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Worcestershire Health Libraries

Psychiatry Handbook

Compiled by

Nick Smith
Librarian
Worcestershire Royal Hospital
Nicholas.Smith@worcsacute.nhs.uk

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Contents
Contents 3
Glossary of terms used in evidence based healthcare 4
List of acronyms 9

1. Introduction 10
2. What is Journal Club? 10
3. Journal Club Organisation 10
4. Guidance for the presenter 10
4.1 Identify a knowledge gap and frame a clinical question 11
4.2 Literature search for best evidence to answer the question 12
4.3 Appraise the evidence 15
4.31 Appraisal tools 15
4.4 Prepare the presentation 15
4.5 Present the findings at Journal Club 15
5. The role of the consultant 16
6. The role of the librarian 16
7. Health Libraries in Worcestershire 16
8. Recommended reading 17
9. References 17

List of figures
Figure 1 Journal Club flow chart 11
Figure 2 The PICO Model 12
Figure 3 PICO questions 12
Figure 4 NHS Evidence search example 13
Figure 5 Example of search results 14

List of appendices
Appendix 1 Record sheet for clinical questions and example 18
Appendix 2 A working example of a Journal Club presentation 20
Appendix 3 Criteria for assessing Journal Club presenters 23

With special thanks to


Ann Daly, Clinical Librarian at BWH
and
Romina Gaston, SpR Psychiatry

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Glossary of terms used in evidence based healthcare

Absolute risk: measures the probability of an event or outcome occurring, for


example, an adverse reaction to the drug being tested.

Absolute risk reduction (ARR): the ARR is the difference in the risk of an event
occurring between two groups, for example, if 6% of patients die after receiving a
new experimental drug and 10% of patients die after having the existing drug
treatment then the ARR is 10% – 6% = 4%. Therefore, by using the new drug 4%
of patients can be prevented from dying.

Bias: influences on a study that can lead to invalid conclusions about a


treatment, which can make that treatment appear better or worse than it is. Bias
can occur by chance or as a result of a systematic error on the design and
execution of a study. It can occur at different stages in the research process, for
example, in the collection, analysis, interpretation or publication of research data.
See also selection bias, performance bias, information bias, confounding factor
and publication bias.

Blinding: the practice of keeping the subjects and / or the investigators of a


study ignorant of the group to which a subject has been assigned. For example,
a trial in which both the patients and doctors are unaware of whether the patients
are taking the experimental or control drugs. The purpose of blinding is to protect
against bias. See also double blind, single blind and triple blind study.

Case control study: a study that starts with the identification of a group of
individuals sharing the same characteristics (eg people with a particular disease)
and a suitable comparison / control group (eg people without the disease). All
subjects are then assessed with respect to things that happened in the past that
might be related to contracting the disease. These studies are also called
retrospective as they look back in time from the outcome to the possible causes.

Clinical governance: a framework through which NHS organisations are


accountable for continuously improving the quality of their services and
safeguarding high standards of care.

Cohort study: an observational study that takes a group (cohort) of patients and
follows their progress in order to measure outcomes such as disease or mortality
rates, and make comparisons according to the treatments that patients received.
Cohorts can be assembled in the present and followed into the future (a
concurrent or prospective cohort study) or identified from past records and
followed forward from that time up to the present.

Confidence interval: a way of expressing certainty about the findings from a


study using statistical measures. A confidence interval describes the range within
which the true value of a measurement (e.g. effect of a treatment) is expected to

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lie within a given degree of certainty. It is usual to interpret a 95% confidence
interval as the range of effects within which we are 95% confident that the true
effect lies.

Confounding factor: a factor that influences a study that can contribute to


misleading findings. For example, two groups of people - one exercising regularly
the other not (the groups have a significant age difference but this is not
considered). In relation to cardiovascular events the outcomes are influenced as
much by age as exercising. Age is therefore the confounding factor.

Control group: a group of patients recruited to a study that receives no


treatment, a treatment of known effect or a placebo – in order to provide a
comparison for a group receiving an experimental treatment, such as a new drug.

