS' CONCLUSIONS
CBT seems to be a little more effective than standard treatment for youth in residential settings. The effects appear about one year after release, but there is no evidence of more long-term effects or that CBT is any better than alternative treatments.
Topics: Adolescent; Adult; Antisocial Personality Disorder; Behavior Therapy; Cognitive Behavioral Therapy; Female; Humans; Male; Residential Treatment; Secondary Prevention
PubMed: 17943869
DOI: 10.1002/14651858.CD005650.pub2 -
The Cochrane Database of Systematic... Jul 2007With the legalization of new forms of gambling there are increasing numbers of individuals who appear to have gambling related problems and who are seeking help. The... (Review)
Review
BACKGROUND
With the legalization of new forms of gambling there are increasing numbers of individuals who appear to have gambling related problems and who are seeking help. The individual and societal consequences are significant. Pathological gambling can result in the gambler jeopardizing or losing a significant relationship or job and committing criminal offences. Pathological gamblers may develop general medical conditions associated with stress. Increased rates have been reported for mood disorders, attention-deficit/hyperactivity disorder, substance abuse or dependence. There is a high risk of suicide and a high correlation with antisocial, narcissistic and borderline personality disorders and alcohol addiction. With increasing public awareness of gambling related problems health funders and practitioners are asking questions about the efficacy of treatments. Consequently quality research into gambling treatment is crucial.
OBJECTIVES
The objective of this review was to complete a systematic review and meta-analysis of all randomised controlled trials (RCTs) of psychological and pharmacological treatments for pathological gambling, from both published and unpublished scientific reports.
SEARCH STRATEGY
Published and unpublished RCTs of treatments of pathological gambling were identified by searches of electronic databases and hand searching journals likely to contain RCTs of gambling treatments. Researchers and gambling treatment centres were contacted by letter. Bibliographies of all identified research studies were scanned to identify other relevant references.
SELECTION CRITERIA
All RCTs of treatments for pathological gambling were eligible for inclusion.
DATA COLLECTION AND ANALYSIS
The data was entered into the Cochrane Review Manager software (REVMAN). The component RCTs were quality rated, with special emphasis on the concealment of treatment allocation and blinding. Relative risk analyses were conducted for the dichotomous outcome of controlled vs. uncontrolled gambling. The relative risks were aggregated using both fixed and random effects models. Tests for heterogeneity were undertaken. Both short-term (1 month or less) and long-term (6 months or longer) outcomes were considered.
MAIN RESULTS
Only four RCTs of psychological treatments were identified. These RCTs were heterogeneous in terms of design, interventions, outcome measurement and follow-up periods. All had small numbers of participants. The studies had poor methodological quality features. The experimental interventions, behavioural or cognitive-behavioural therapy (BT/CBT), were more efficacious than the control interventions in the short-term (relative risk 0.44, 95% confidence interval (CI) 0.24-0.81). There was a trend for long-term treatment with BT/CBT to be more efficacious than the control treatments, but the statistical significance of this was sensitive to the statistical model used for meta-analysis. With a fixed effect model the relative risk was 0.56 (95% CI 0.33-0.95); the relative risk with a random effects model was 0.61 (95% CI 0.25-1.47).
AUTHORS' CONCLUSIONS
This systematic review revealed a paucity of evidence for effective treatment of pathological gambling. As gambling is becoming more accessible in many countries and there is epidemiological evidence of increasing rates of pathological gambling, more rigorous RCTs are required.
Topics: Behavior Therapy; Disruptive, Impulse Control, and Conduct Disorders; Gambling; Humans
PubMed: 17636678
DOI: 10.1002/14651858.CD001521.pub2