Online First articles may not be available until 09:00 (UK time) Friday.
Press releases Saturday 4 August 2007
Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://bmj.com).
(1) Overstretched armed forces leading to mental health problems
(2) Should patients be paid to take medicines?
(3) Abstinence programmes fail to cut risk of HIV infection
(4) Screening improves detection of major stroke risk factor
(1) Overstretched armed forces leading to mental health problems
(Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study)
BMJ Online First
Prolonged periods of deployment among Britain's armed forces is associated with mental health problems, finds a study published on bmj.com today.
Deployment is an essential ingredient of military life. However, research shows that an increase in the pace of military operations "operational tempo" may have an effect on health and place strain on families.
The UK armed forces have recommended deployment levels called the harmony guidelines, reflecting the need to balance rest and recuperation with deployment. In times of simultaneous major operations, such as those in Iraq and Afganistan, this tool is helpful for monitoring overstretch as a measure of over-commitment.
So a study carried by Professor Roberto Rona and colleagues at King's College London, set out to assess whether deployments above these guidelines (calculated as 13 months or more in a three year period) have an effect on psychological health.
They studied the number and duration of deployments in the last three years of a random sample of 5,547 regular military personnel. Mental health and alcohol use were assessed using recognised scoring methods.
Other outcomes included intentions to stay in the military and problems at home during and after deployment.
All analyses were adjusted for factors such as age, gender, rank, marital status and Service. Further adjustments were made for role in theatre (combat or support), type of deployment (war or peace enforcement operations), and time spent in a forward area in close contact with the enemy.
They found that those who were deployed for 13 months or more over a three year period were more likely to have symptoms of post traumatic stress disorder and problems at home during and after deployment. This was particularly apparent in those with direct combat exposure. The prevalence of severe alcohol problems also increased with longer deployment.
There was no association between duration of deployment and intention to stay in the military.
The relation between number of deployments and psychological symptoms was less consistent and there was no link between number of deployments and problems at home.
There was a moderately strong association between post traumatic stress disorder and a longer than expected period of deployment for the most recent deployment. This is consistent with a survey of US troops in Iraq, which found that an uncertain date of returning home increased psychological distress.
These results suggest that deployment above the recommended limit (overstretch) in the UK armed forces is associated with poor mental health and problems at home, say the authors. This may be more apparent in those with direct combat exposure.
They call for a clear and explicit policy on the duration of each deployment to help reduce the risk of post traumatic stress disorder.
Contact:
Roberto Rona, Professor of Public Health, King's College London, King's Centre for Military Health Research, Weston Education Centre, London, UK
Email: Roberto.rona{at}iop.kcl.ac.uk
(2) Should patients be paid to take medicines?
(Head to Head: Is it acceptable for people to be paid to adhere to medication?)
http://www.bmj.com/cgi/content/short/335/7613/232
Last week, it was announced that drug addicts in England are to be given shopping vouchers for complying with treatment programmes. In this week's BMJ, two experts debate whether it is acceptable for people to be paid to adhere to medication.
Rewarding patients to cooperate is not new, argues Tom Burns, a senior psychiatrist at Warneford Hospital in Oxford. Most mental health practitioners reward patients for "healthy" behaviour and financial incentives are no different.
People who criticise money for medicines emphasise the "exploitation of impoverished patients" and worries about how patients would spend the money. But whether a payment represents a just reward or immoral exploitation depends on the circumstances not the transaction, he writes.
Far from being unethical and unacceptable, he believes that money for medication is a refreshingly honest acknowledgement of the different perspectives of the two parties involved.
Rather than a way to manipulate patients to do what we want them to do it provides a model of respectful exchange, he concludes.
But Joanne Shaw, Chairman of Ask About Medicines, believes that payment is not the way to solve the high costs of non-adherence to medication. Paying for adherence, whether in the form of cash or non-financial benefits, creates perverse incentives and undermines the therapeutic alliance between patients and doctors that is needed for long term health care, she writes.
As soon as money is introduced into the equation, we have created the conditions for fraud, so our first problem is one of policing, she says. Paying people to take medicines also sends a signal that they need to be compensated for doing something that is not inherently in their own interests.
Convincing people to accept treatment when they are reluctant to do so is a genuine problem, but paying for adherence, however seductive it may appear, will never be the way to solve it, she concludes.
Contacts:
Tom Burns, Chair of Social Psychiatry, Department of Psychiatry, Warneford Hospital, Oxford, UK
Email: tom.burns{at}psych.ox.ac.uk
Joanne Shaw, Chairman, Ask About Medicines, London, UK
Email: Joanne.shaw{at}healthstrategy.org
(3)
Abstinence programmes fail to cut risk of HIV infection
(Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review)
http://www.bmj.com/cgi/content/short/335/7613/248
(Editorial: Is there a role for abstinence only programmes for HIV prevention in high income countrie)
http://www.bmj.com/cgi/content/short/335/7613/217
Programmes that exclusively encourage abstinence from sex do not seem to affect the risk of HIV infection in high income countries, finds a review of the evidence in this week's BMJ.