Controlled clinical trial (CCT): a study testing a specific drug or other treatment
involving two or more groups of patients with the same disease. One (the
experimental group) receives the treatment that is being tested and the other (the
comparison or control group) receives an alternative treatment, a placebo or no
treatment. The two groups are followed to compare differences in outcomes to
determine the effectiveness of the experimental treatment.

Cross sectional study: the observation of a defined group at a single point in


time – a snapshot. This type of study contrasts with a longitudinal study which
follows subjects over a period of time.

Double blind study: a study in which both the subject (patient) and the observer
(investigator / clinician) is unaware of which treatment or intervention the patient
is receiving. The purpose of this blinding is to protect against bias.

Event rate: the proportion of patients in a group where a specified health event
or outcome is observed. For example, if in 100 patients the event is observed in
23, then event rate is 0.23. Control event rate (CER) and experimental event rate
(EER) are the terms used in control and experimental groups of patients.

Heterogeneity: when the results or estimates of effects of treatment from


separate studies appear to be different.

Homogeneity: when the results from separate studies appear similar.

Information bias: pertinent to all types of study and can be caused by poorly
designed questionnaires, observer or interviewer bias, response error and
measurement error.

Intention to treat analysis: an analysis of a clinical trial where patients are


analysed according to the group to which they were initially randomly allocated,
regardless of whether or not they had dropped out, fully complied with the

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treatment or crossed over and received the alternative treatment. Intention to
treat analysis are favoured in assessments of clinical effectiveness as they reflect
the non compliance and treatment changes that are likely to occur when the
treatment is used in practice.

Meta analysis: results from a collection of independent studies (investigating the


same treatment) are pooled using statistical techniques to synthesise their
findings into a single estimate of treatment effect.

Number needed to treat (NNT): this measures the impact of a treatment or


intervention. It states how many patients need to be treated in order to prevent
an event that would otherwise occur. For example, if the NNT = 3 then three
patients would have to be treated to prevent one adverse outcome. The closer
the NNT is to 1, the better the treatment. The number needed to harm (NNH) is
the number of patients that would need to receive a treatment to cause one
additional adverse event, for example, if the NNH = 4 then four patients would
have to be treated for one adverse outcome to occur.

Observational study: a research method that involves watching, listening and


recording behaviours and actions.

Odds ratio (OR): odds are a way of representing probability that provides an
estimate (usually with a confidence interval) for the effect of a treatment. Odds
are used to convey the idea of risk and an odds ratio of 1 between two treatment
groups implies that the risk of an adverse outcome is the same in each group.

P value: the P value is a measure of probability that a difference between groups


happened by chance. It has a value ranging from zero to one. For example, P=
0.01 means there is a 1 in 100 chance that the result occurred by chance. The
lower the P value, the more likely it is that the difference between groups was
caused by treatment. P values tell us whether an effect can be regarded as
statistically significant or not, it does not relate to how large the effect might be,
for which we need the confidence interval.

Performance bias: the systematic difference in care provided (apart for the
intervention). For example, carers treating patients differently according to which
group they are in.

Prospective study: a study in which subjects are entered into research and then
followed up over a period of time with future events recorded as they happen.

Publication bias: studies with statistically significant (or positive) results are
more likely to be published than those with non significant (or negative) results.

Qualitative research: research used to explore and understand people’s beliefs,


experiences, attitudes, behaviour and interactions.

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Quantitative research: research that generates numerical data.

Randomisation: a method that uses the play of chance to assign subjects to


groups in a research study, for example, by using a random numbers table or a
computer generated random sequence.

Randomised controlled trial (RCT): a study to test a specific drug or other


treatment in which subjects are randomly assigned to two or more groups: one
(the experimental group) receiving the treatment that is being tested and the
other (the comparison or control group) receiving an alternative treatment, a
placebo or no treatment. The two groups are followed to compare differences in
outcomes to determine the effectiveness of the experimental treatment.

Relative risk (RR): a summary measure that represents the ratio of the risk of a
given event or outcome (eg an adverse reaction to the drug being tested) in one
group of subjects compared with another. When the risk of events is the same in
the two groups the relative risk is one. In a study comparing two treatments, a
relative risk of two would indicate that patients receiving one of the treatments
had twice the risk of an adverse outcome than those receiving the other
treatment.

Retrospective study: a study that deals with the present / past and does not
involve studying future events.

