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Comparative Efficacy and Acceptability of Interventions for Major Depression in Older Persons: Protocol for Bayesian Network Meta-Analysis

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Open Access Protocol BMJ Open: first published as 10.1136/bmjopen-2017-019819 on 21 January 2018. Downloaded from Comparative efficacy and acceptability of interventions for major depression in older persons: protocol for Bayesian network meta-analysis Tau Ming Liew,1,2,3 Cia Sin Lee4 To cite: Liew TM, Lee CS. ABSTRACT Strengths and limitations of this study Comparative efficacy and Introduction Major depression is a leading cause of acceptability of interventions disability and has been associated with adverse effects ► This systematic review and meta-analysis will for major depression in in older persons. While many pharmacological and non- older persons: protocol provide a comprehensive summary on the efficacy pharmacological interventions have been shown to be for Bayesian network and acceptability of all available interventions for effective to address major depression in older persons, meta-analysis. BMJ Open major depression in older persons. there has not been a meta-analysis that consolidates all the 2018;8:e019819. doi:10.1136/ ► The results will provide the highest level of evidence available interventions and compare the relative benefits bmjopen-2017-019819 to inform clinicians on the best choice of treatment of these available interventions. In this study, we aim to ► Prepublication history for from among the many available pharmacological conduct a systematic review and network meta-analysis this paper is available online. and non-pharmacological interventions. to compare the efficacy and acceptability of all the known To view these files, please visit ► This protocol has been developed in accordance pharmacological and non-pharmacological interventions for the journal online (http:// dx. doi. with the Preferred Reporting Items for Systematic major depression in older persons. org/ 10. 1136/ bmjopen- 2017- Reviews and Meta-analyses Protocols statement and 019819). Methods and analysis We will search Medline, Embase, has been registered with International Prospective PsycINFO, Cumulative Index to Nursing and Allied Health, Register of Systematic Reviews . Cochrane Central Register of Controlled Trials and references Received 27 September 2017 ► The overall quality of evidence will be assessed of other review articles for articles related to the keywords Revised 23 November 2017 using the Grading of Recommendations Assessment, of ‘randomised trial’, ‘major depression’, ‘older persons’ and Accepted 29 November 2017 Development and Evaluation approach. ‘treatments’. Two reviewers will independently select the ► This systematic review will be limited to studies eligible articles. For each included article, the two reviewers http://bmjopen.bmj.com/ which are reported in English language and have will independently extract the data and assess the risk of been peer reviewed. bias using the Cochrane revised tool for risk of bias. Bayesian network meta-analyses will be conducted to pool the depression scores (based on standardised mean difference) 3 and the all-cause discontinuation across all included medical comorbidities, with reported rates studies. The ranking probabilities for all interventions will of up to 5% in community-dwelling older 3–5 3 6 be estimated and the hierarchy of each intervention will be persons, 5%–10% in primary care and summarised as surface under the cumulative ranking curve as high as 37% after critical care hospitalisa- (SUCRA). Meta-regression and sub-group analyses will also tions.3 7 Major depression has a significant on September 28, 2021 by guest. Protected copyright. be performed to evaluate the effect of study-level covariates. impact on the older populations and has been The quality of the evidence will be assessed using the linked to higher risk of suicide,4 myocardial Grading of Recommendations Assessment, Development and infarction,8 stroke,9 all-cause mortality4 10 and Evaluation approach. increasing health services use.4 Ethics and dissemination The results will be disseminated Many of the interventions for major through conference presentations and peer-reviewed 1 Department of Geriatric publications. They will provide the consolidated evidence to depression in older persons have had recent Psychiatry, Institute of Mental inform clinicians on the best choice of intervention to address meta-analyses confirming their efficacy when Health, Singapore major depression in older persons. compared with control groups. These include 2Psychotherapy Unit, Institute of 11–14 PROSPERO registration number CRD42017075756. antidepressants, cognitive behavioural Mental Health, Singapore 15 16 3 therapy, problem-solving therapy, psycho- Saw Swee Hock School 17–19 of Public Health, National