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Shared decision making not for all patients

Clinical question To what extent do people want to be involved in their own health care decisions?

Bottom line Older, less educated people and those in poorer health prefer to rely more on their physician for information, rather than on their own knowledge, and would rather let their physician make health care decisions. Almost all people, however, want to know their options, even if they abdicate the decision making. (Level of evidence = 4)

Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med. 2005;20:531-535.

Synopsis There has been a move in medicine to involve patients more in their own care and decision-making. The researchers conducted this study in conjunction with the General Social Survey, a nationwide survey in the United States consisting of face-to-face interviews with English-speaking adults. The survey interviewed 2,750 people, of whom 56% were female, 14.5% African-American, and 7.3% Hispanic. The survey asked respondents about their general opinion toward decision-making and whether their responses might be different in specific instances in which they have to make decisions about their health. Almost all respondents (96%) wanted to know their options, agreeing with the statement: “I prefer that my doctor offers me choices and asks my opinions.” Almost half of the respondents (44%) agreed with the statement: “I prefer to rely on my doctor’s knowledge and not try to find out about my condition on my own.” When it comes to making decisions about treatment, 52% of respondents agreed with the phrase: “I prefer to leave decisions about my medical care up to my doctor.” Answers did not vary by income category or health insurance status. The desire of respondents to use their own knowledge and make their own decisions increased with education level, and women preferred a more patient-directed approach than did men. Respondents who characterized their health as excellent were more likely to be self-reliant, whereas respondents who reported their health to be poor preferred a clinician-directed approach. Respondents older than 45 years preferred to be more physician-directed, and this preference increased with age.

No difference among new antidepressants

Clinical question Which of the newer antidepressants is safer and more effective?

Bottom line When it comes to the new, nontricyclic antidepressants, the medical literature does not give us any clear guidance as to which one is more effective, of faster onset, safer, or better tolerated. Sexual side effects are lower with bupropion, and nausea seems to occur more often with venlafaxine. Other research has shown these new drugs to be no more effective or better tolerated than tricyclic antidepressants. For now, start your patient on your preferred antidepressant, but realize that most patients will need to switch to another drug at least once. (Level of evidence = 1a)

Hansen RA, Gartlehner G, Lohr KN, et al. Efficacy and safety of second-generation antidepressants in the treatment of major depressive disorder. Ann Intern Med. 2005;143: 415-426.

Synopsis The researchers who performed this systematic review and meta-analysis of the safety, tolerability, and effectiveness of the newer antidepressants used six databases to find all randomized, controlled studies of one antidepressant versus another of at least 12 weeks’ duration. They also searched reference lists of review articles, contacted pharmaceutical manufacturers, and tried, unsuccessfully, to obtain unpublished data filed with the FDA. Two researchers independently reviewed the articles for eligibility, and the data were abstracted from the selected studies by trained reviewers and were then evaluated by another researcher. The 46 studies, 85% of which were sponsored by a pharmaceutical company, were of variable quality. The quality of most of the effectiveness studies (21 of 22) was fair, and one study was rated as good. Twenty of these trials found no difference between the two antidepressants they evaluated. Two trials found a difference in at least one outcome: escitalopram (Lexapro) produced improved depression scores versus citaprolam (Celexa) in one study but not in another, and paroxetine (Paxil) was found to be more effective than fluoxetine (Prozac) in one of eight studies comparing the two drugs. In the meta-analysis, combining the results of six studies found no difference between fluoxetine and paroxetine. In five studies of a total of 1,190 patients, sertraline (Zoloft) was slightly more effective than fluoxetine (relative benefit=1.1; 95% CI, 1.01-1.20). Venlafaxine (Effexor) was also slightly more effective than fluoxetine in six studies of more than 1,300 patients (relative benefit=1.12; 95% CI, 1.02-1.23). Faster onset of action was not identified consistently for any specific drug. Similarly, quality of life was not significantly different with any of the drugs. The overall incidence of adverse effects and the discontinuation rates were similar among the antidepressants, although specific adverse effects were significantly different. Nausea and vomiting rates were consistently higher for venlafaxine than for other antidepressants. Sexual side effects were less frequent with bupropion (Wellbutrin) than with sertraline and fluoxetine and were more frequent with paroxetine, sertraline, and mirtazapine (Remeron). Weight gain was not systematically compared but seemed to be highest in the patients receiving mirtazapine and lowest in those receiving fluoxetine.

Melanoma incidence is not really rising

Clinical question Has the incidence of skin melanoma increased?

Bottom line This study provides preliminary evidence that the incidence of melanoma is increasing not because of factors such as skin burns and ozone layer holes but simply because more dermatologists are performing biopsies of more lesions. In a 5-year period, the incidence of melanoma increased 2.4-fold, whereas the biopsy rate over this same period increased a similar 2.5 times. (Level of evidence = 2c)

Welch HG, Woloshin S, Schwartz LM. Skin biopsy rates and incidence of melanoma: population based ecological study. BMJ. 2005;33:481-484.

Synopsis The incidence of skin melanoma is now 6 times higher than it was in 1950. The researchers conducting this study attempted to determine whether the true incidence is rising or whether the increase is simply due to an increased biopsy rate. Histologic diagnosis of melanoma is difficult, and several studies have shown that pathologists cannot agree on which samples are really melanoma (see Pathology as art appreciation: melanoma diagnosis, available at http://www. jr2.ox.ac.uk/bandolier/band37/b37-2.html). This study compared skin biopsy rates for people older than 65 years with the incidence of melanoma over 5 years in nine geographical areas in the United States. Over this period, the number of biopsies in this age group increased 2.5-fold, from 1 in 35 people to 1 in 14 people. The incidence of melanoma increased 2.4-fold, from 1 in every 2,222 people to 1 in every 925 people. Despite this increase in diagnoses, mortality due to melanoma changed little. Although these data don't prove it, they suggest that melanoma diagnoses have increased simply because more biopsies of lesions are being performed than in the past.

Levels of evidence are explained at http://www.infopoems.com/levels.html.