Risk ratio: ratio of the risk of an undesirable event or outcome occurring in a


group of patients receiving experimental treatment compared with a comparison
(control) group.

Selection bias: selection bias occurs if the characteristics of the sample group
differ from those of the wider population or when there are systematic differences
between comparison groups of patients in a study in terms of prognosis or
responsiveness to treatment.

Sensitivity: in diagnostic testing sensitivity refers to the chance of having a


positive test result given that you have the disease. 100% sensitivity means that
all those with the disease will test positive, but this is not the same the other way
around. A patient could have a positive test result but not have the disease – this
is called a false positive. The sensitivity of a test is also related to its negative
predictive value (true negatives) - a test with a sensitivity of 100% means that all
those who get a negative test result will not have the disease. To fully judge the
accuracy of a test, its specificity must also be considered.

Single blind study: a study in which either the subject or the observer is
unaware of which treatment or intervention the subject is receiving.

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Specificity: in diagnostic testing specificity refers to the chance of having a
negative test result given that you do not have the disease. 100% specificity
means that all those without the disease will test negative, but this is not the
same the other way around. A patient could have a negative test result but still
have the disease - this is called a false negative. The specificity of a test is also
related to its positive predictive value (true positives) – a test with a specificity of
100% means that all those having a positive test result definitely have the
disease. To fully judge the accuracy of a test, its sensitivity must also be
considered.

Systematic review: a review, in which evidence from studies has been


identified, appraised and synthesised in a methodical way according to a
predetermined criteria.

Triple blind study: a study in which the statistical analysis is carried out without
knowing which treatment patients received, in addition to the patients and
clinicians being unaware of which treatment was used.

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List of acronyms

BWH Birmingham Women’s Hospital


CASP Critical appraisal skills programme
CAT Critical appraisal topic
CEBM Centre for Evidence Based Medicine
EBH Evidence based healthcare
ERC Education Resource Centre
GATE Graphical Appraisal Tool for Epidemiological Studies
NICE National Institute for Health and Clinical Excellence
NLH National Library for Health
PICO Population, Intervention, Comparison, Outcome – terms used to
help formulate a structured clinical question
RAAMbo Representative, Allocated, Accounted, Measured, blind, objective –
terms used to help appraise a study
RCPSYCH Royal College of Psychiatrists
RHL Reproductive Health Library
WHL Worcestershire Health Libraries
WMHPT Worcestershire Mental Health Partnership Trust
WHO World Health Organisation

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Psychiatry Handbook

1. Introduction

Journal clubs are integral to the practice of Evidence-Based Healthcare (EBH).


This is the process of improving patient care and practice by using existing
current evidence to influence decisions. Evidence-based healthcare "takes place
when decisions that affect the care of patients are taken with due weight
accorded to all valid, relevant information". (Hicks: 1997) Worcestershire Health
Libraries (WHL) and Worcestershire Mental Health Partnership Trust (WMHPT)
aim to promote evidence-based practice through the Psychiatry Journal Club and
to comply with clinical governance standards.

2. What is a Journal Club?

Journal Club is a teaching programme that supports trainee doctors to learn the
principles and practice of EBH. It is an important feature of a doctor’s education
and the Royal College of Psychiatrists state that all trainees should present at a
journal club which form part of the workplace based assessments. The format of
Journal Club is group, problem based learning in which a presenter (typically a
trainee doctor) delivers a structured interactive presentation to an audience of
fellow practitioners. The content of the presentation is the critical appraisal of a
research paper with the aim of determining research that is trustworthy and can
directly apply to clinical practice; therefore the paper identified ideally needs to be
a ‘real’ problem or issue that has been encountered locally. The presentation is
followed by group discussion in which appraisal is continued in light of the
presenter’s findings, and application of findings into practice determined.

3. Journal Club Organisation

A rota is prepared indicating the date individual doctors are required to present in
Journal Club which is then issued to all psychiatry staff. Doctors familiar with the
process are allocated first on the rota to enable new doctors an opportunity to
look and learn. The Psychiatry Journal Club is held in the Charles Hastings
Education Centre every Friday (except last Friday of the month) at 12.00 – 12.30.
Each room has computers, a data projector and flip-chart to assist with
presentations.

