Reasons for Use of and Experiences with Homeopathic Treatment as an Adjunct to Usual Cancer Care: Results of a Small Qualitative Study.

BACKGROUND: A significant proportion of patients with cancer consult with homeopaths. No former qualitative study has reported on experiences with homeopathy in this patient group. This study aimed to learn about the reasons for, and experiences with, treatment provided by homeopaths among Danish patients with cancer. METHODS: A small qualitative semi-structured interview study was carried out to collect preliminary knowledge to learn about reasons for and experiences with treatment provided by homeopaths as an adjunct to usual care among patients with cancer. Thematic analysis was used for the development of themes. RESULTS: Five patients, diagnosed with cancer, were interviewed. On the basis of qualitative interviews five themes emerged: concerns and hopes, obstacles and support, internal health locus of control, whole person approach, and improved well-being. CONCLUSION: The cancer patients in this study sought homeopathy to address their hopes and concerns and to help them face obstacles and find support. They were actively taking responsibility for their own health and valued the whole person approach used by their homeopaths. Participants reported improved well-being both at the physical and mental levels. The results provide a basis for further research to learn more from patients' experiences with this intervention. Such knowledge could potentially be helpful to improve healthcare practitioners' communication with patients, and thereby patients' overall care.

Systematic Review and Meta-Analysis of Randomised, Other-than-Placebo Controlled, Trials of Non-Individualised Homeopathic Treatment.

INTRODUCTION: This study focuses on randomised controlled trials (RCTs) of non-individualised homeopathic treatment (NIHT) in which the control (comparator) group was other than placebo (OTP). OBJECTIVES: To determine the comparative effectiveness of NIHT on health-related outcomes in adults and children for any given condition that has been the subject of at least one OTP-controlled trial. For each study, to assess its risk of bias and to determine whether its study attitude was predominantly 'pragmatic' or 'explanatory'. METHODS: Systematic review. For each eligible trial, published in the peer-reviewed literature up to the end of 2016, we assessed its risk of bias (internal validity) using the seven-domain Cochrane tool, and its relative pragmatic or explanatory attitude (external validity) using the 10-domain PRECIS tool. We grouped RCTs by whether these examined IHT as alternative treatment (study design 1a), adjunctively with another intervention (design 1b), or compared with no intervention (design 2). RCTs were sub-categorised as superiority trials or equivalence/non-inferiority trials. For each RCT, we designated a single 'main outcome measure' to use in meta-analysis: 'effect size' was reported as odds ratio (OR; values > 1 favouring homeopathy) or standardised mean difference (SMD; values < 0 favouring homeopathy). RESULTS: Seventeen RCTs, representing 15 different medical conditions, were eligible for study. Three of the trials were more pragmatic than explanatory, two were more explanatory than pragmatic, and 12 were equally pragmatic and explanatory. Fourteen trials were rated 'high risk of bias' overall; the other three trials were rated 'uncertain risk of bias' overall. Ten trials had data that were extractable for analysis. Significant heterogeneity undermined the planned meta-analyses or their meaningful interpretation. For the three equivalence or non-inferiority trials with extractable data, the small, non-significant, pooled effect size (SMD = 0.08; p = 0.46) was consistent with a conclusion that NIHT did not differ from treatment by a comparator (Ginkgo biloba or betahistine) for vertigo or (cromolyn sodium) for seasonal allergic rhinitis. CONCLUSIONS: The current data preclude a decisive conclusion about the comparative effectiveness of NIHT. Generalisability of findings is restricted by the limited external validity identified overall. The highest intrinsic quality was observed in the equivalence and non-inferiority trials of NIHT.

Systematic Review and Meta-Analysis of Randomised, Other-than-Placebo Controlled, Trials of Individualised Homeopathic Treatment.

