ABSTRACTS - World Psychiatric Association

Health Organization has recently released global recommendations
and guidelines on task shifting for scaling up HIV care and proposes
the “adoption or expansion of a task shifting approach as one method
of strengthening and expanding the health workforce to rapidly
increase access to HIV and other health services”. The scarcity of specialist
mental health human resources in developing countries, compounded
by their inequitable distribution and inefficient utilization,
has been well documented. This human resource gap will remain
large for the foreseeable future, and is likely to be worsened as populations
grow in many countries and as specialists emigrate. We present
a perspective on the role of task shifting to scale up mental health
care, by empowering community and primary health workers to
deliver specific tasks, the evidence base which supports the effectiveness
of task shifting interventions in mental health care, the role of
mental health specialists in such intervention programs, and future
research and program opportunities.
US15.3.
THE INTERFACE BETWEEN PRIMARY CARE
AND SPECIALIZED MENTAL HEALTH SERVICES:
IS IT LOSING IMPETUS
R. Araya
University of Bristol, UK
There was great interest in the 1980s and 1990s to propose and test a
variety of working models for the interface between primary care and
mental health services. There is some evidence to suggest that gradually
this interest may have diminished. Some reasons that may explain
this situation include the preferential attention given to research and
development on models to improve the resolution of selected priority
health problems in primary care or the difficulties to break the existing
formal and informal boundaries between primary care and psychiatry.
The situation is rather different in countries with different levels
of development. In some low-income countries there are few psychiatrists
but there are other forms of specialized mental health services.
Unsurprisingly in those countries psychiatrists may not be at the
centre of this interface. In other more resourceful middle-income
countries with a reasonable number of psychiatrists, other members
of the team – often psychologists – play a much more active role in
this interface. In some high-income countries, some people have
argued that perhaps the central role of the psychiatrist in this interface
should be scrutinized more carefully. Several successful experiences
with nurse specialists and psychologists are worth a more careful
evaluation. There is some evidence to suggest that some treatment
practices deeply established in developed countries may have little
empirical support for their existence. Some have argued that disinvesting
in some of these costly practices may be an option.
US16.
EFFECTIVENESS AND COST-EFFECTIVENESS
OF PHARMACOLOGICAL TREATMENTS
IN PSYCHIATRY: EVIDENCE FROM PRAGMATIC
TRIALS
US16.1.
UTILIZING THE RESULTS OF PRACTICAL CLINICAL
TRIALS TO OPTIMIZE TREATMENT FOR INDIVIDUAL
PATIENTS
J.A. Lieberman
Columbia University College of Physicians and Surgeons,
New York State Psychiatric Institute, New York, NY, USA
There is a saying that doctors should “use a new treatment fast while
it still works”. This is because clinicians have grown accustomed to
the fact that new drugs are approved based on their testing in rigorous
clinical trials with great fanfare and high expectations, which they
rarely live up to when used in routine clinical settings. This disconnect
reflects the so-called “efficacy-effectiveness gap”. This gap refers to the
reasons why the results of randomized clinical trials designed largely
to gain regulatory approval for new drugs or additional indications for
the marketed drugs do not accurately reflect how drugs work when
they are applied to broad patient populations in real world settings
and can best be filled by the conduct of practical clinical trials which
aim to determine treatment effectiveness in representative patient
populations in ecologically valid clinical settings. Consequently, there
is an increasing recognition of the urgent need for more practical clinical
trials that will evaluate the comparative effectiveness of currently
marketed treatments, so that we know how best to utilize them and
whether they justify their cost. This paper describes the role of the various
types of studies in the course of drug development and then
emphasizes the unique features and information that practical trials
can provide. In this context the recently published CATIE, CUTLASS,
EUFEST and TEOSS trials are reviewed and analyzed.
US16.2.
EFFECTIVENESS OF SECOND-GENERATION
ANTIPSYCHOTICS IN FIRST EPISODE
SCHIZOPHRENIA: THE EUFEST STUDY
R.S. Kahn
Department of Psychiatry, Rudolf Magnus Institute
of Neuroscience, University Medical Centre Utrecht,
The Netherlands
Second-generation antipsychotic drugs were introduced over a decade
ago for the treatment of schizophrenia; however, their purported clinical
effectiveness compared with first-generation antipsychotic drugs is
still debated. We aimed to compare the effectiveness of second-generation
antipsychotic drugs with that of a low dose of haloperidol, in firstepisode
schizophrenia. We did an open randomised controlled trial of
haloperidol vs. second-generation antipsychotic drugs in 50 sites, in 14
countries. Eligible patients were aged 18-40 years, and met diagnostic
criteria for schizophrenia, schizophreniform disorder, or schizoaffective
disorder. 498 patients were randomly assigned by a web-based
online system to haloperidol (1-4 mg/day; n=103), amisulpride (200-
800 mg/day; n=104), olanzapine (5-20 mg/day; n=105), quetiapine
(200-750 mg/day; n=104), or ziprasidone (40-160 mg/day; n=82). Follow-up
was at one year. The primary outcome measure was all-cause
treatment discontinuation. Patients and their treating physicians were
not blinded to the assigned treatment. Analysis was by intention to
treat. The number of patients who discontinued treatment for any
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