Editorial
Sergei Bobylev/ITAR-TASS Photo/Corbis
Evidence and doubt in the translation of research into care
See Correspondence page 659
For the meta-analysis see http://www.thelancet.com/ journals/lancet/article/ PIIS0140-6736% 2814%2960584-5/fulltext For David Naylor’s remarks see Lancet 1995: 345: 840–42
If patients, health systems, and societies are to benefit from research, then research findings need to be incorporated into practice. That this has not yet happened widely for the treatment of acute ischaemic stroke, despite its increasing incidence in ageing populations, the ruinous sequelae without treatment, and a licensed medical intervention proven to improve outcomes, raises serious questions about the extent to which patients are actually benefiting from evidence. In the correspondence section of today’s Lancet, Roger Shinton expresses his concerns about the studies on which treatment with alteplase is based. In response are letters from trialists, meta-analysts, and a regulator. A meta-analysis of individual data from 6756 patients in nine randomised trials published on Aug 6 is available to help readers draw their own conclusions. Included in the debate about alteplase are broader issues that concern the application of evidence to individuals and the doctor–patient relationship. It is the treating physician who will witness the short-term increase in catastrophic intracranial bleeds with alteplase and must
deal with the consequences to the patient and relatives; whereas the probable benefits of greater independence at 18 months may never be known to the admitting team. Yet, as David Naylor pointed out in The Lancet almost 20 years ago, personal experience can be an unreliable guide to population outcomes. Disappointing results from recent large trials of treatment for acute stroke, show a clear need for better interventions with a more generous time-window and lower risk of adverse events. As such trials are designed and implemented, researchers need to appreciate the concerns of clinicians, whose support is needed to improve the uptake of promising treatments. On the present evidence, and until new research (or regulators) suggest otherwise, alteplase has an important role in the early treatment of acute ischaemic stroke. Those who care for such patients also have an important role and responsibility to provide rapid, unbiased, up-to-date information about treatment choices, so that, when indicated, alteplase can be given as early as possible to secure the best outcomes. The Lancet
Radius Images/Corbis
Doing more to prevent suicide
For the UK’s National Confidential Inquiry into Suicide and Homicide by People with Mental Illness report see http://www.bbmh. manchester.ac.uk/cmhr/ centreforsuicideprevention/nci/ reports/Annualreport2014.pdf For The Lancet Psychiatry Series on suicide see http://www. lancet-journals.com/psychiatry_ preview
638
The recent suicide of American actor Robin Williams is likely to fade from the news within weeks, but the thousands of people who will remain at risk of suicidal behaviour in the USA and elsewhere must not be forgotten. According to the UK’s National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, there were more than 3000 deaths by suicide in patients with mental illness after discharge from hospital during 2002–12. Amid the poignant news coverage of Robin Willams’s death, now is a good time to reflect on the underlying science and research evidence. Although previous mental illness is a recognised and much studied underlying risk factor, most people with psychiatric disorders will not experience suicidal behaviour. So, to prevent suicidal behaviour, the key contributing factors need to be better understood. As part of a Series on suicide in May’s issue of The Lancet Psychiatry, Kees van Heeringen and John Mann described the neurobiological basis of suicide, in the hope that people at high risk of suicide might be identified through genomic
markers and neuroimaging as a first step for targeted prevention. Rory O’Connor and Matthew Nock assessed the literature on suicidal behaviour and noted that most people with suicidal thoughts do not receive treatment, partly because people try to cope themselves or do not see the need for help. Treatments aimed at depression have not been shown to reduce suicidal thoughts or behaviours. There is some evidence that specific cognitive and behavioural treatments might be beneficial to reduce recurrent suicidal behaviour. Their role in prevention of a first suicide attempt is unknown. New research on psychological treatments is urgently needed. Acquisition of robust evidence on treatments for people at risk of suicide must be accompanied by public health research aimed at understanding and mitigating the social and other factors which could contribute to suicidal thoughts and behaviours. The legacy of Robin Williams’s tragic death might be to help focus attention on this neglected area and strengthen research efforts for suicide prevention. The Lancet www.thelancet.com Vol 384 August 23, 2014
