Title
The title of the article is the first part of a study to be encountered and Taylor (1998) states that a title should draw the reader’s attention to the concise area of study and make reference to the research approach. The title is consistent with both of these recommendations as it informs the reader that the study is on the “efficacy and safety” of “antidepressants in the treatment of depressive disorder”.
Abstract
The purpose of an abstract is to provide readers with information from which they can decide if the article would be of interest to them. The abstract should briefly summarise the aim of the study, the design, including the method, sample, samplings and main findings (Parahoo, 1997).
In this study an expansion of the general themes and condensation of the main report is given and the reader is able to make an informed choice about the relevance of the article for their purpose. It has been identified as a quantitative study (e.g. pharmaceutical abstracts were searched from randomized, controlled trials, and observational studies) and clearly outlines the research question to be answered.
Although the method of sampling and main findings was identified, one area was vague to match. For example, in the study selection of the abstract “the authors reviewed 46 head-to-head randomized, controlled trials”, but under study selection in the main findings it did not clearly state this. This might be confusing to some readers.
The Introduction
In the introduction, the researcher’s discuss the serious disabling illness that major Depressive Disorder has on more than 16% of adults in the United States. They further stated that the economic burden of depressive disorders was estimated to be $83.1 billion. Compared to the first generation antidepressants, the selective serotonin reuptake inhibitors (SSRIs) and other second generation antidepressants have comparable efficacy and comparable or better side effect profiles (Hansen et al. 2005). However, comparative differences in efficacy, tolerability, and safety, are not well defined for the second generation drugs. For this reason, the purpose of the author’s research is to help policy makers make informed choices about the use of SSRIs and newer antidepressants. Given the prominent role of drug therapy in psychiatric disease, and the prevalent use of these drugs, the research goal is to summarise comparative data on efficacy, tolerability and safety of new antidepressants (Hansen, et al., 2005). Moreover, key questions designed to address the goal and purpose was formulated by the authors and a group of experts from programs such as the Canadian Co-ordinating Office for Health Technology Assessment. Funding was also provided for this research. The goal of this study is to provide the latest medical news to physicians and other healthcare professionals in order to enhance patient care (Hansen et al, 2005). Overall, the introduction gives a clear explanation for the study.
The Literature Review
The Literature review serves to put the current study into the context of what is already known about the phenomenon (Parahoo, 1997). The authors of this study critically looked at existing research that was significant to the work they were carrying out. Some of the primary sources retrieved were from MEDLINE, EMBASE, PsychLit; the Cochrane Library and the International Pharmaceutical. A comprehensive search was conducted from 1980 to 2005 (February) to capture literature relevant to the scope of the topic (Hansen et al, 2005). Other sources searched include articles, letters to editors, and citations. Overall, the literature search was comprehensive, and it was also successful in summarizing, by comparing various views.
Hypotheses and Variables
The tremendous volume and large variability in the quality of evidence to support use of first and second generation antidepressants makes it difficult to make evidence-based decisions. In terms of comparisons of SSRIs with SSRIs efficacy or effectiveness, the author’s did not recognize systematic differences between findings of trials that were related to their quality rating, sample size, non-inferiority design, or duration. A null hypotheses was not identified in this study.
The Methodology
To address the purpose for this research, the methodology uses three questions to formulate the research investigation. The study selection identified that the abstracts were independently reviewed by two people. The authors focused on randomized, controlled trials, meta-analyses, and observational studies on 10 types of medications.
The researchers included placebo-controlled trials, head-to-head trials, and observational studies with large samples (>100 patients). However, a larger sample size for observational studies was required to detect adverse events that were not frequent enough to be apparent in smaller trials. Although the author’s did not claim saturation, I believe they have achieved it through an adequate sample selection of effectiveness trials, which they define as conducted in primary care settings, by adequate duration of follow-up (≥3 months), and having minimal inclusion and exclusion criteria (so that participants represented the general population), to name a few.
Multiple designs (e.g. relational and descriptive designs) were clearly used in this article. Relational designs express association and differences between and among variables numerically. These include correlational studies and studies examining differences. Various tables in this research indicate comparisons of one SSRI with another. These also show that explanations, especially causality are difficult to establish in these designs. Descriptive designs describe characteristics of population’s (e.g. physical and socio-demographic variables). These are evident descriptions seen on the individual cases of the researched population (as indicated in the full report).
Methods for combining data from several studies and sources exist and appear to be quite useful. Meta-analyses combine the findings of a number of studies into one study, which is what they have done in this case. It also uses special statistics to reach their findings but can also have its limitations too (Parahoo, 1997). The collection of data from the multiple trials in this research enhances the precision and accuracy of any pooled result. It presumes that the differences among studies are primarily due to chance. In this research, differences in the direction or size of treatment effects is caused by other factors, including subtle differences in treatments, outcome measures, study design, and study quality. Thus meta-analyses generates misleading results by ignoring meaningful heterogeneity among studies, entrenching the biases in individual studies, and introducing further biases through the process of finding studies and selecting results to be pooled. I believe the research design has been identified and appropriately researched (Hansen et al, 2005).