4. Guidance for the presenter

Presenters should ideally start to prepare a couple of weeks prior to Journal


Club.

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There are four stages to follow:
• Identify a knowledge gap and frame a clinical question
• Literature search for best evidence to answer that question
• Appraise the evidence
• Prepare the presentation and present the findings at Journal Club

Figure 1 provides a Journal Club flow chart.

Gap in knowledge identified

Formulate a clinical question using PICO method

Search for evidence (Embase, Medline, Psychinfo)

Select the best evidence

Critically appraise

Present at Journal Club


Figure 1: Journal club flow chart

4.1 Identify a knowledge gap and frame a clinical question

The first step in EBH is to define a structured clinical question. The question
should transpire during clinical practice (appendix 1 provides a record sheet for
noting clinical questions). Once an area of interest has been identified it is then
necessary to frame the question using the PICO model (population, intervention,
comparison and outcome). PICO is an approach to formulating a structured
question and is used to support understanding of the facets or separate parts of
a clinical query. It is also useful to help with identifying relevant search terms.
Figure 2 provides the facets and an explanation of each. Not every clinical query
will fit perfectly into the PICO model. Sometimes you will have only various
components of the PICO model; and the PICO method is not so useful for
diagnosis or prognosis queries; however it is a useful tool to get you thinking
about your clinical question and the different search terms you will use.

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PICO Explanation
Population or Patient Which patient group is the question
relating to?
Intervention Which intervention or type of therapy is
being used?
Comparison What is the intervention being compared
with? (placebo, nothing, another
treatment)
Outcome What is the outcome of interest?

Figure 2: The PICO model

Figure 3 provides a number of worked examples of using the PICO method to


define a searchable question.

Clinical Query Structured PICO Question


For people with schizophrenia, do P: Schizophrenia
family interventions, when compared to I: Family Intervention
other psychological treatments C: Other Psychological treatment
decrease the likelihood of relapse? O: Relapse

An elderly patient who is being treated P: Major depressive disorder


for unipolar major depression wants to I: Citalopram
know if citalopram will help prevent C: None
another episode. O: Relapse or recurrence or prevention
A 26 year old woman with P: Schizophrenia (young women)
schizophrenia has been successfully I: Antipsychotics
treated with olanzapine for the past 4 C: Olanzapine
years. She is concerned about her O: Weight gain
weight gain and wants to switch to
another that will not cause weight gain.
A 30 year old man has been taking P: Depression
Zoloft for mild depression. He’s I: Zoloft
concerned, however about the sexual C: None
side effects of the drug. Are SSRIs O: Sexual dysfunction
associated with sexual dysfunction?
Figure 3: Examples of PICO in action

4.2 Literature search for best evidence to answer the question

The second stage in EBH is a literature search to identify a study that will help
answer your question. When searching for evidence use terms identified in PICO
and consider an appropriate research design (cross sectional study, qualitative
research, cohort study, randomised controlled trial). A good starting point is NHS
Evidence (NHSE) as this offers access to all relevant clinical databases (see
Figure 4). However an Athens username and password is needed, this can be

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freely obtained by any NHS employee from the NHSE website or ask your
librarian for more information. The Cochrane Library is also an excellent resource
for systematic reviews and is freely available on the web.

The paper selected for presentation at Journal Club should be clinically relevant.
It might also be that a senior clinician recommends a study, in which case a
complete literature search is not necessary. Below is a list of resources to
consider referring to for a feel of the literature. During the presentation it is useful
to provide details of relevant guidelines, for example, NICE / RCPSYCH /
WMHPT and to identify issues of concern such as that guidelines might be
unclear, outdated or unspecific to the question being presented.

WMHPT Guidelines
http://192.168.42.166/Policies_and_Procedures/DtGP.asp (Intranet site)

National Institute for Health and Clinical Excellence (NICE) Guidelines


http://guidance.nice.org.uk/

Royal College of Psychiatrists (RCPSYCH) Guidelines


http://www.rcpsych.ac.uk/publications/niceguidelines.aspx

International guidelines, major trials and critically appraised topics TRIP


http://www.tripdatabase.com/index.html

The Cochrane Library


http://thecochranelibrary.com

NHS Evidence
http://www.library.nhs.uk An Athens password is required.