Sergei Bobylev/ITAR-TASS Photo/Corbis
Evidence and doubt in the translation of research into care
See Correspondence page 659
For the meta-analysis see http://www.thelancet.com/ journals/lancet/article/ PIIS0140-6736% 2814%2960584-5/fulltext For David Naylor’s remarks see Lancet 1995: 345: 840–42
If patients, health systems, and societies are to benefit from research, then research findings need to be incorporated into practice. That this has not yet happened widely for the treatment of acute ischaemic stroke, despite its increasing incidence in ageing populations, the ruinous sequelae without treatment, and a licensed medical intervention proven to improve outcomes, raises serious questions about the extent to which patients are actually benefiting from evidence. In the correspondence section of today’s Lancet, Roger Shinton expresses his concerns about the studies on which treatment with alteplase is based. In response are letters from trialists, meta-analysts, and a regulator. A meta-analysis of individual data from 6756 patients in nine randomised trials published on Aug 6 is available to help readers draw their own conclusions. Included in the debate about alteplase are broader issues that concern the application of evidence to individuals and the doctor–patient relationship. It is the treating physician who will witness the short-term increase in catastrophic intracranial bleeds with alteplase and must
deal with the consequences to the patient and relatives; whereas the probable benefits of greater independence at 18 months may never be known to the admitting team. Yet, as David Naylor pointed out in The Lancet almost 20 years ago, personal experience can be an unreliable guide to population outcomes. Disappointing results from recent large trials of treatment for acute stroke, show a clear need for better interventions with a more generous time-window and lower risk of adverse events. As such trials are designed and implemented, researchers need to appreciate the concerns of clinicians, whose support is needed to improve the uptake of promising treatments. On the present evidence, and until new research (or regulators) suggest otherwise, alteplase has an important role in the early treatment of acute ischaemic stroke. Those who care for such patients also have an important role and responsibility to provide rapid, unbiased, up-to-date information about treatment choices, so that, when indicated, alteplase can be given as early as possible to secure the best outcomes. The Lancet
Radius Images/Corbis
Doing more to prevent suicide
For the UK’s National Confidential Inquiry into Suicide and Homicide by People with Mental Illness report see http://www.bbmh. manchester.ac.uk/cmhr/ centreforsuicideprevention/nci/ reports/Annualreport2014.pdf For The Lancet Psychiatry Series on suicide see http://www. lancet-journals.com/psychiatry_ preview
638
The recent suicide of American actor Robin Williams is likely to fade from the news within weeks, but the thousands of people who will remain at risk of suicidal behaviour in the USA and elsewhere must not be forgotten. According to the UK’s National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, there were more than 3000 deaths by suicide in patients with mental illness after discharge from hospital during 2002–12. Amid the poignant news coverage of Robin Willams’s death, now is a good time to reflect on the underlying science and research evidence. Although previous mental illness is a recognised and much studied underlying risk factor, most people with psychiatric disorders will not experience suicidal behaviour. So, to prevent suicidal behaviour, the key contributing factors need to be better understood. As part of a Series on suicide in May’s issue of The Lancet Psychiatry, Kees van Heeringen and John Mann described the neurobiological basis of suicide, in the hope that people at high risk of suicide might be identified through genomic
markers and neuroimaging as a first step for targeted prevention. Rory O’Connor and Matthew Nock assessed the literature on suicidal behaviour and noted that most people with suicidal thoughts do not receive treatment, partly because people try to cope themselves or do not see the need for help. Treatments aimed at depression have not been shown to reduce suicidal thoughts or behaviours. There is some evidence that specific cognitive and behavioural treatments might be beneficial to reduce recurrent suicidal behaviour. Their role in prevention of a first suicide attempt is unknown. New research on psychological treatments is urgently needed. Acquisition of robust evidence on treatments for people at risk of suicide must be accompanied by public health research aimed at understanding and mitigating the social and other factors which could contribute to suicidal thoughts and behaviours. The legacy of Robin Williams’s tragic death might be to help focus attention on this neglected area and strengthen research efforts for suicide prevention. The Lancet www.thelancet.com Vol 384 August 23, 2014