For data collection, the authors designed and used a structured abstraction form to ensure consistency of appraisal for each study. Trained reviewers abstracted data from each study and assigned an initial quality rating. A senior reviewer, read each abstracted article, and evaluated completeness of data extraction, and confirmed quality of rating. The authors assessed the internal validity (quality) trials based on predefined criteria from the US Preventive Services Task Force and one other source. Internal validity (generalisability) was assessed and reported but did not influence quality ratings. Internal validity included elements of randomization, allocation concealment, similarity of compared groups at baseline, and overall and differential loss to follow-up. The design for data collection appeared appropriate to address the research issue. The researchers stated clearly what areas were covered for data collection.
In the data analysis, the researchers did not directly comment on the trustworthiness of the research through credibility, dependability, and confirmability. However given the small number of component studies in the meta-analyses, evidence should be viewed cautiously. All statistical analyses were conducted using StatsDirect, version 2.3.8. Even though the funding sources contributed to the development of the key questions, they had no role in the conduct of reporting of the study or in the decision to submit the manuscript for publication.
An outline of the researcher’s qualifications was not provided in this article. However, each author is recognized, at the beginning (under the main title).
Ethics is an important part of any research. Issues relating to the study design, recruitment of participants, feedback and data collection methods were all subjected to the scrutiny of a departmental ethics committee and approval was obtained. There are ethical issues in all research however, the researchers have not considered and included this in the report.
Results
The results found that 894 studies served as the database for the current review. Among randomized trials, 60% were less than 12 weeks in duration, and most focused on patients younger than 60 years old. The rate of pharmaceutical sponsorship for these trials was 85%, and the authors found that the few studies that suggested a benefit of one antidepressant over another were usually funded by the superior medication’s manufacturer (Hansen et al, 2005).
Randomization, controlled trials, meta-analyses, and observational studies of 10 types of medications were the main focus of the researchers. Studies acceptable for review focused on head-to-head trials of these antidepressants in primary care settings. Minimal follow-up time for inclusion in the current review was three months.
In comparing randomized trials of SSRI agents with one another, only a minority of research demonstrated a statistically significant difference in terms of efficacy of treatment. Three efficacy studies judged to be of fair to good quality failed to determine a difference between agents. These medications also appeared generally similar in terms of their onset of action and effects on quality of life. Meta-analyses suggested a modestly superior effect of sertraline over fluoxetine in response to treatment.
The main themes that seem to emerge throughout the data are the effectiveness and efficacy of one medication against another.
Discussion
One limitation that the researchers have reported in this study is that quantitative analyses could not be conducted for many drug comparisons as the measure and quality of the evidence were inadequate. The majority of published evidence was from trials sponsored by the pharmaceutical companies, and publication bias may have occurred.
The researchers found that overall, second-generation antidepressants did not differ significantly for treatment of patients with major depressive disorder. I believe the discussion contributed to greater understanding of the researched topic and to an extent, verified the researcher’s findings. The discussion and conclusion section also summarizes the main points very well.
Relevance of the study to Health Professional Practice
This article is intended for primary care physicians, psychiatrists, and other specialists who care for patients with depression. Primary care physicians usually initiate treatment of depression, and the choice of treatment usually centres on antidepressant medications. While older medications, such as tricyclic antidepressants, are limited by a higher rate of adverse effects, more drug interactions, and danger in overdose, newer agents appear generally better tolerated and safer when taken with other medications or in overdose. However, the researchers of the current review note that newer antidepressants are not significantly more effective in improving depression when compared with other medications (Hansen et al, 2005).
From an undergraduate’s perspective in psychology, critically researching an issue is important as a future practitioner because it involves continual seeking of knowledge - continual asking of questions - and continual learning of how diverse circumstances require diverse methods to bring about key interventions and solutions. I have also gained an appreciation for research as this will enhance my understanding of the research-based information presented in my psychology classes.
Conclusion
Overall the article was interesting with clear aims and use of appropriate methodology. The authors focused on randomized, controlled trials, meta-analyses, and observational studies of various types of medications. From the study it emerged that second-generation antidepressants did not differ substantially for treating patients with major depressive disorder. I believe that evidence from clinical trials of antidepressants should be made public, regardless of the sponsor or direction of the findings.
This essay raises multiple questions on the use of quantitative investigations. Although I appreciate the importance of research in my discipline, I still have a lot to learn and gain from this paper. My impression of research is that it is made up of many different approaches – each asking a different set of questions and therefore getting different answers. It is complex – it is diverse – it is controversial – it is necessary.
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