Mental Health specialist library


http://www.library.nhs.uk/mentalhealth/

Figure 4: An example of a very simple free-text search in Medline

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Figure 5: Examples of some of the results from previous search (Figure 4)

The above screenshot shows a selection of results from the search run in figure
4. Where possible links will be attached to the results pointing to the full-text
where available, for example, result number 3 has links explaining that the full-
text is available at Redditch Health Library. The article can then be photocopied
prior to journal club using the psychiatry photocopy card.

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4.3 Appraise the Evidence

The next stage is to critically appraise the selected study using an appraisal tool.
One such tool is the Graphic Appraisal Tool for Epidemiological studies (GATE
Frame) available at http://ebm.bmj.com/cgi/content/full/11/2/35, which can be
used for therapy and diagnostic questions. A second very useful tool is the
Critical Appraisal Skills Programme (CASP) resources available at
http://www.phru.nhs.uk/Pages/PHD/resources.htm that can be used for all type
questions. Finally, CATmaker, a computer assisted critical appraisal tool that
calculates useful clinical measures can be used to appraise most type questions.

4.31 Appraisal Tools

Below is a series of links to appraisal tools that you may find of use when
preparing for journal club.
CASP tools - http://www.phru.nhs.uk/Pages/PHD/resources.htm
CEBM - http://www.cebm.net/index.aspx?o=1157
GATE - http://ebm.bmj.com/cgi/content/extract/11/2/35
RCPSYCH - http://www.rcpsych.ac.uk/pdf/app2.pdf

4.4 Prepare the Presentation


The presentation should be long enough to fill a half hour journal club session.
Allowing time for discussion of the results and clinical relevance of the article
presented. Presentations should cover background subject knowledge, the aims
and objectives of the article, the methodology, results and conclusions. It is
useful to say where the paper was obtained from (if you have time) and why it is
clinically relevant. Most presenters use PowerPoint to highlight the important
facts and conclusions, but flip charts are available for interactive sessions too.
Some presenters prefer to not use any media, but instead split the journal club
into groups to facilitate discussion of the methods and results of a particular
article. It is up to the presenter to use whichever media they feel comfortable
with.

4.5 Present the findings at Journal Club


The presenter should arrive five minutes before the start of the session to test the
presentation media. Journal Club represents learning in small group sessions
through interaction, discussion, and giving and receiving feedback. Therefore it is
important to listen and take note of feedback. Request clarification or say I don’t
know if unsure of an answer, and don’t feel the need to be positive about the
study presented, it is not uncommon for medical research to have flaws! If a
query arises whereby a literature search is needed to find relevant evidence,
then the librarian can perform a literature search and present results to journal
club members.

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5. The role of the consultant
Consultants can attend Journal Club whenever commitments allow, and similar
to the chairperson, play an active part in the discussion. Presenters may invite
individual consultants known to have a particular interest in the topic being
presented.

6. The role of the librarian


The librarian is always available to help with any literature search problems and
obtaining a full-text copy of the article. The librarian also presents sessions on
search skills periodically.

7. Health Libraries in Worcestershire


Worcestershire Health Libraries have libraries based at Worcester, Redditch,
Kidderminster and Evesham. Staff are available for training and advice during
opening times below

Library Rowlands Library


Contact: Nick Smith
Address: Charles Hastings Education Centre,
Worcestershire Royal Hospital
Telephone: 01905 763333 ext: 33760 or 01905 760601 (direct)
Fax: 01905 760866 (direct) 33761 (internal)
E-Mail: Rowlands.enquiries@worcsacute.nhs.uk
Opening Times: Monday-Friday: 08:30-17.00

Library Redditch Health Library


Contact: David Chamberlain
Address: Alexandra Education Centre, Alexandra Hospital
Telephone: 01527 503030 ext: 45770 or 01527 505770 (direct)
Fax: 01527 505756 (direct) 45756 (internal)
E-Mail: alex.library@worcsacute.nhs.uk
Opening Times: Monday-Friday: 08.30-17.00

Library Kidderminster Health Library


Contact: Jan Brown
Address: Education Centre, Kidderminster Hospital
Telephone: 01562 823424 ext: 55253 or 01562 512344 (direct)
Fax: 01562 825733
E-Mail: khl@worcsacute.nhs.uk
Staffed hours Mon-Thurs: 09.30-16.30; Fri: 09.30-14.30

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8. Recommended reading
All the books below are available for loan from Worcestershire Health
libraries

Brown T and Wilkinson G (2005). Critical reviews in psychiatry, 3rd Edition.