logical interventions in general and University of Singapore INTRODUCTIOn the various forms of non-pharmacological 4SingHealth Polyclinics, Rationale interventions.20–22 However, none of the Singapore Major depression has been identified by meta-analyses had compared all the phar- Correspondence to the WHO as one of the leading cause of macological and non-pharmacological inter- 1 2 Dr Tau Ming Liew; disability globally. In older persons, its ventions together to demonstrate the relative tau_ ming_ liew@ imh. com. sg prevalence rates rise with the increase in benefits of each intervention. It is unknown Liew TM, Lee CS. BMJ Open 2018;8:e019819. doi:10.1136/bmjopen-2017-019819 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2017-019819 on 21 January 2018. Downloaded from whether the different types of pharmacological and We will include studies with non-pharmacological inter- non-pharmacological interventions have comparable effi- ventions, including but not limited to28–30: cacy and are equally suitable for older persons with major ► psychological interventions such as cognitive behav- depression. ioural therapy, problem-solving therapy, interper- sonal therapy, family interventions or psychodynamic Objectives therapy; In this study, we aim to conduct a systematic review ► procedural interventions such as electroconvulsive and network meta-analysis to compare the efficacy and therapy, transcranial magnetic stimulation, transcra- acceptability of all the available pharmacological and nial direct-current stimulation or bright light therapy. non-pharmacological interventions for major depression We will also include studies which reported on combi- in older persons. The use of network meta-analysis allows nations of any of these pharmacological and non-pharma- us to pool the evidence on various interventions and rank cological interventions. their benefits relative to each other.23 It also allows us to We will exclude studies which focused primarily on conduct indirect comparison of the different interven- health service models of care but were not related to any tions, even when there is no direct evidence in the litera- modality of intervention, such as studies which evaluated ture to allow head-to-head comparisons. the effectiveness of home treatment, training of general practitioners, multidisciplinary approach or stepped-care approach. METHODS AND ANALYSIS This protocol is developed in accordance with the Comparators Preferred Reporting Items for Systematic Reviews and We will accept control conditions such as placebo inter- Meta-analyses (PRISMA) statement.24 25 It has also vention, waiting list, treatment as usual, as well as no been registered with the International Prospective intervention. We will also include studies with active Register of Systematic Reviews (registration number comparators such as those which compare between two CRD42017075756). different interventions within the same studies. Outcomes Eligibility criteria We will only include a study if it reports the depression Participants and settings scores or the all-cause discontinuation in each study arm We will include studies which recruited participants who following intervention. were: ► 60 years old and above; Study designs and publication types ► diagnosed with major depression based on formal We will only include randomised controlled trials (RCTs), http://bmjopen.bmj.com/ criteria by the Diagnostic and Statistical Manual of which aimed to demonstrate the superiority of a treat- Mental Disorders or International Classification of ment to another (also known as superiority trials) and Diseases; will not include equivalence or non-inferiority trials. ► having a current episode of major depression (ie, the The following study designs or publication types will also participants were symptomatic and not in remission be excluded: qualitative studies, observational studies, at the point of recruitment and the intervention was meta-analyses, case reports, case series, ecological studies not intended primarily for the prevention of future and policy papers. We intend to include only higher quality relapses). evidence and hence will exclude non-randomised trials on September 28, 2021 by guest. Protected copyright. We will exclude studies which recruited participants and publications which were not peer-reviewed (such as with treatment-resistant depression, subthreshold depres- conference proceedings, letters and comments). sion, bipolar depression, depression in dementia or psychotic depression. We will not include maintenance Language and time frame studies for major depression as such studies primarily We will only include studies which are reported in the focused on the prevention of relapses in participants who English language. Apart from that, we do not impose any had been asymptomatic or in remission at the point of time
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