This also calls into question the continued use of public money to fund abstinence only programmes in the United States.
Abstinence only programmes encourage sexual abstinence as the exclusive means of preventing HIV infection, without promoting safer sex behaviours, but their effectiveness in high income settings remains unclear.
At present, thirty-three per cent of HIV prevention funds from the US President’s Emergency Plan for AIDS Relief (PEPFAR) are used for abstinence only programmes. This limits the funding available for other safer sex strategies. Domestic US programs also receive substantial federal and state funding.
A pre-existing review has already examined programme effectiveness in low income countries, so researchers at the University of Oxford reviewed 13 trials involving over 15,000 US youths to assess the effects of abstinence only programmes in high income countries.
Programmes aimed to prevent HIV infection or HIV and pregnancy. They measured self reported biological and behavioural outcomes such as sexually transmitted infection, pregnancy, frequency of unprotected sex, number of partners, and sexual initiation.
Compared with various controls, no programme had a beneficial effect on incidence of unprotected vaginal sex, number of partners, condom use, sexual initiation, incidence of pregnancy, or incidence of sexually transmitted infection.
The results also suggest that abstinence only programmes did not increase primary abstinence (prevention) or secondary abstinence (decreased incidence and frequency of recent sex).
Despite some study limitations, these conclusions are consistent with previous reviews that found no evidence of an effect of abstinence only programmes in developing countries or the United States, say the authors. They call for more rigorous evaluations of these programmes in the future.
They also point out that the US Senate has agreed to extend funding of community based abstinence education (CBAE) to $141m which, in view of this evidence, needs to be reconsidered, they argue.
In contrast to abstinence only programmes, programmes that promote the use of condoms greatly reduce the risk of acquiring HIV, especially when such programmes are culturally tailored behavioural interventions targeting people at highest risk of HIV infection, say researchers in an accompanying editorial.
They suggest that in the United States priority should be given to culturally sensitive, sex specific, behavioural interventions that target Black and Hispanic patients in clinics for sexually transmitted infections, men who have sex with men, and adolescents being treated for drug misuse who are at highest risk of acquiring HIV.
In the developing world the contribution of the "ABC" message (abstinence, be faithful, use a condom) also remains unknown, they conclude.
Contacts:
Paper: Paul Montgomery or Kristen Underhill, Centre for Evidence-Based Intervention, University of Oxford, UK
Email: jpaul.montgomery{at}socres.ox.ac.uk or kristen.underhill{at}socres.ox.ac.uk
(4) Screening improves detection of major stroke risk factor
(Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial)
BMJ Online First
The prevalence of atrial fibrillation rises with age, from about 1% in the whole population to about 5% in people aged over 65. It can be diagnosed using a simple low cost test (electrocardiography) and the risk of serious problems, such as stroke, can be dramatically reduced by treatment.
There are two types of screening for atrial fibrillation - opportunistic and systematic (or total population) screening. In opportunistic screening, a healthcare professional would take a patient’s pulse during a consultation and, if the pulse was irregular, electrocardiography would be performed to confirm the diagnosis. In systematic screening, the whole target population would be invited for screening by electrocardiography.
So researchers set out to test whether screening was more effective than routine care in detecting atrial fibrillation in the community, and compared opportunistic with total population screening.
They identified 14,802 patients aged 65 or over from 50 general practices in England (split into 25 intervention and 25 control practices).
Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and electrocardiography if the pulse was irregular). Screening took place over 12 months in each practice from October 2001 to February 2003. No active screening took place in control practices.
Screening practices identified substantially more cases of atrial fibrillation than control practices. Systematic and opportunistic screening detected similar numbers of new cases.
The screening processes, whether systematic or opportunistic, did not raise anxiety and were acceptable to patients.
This finding suggests that routine electrocardiography within this population is unnecessary for the detection of atrial fibrillation as long as healthcare professionals are conscientious about feeling the pulse, say the authors.
As the detection rates were essentially identical for the two methods, the more labour intensive, costly, and intrusive approach with systematic screening cannot be justified, they conclude.
Contact:
Richard Hobbs, Department of Primary Care and General Practice, University of Birmingham, UK
Email: f.d.r.hobbs{at}bham.ac.uk
FOR ACCREDITED JOURNALISTS
Embargoed press releases and articles are available from:
Public Affairs Division, BMA House, Tavistock Square London WC1H 9JR
(contact: pressoffice{at}bma.org.uk)
and from:
the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
What's new
Latest blogs
Find BMJ on:
Services
Tools
Online poll
Resources
Print issues