Gaskell. London.

Glasziou P et al (2003). Evidence based medicine. BMJ Books. London.

Hamer S and G Collinson (2005). Achieving evidence based practice, 2nd Edition.
Bailliere Tindall. London.

Heneghan C (2006). Evidence based medicine toolkit. BMJ Books. London.

Khan KS et al (2003). Systematic reviews to support evidence based medicine:


how to review and apply findings of healthcare research. The Royal Society of
Medicine Press Limited. London.

Lawrie SM et al (2000). Critical appraisal for psychiatry: Elsevier Churchill


Livingstone. Edinburgh.

Straus S et al (2005). Evidence based medicine: how to practice and teach EBM,
3rd Edition. Churchill Livingston. London.

10. References
Centre for Evidence Based Medicine (2007). Available at: http://www.cebm.net/

Coomarasamy, A et al (2005). Journal Club Handbook 2005.

Davies J et al (2006). Journal Club Handbook 2006.

Daly A and Raza A (2008). Birmingham Women’s Hospital journal club handbook

Jackson R et al (2006). Evidence-Based Medicine 11 35-38. Also available at:


http://ebm.bmj.com/cgi/content/full/11/2/35?rss=1 (Athens password required).

Sackett DL (1996). Evidence based medicine: what it is and what it isn't. BMJ
312 (7023) 71-72.

Sackett DL (1997). Choosing the best research design for each question. BMJ
315 (7123) 1636. Also available
at:http://www.bmj.com/cgi/content/full/315/7123/1636 (Athens password
required).

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Appendix 1: Planning a Search Strategy
Please use the table below to help plan your search strategy. It is very important
to think about the separate terms you will need to use before starting your
search.

Library staff can help with any query you may have when compiling your search
strategy or performing your search, also see the worked example on the second
page for guidance.

Clinical Scenario What information do you have?

PICO Assessment Patient, population or problem

Intervention (treatment), prognostic factor


or exposure?

Comparison (if any)

Outcome(s) of interest (if any)


(e.g. are you interested in diagnosis, prognosis,
effectiveness of treatment, statistics?)

Clinical Question What is the question behind the clinical


scenario? Or try and think what your
ideal article title would be?
Are you looking for a particular type of
Type of Research research paper?
(e.g. Systematic Reviews, RCTs, Case Studies)

Search Limits Do you want to restrict your search?


(e.g. by date of publication, by language etc.)

Keywords and/or Think of keywords, phrases, synonyms


Phrases etc.

Search Strategy How will you combine your words and


phrases using AND, OR, NOT?

Are you going to do a MeSH (Medical


Subject Headings) or keyword search or
both?

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Search Strategy Example:

Clinical Scenario What information do you have? A patient with schizophrenia has
presented and is requesting
family intervention as opposed
to other psychological
treatments; you are not sure
about the effectiveness of family
therapy and need to find
literature to support your
actions.

PICO Assessment Patient, population or problem Patient with schizophrenia

Intervention (treatment), prognostic factor Family therapy


or exposure?

Comparison (if any) Other psychological treatment

Outcome(s) of interest (if any)


(e.g. are you interested in diagnosis, prognosis, Prevention of relapse
effectiveness of treatment, statistics?)

Clinical Question What is the question behind the clinical For people with schizophrenia,
scenario? Or try and think what your do family interventions, when
ideal article title would be? compared to other psychological
treatments decrease the
likelihood of relapse?
Are you looking for a particular type of
Type of Research research paper? All types
(e.g. Systematic Reviews, RCTs, Case Studies)

Search Limits Do you want to restrict your search? English articles in the last ten
(e.g. by date of publication, by language etc.) years

Keywords and/or Think of keywords, phrases, synonyms Schizophrenia, family


Phrases etc. intervention, psychological
treatment, relapse.

Search Strategy How will you combine your words and Schizophrenia
phrases using AND, OR, NOT? AND
Family intervention
Are you going to do a MeSH (Medical AND
Subject Headings) or keyword search or Psychological Treatment
both? AND
Relapse

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Appendix 2: Example of a Journal Club presentation (paper available from
Library)

1. 2.

Anaesthesia and
Electroconvulsive Therapy: A
Retrospective Study Comparing
Etomidate and Propofol

Journal Of ECT. Volume 22,


Number 3, September 2006

3. 4.

What are we looking at Method: What was wrong?

• Are the results of the study valid (i.e. • Retrospective


method) ? • Nonrandomized
• Unblinded
• What are the results ?
• Clinicians global assessment rather than
• Will the results help look after patients ? standard rating scale for main outcome
measure.
• No objective measure of severity of illness,
comorbidity,
comorbidity, past psychiatric history of
depression. All have an effect on ECT course.

5. 6

Method: What was wrong? Method: What was wrong?

• Small study that doesn’


doesn’t have enough • No data on ASA grade between the two
patients for its own power calculation. groups.
• Excluded patients do not have anaesthetic • Adverse effects as a consequence of
drug mentioned. anaesthesia is defined as an event
occurring on more than one occasion.
• Data collected entirely by none • Only assesses acute ECT treatment.
anaesthetists when this study is looking at
differences between anaesthetic drugs.
• ECT machine changed during study period
and this has not been analysed.

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7. 8.

Method: What was right? Method: What was right?


• Propofol and etomidate used in approx equal • All patients are accounted for at
numbers and through course of ECT. conclusion of study-
study- though you would
• Though not randomized, patient characteristics expect this in a retrospective study.
at baseline similar between the two groups • Patients not highly selected population!
though no comparison of physical health or ASA (Unless you count patients undergoing
status has been made. acute ECT as an already highly selected
• Reasonable exclusion criteria. group.)
• Standard statistical package used.

9. 10.

What are the results? 1. Length of ECT course

• The study identifies four outcome • There is a significant (P=0.004) difference


measures: in time to recovery between the two
1. length of ECT course groups (etomidate
(etomidate 9.8, SD 3.5 vs propofol
2. safety profile of the induction agents. 12.3, SD 3.0), equivalent to almost 3 ECT
sessions.
3. number of missed fits
• It is important to note that this primary
4. initial, final and total dose during ECT outcome measure is based on a global
clinical assessment and not a standardized
rating scale.

11. 12.
2. Safety profile of the anaesthetic
3. Total number of missed fits
agents.
• No statistical difference between the two • No significant difference in missed fits
agents.
between the two groups.
• It is important to note that defining an
adverse event as one that occurs on more
than one occasion is not how adverse
anaesthetic reactions are recorded. All
adverse reactions are recorded. Death is
an adverse event which would apparently
only have been recorded had it occurred
twice in an ECT course!

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13. 14.
Will the results help look after
4. Initial, final and total ECT dose
patients?
• No significant difference between initial • Is it applicable to our patients?
seizure threshold between the two groups. • Do the findings if accurate have clinical
• Highly significant difference (P<0.0001) in implications?
final seizure threshold (etomidate
(etomidate 113.8,
SD 63.2 vs propofol 138.9, SD 195.7). • Is this study good enough to change our
practice?
• Highly significant difference (P<0.0001) in
total dose of ECT (mC
(mC)) (etomidate
(etomidate 1506.2,
SD 912.3 vs propofol 3077.0 SD 1608.5)

15. 16.

Applicable to our patients? Clinical implications

• This study for all its faults is really quite • Significantly higher amounts of electrical
applicable to current ECT treatment in the charge are delivered over the course of an
district general hospital setting in this ECT treatment in the propofol group and
country. they have a longer treatment course to
recovery.
• Though of economic significance it is not
possible to comment whether there are
clinical implications.

17.
Is it good enough to change what
we do?
• I don’
don’t think so as there are many
problems with the study design. Though
as the authors comment it is new data
which may warrant further study with a
well designed prospective RCT.

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Appendix 2: Journal Club presentation assessment sheet

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