BACKGROUND: This study focuses on randomised controlled trials (RCTs) of individualised homeopathic treatment (IHT) in which the control (comparator) group was other than placebo (OTP). AIMS: To determine the comparative effectiveness of IHT on health-related outcomes in adults and children for any clinical condition that has been the subject of at least one OTP-controlled trial. For each study, to assess the risk of bias and to determine whether its study attitude was predominantly 'pragmatic' or 'explanatory'. METHODS: Systematic review. For each eligible trial, published in the peer-reviewed literature up to the end of 2015, we assessed its risk of bias (internal validity) using the seven-domain Cochrane tool, and its relative pragmatic or explanatory attitude (external validity) using the 10-domain PRECIS tool. We grouped RCTs by whether they examined IHT as an alternative treatment (study design Ia), adjunctively with another intervention (design Ib), or compared with a no-intervention group (design II). For each RCT, we identified a 'main outcome measure' to use in meta-analysis: 'relative effect size' was reported as odds ratio (OR; values >1 favouring homeopathy) or standardised mean difference (SMD; values < 0 favouring homeopathy). RESULTS: Eleven RCTs, representing 11 different medical conditions, were eligible for study. Five of the RCTs (four of which in design Ib) were judged to have pragmatic study attitude, two were explanatory, and four were equally pragmatic and explanatory. Ten trials were rated 'high risk of bias' overall: one of these, a pragmatic study with design Ib, had high risk of bias solely regarding participant blinding (a bias that is intrinsic to such trials); the other trial was rated 'uncertain risk of bias' overall. Eight trials had data that were extractable for analysis: for four heterogeneous trials with design Ia, the pooled OR was statistically non-significant; collectively for three clinically heterogeneous trials with design Ib, there was a statistically significant SMD favouring adjunctive IHT; in the remaining trial of design 1a, IHT was non-inferior to fluoxetine in the treatment of depression. CONCLUSIONS: Due to the low quality, the small number and the heterogeneity of studies, the current data preclude a decisive conclusion about the comparative effectiveness of IHT. Generalisability of findings is limited by the variable external validity identified overall; the most pragmatic study attitude was associated with RCTs of adjunctive IHT. Future OTP-controlled trials in homeopathy should aim, as far as possible, to promote both internal validity and external validity.

Prevalence of homeopathy use by the general population worldwide: a systematic review.

AIM: To systematically review surveys of 12-month prevalence of homeopathy use by the general population worldwide. METHODS: Studies were identified via database searches to October 2015. Study quality was assessed using a six-item tool. All estimates were in the context of a survey which also reported prevalence of any complementary and alternative medicine use. RESULTS: A total of 36 surveys were included. Of these, 67% met four of six quality criteria. Twelve-month prevalence of treatment by a homeopath was reported in 24 surveys of adults (median 1.5%, range 0.2-8.2%). Estimates for children were similar to those for adults. Rates in the USA, UK, Australia and Canada all ranged from 0.2% to 2.9% and remained stable over the years surveyed (1986-2012). Twelve-month prevalence of all use of homeopathy (purchase of over-the-counter homeopathic medicines and treatment by a homeopath) was reported in 10 surveys of adults (median 3.9%, range 0.7-9.8%) while a further 11 surveys which did not define the type of homeopathy use reported similar data. Rates in the USA and Australia ranged from 1.7% to 4.4% and remained stable over the years surveyed. The highest use was reported by a survey in Switzerland where homeopathy is covered by mandatory health insurance. CONCLUSIONS: This review summarises 12-month prevalence of homeopathy use from surveys conducted in eleven countries (USA, UK, Australia, Israel, Canada, Switzerland, Norway, Germany, South Korea, Japan and Singapore). Each year a small but significant percentage of these general populations use homeopathy. This includes visits to homeopaths as well as purchase of over-the-counter homeopathic medicines.

A patient reported outcome measure in homeopathic clinical practice for long-term conditions.

BACKGROUND: This study was initiated as part of a quality improvement audit process to create standards around goal setting with our patients to understand and improve outcomes of homeopathic treatment. METHOD: We used the Measure Yourself Medical Outcome Profile (MYMOP2) as a tool to assist clinicians in setting the treatment goals across a wide range of diagnoses and other complaints in routine clinical practice at the Bristol Homeopathic Hospital. The data collected from the MYMOP2 is of significance in its own right and the results are now reported in this paper. RESULTS: A total of 198 patients with a wide range of complaints attended one to five consultations with 20 homeopathic doctors. Diagnostic categories were most commonly neoplasms (16.7%), psychological (13.9%) and genitourinary complaints (12.3%), with 66.7% suffering from these problems for at least one year. The three symptoms that bothered patients the most were pain, mental symptoms and tiredness/fatigue. A paired-samples t-test using an intention-to-treat analysis showed that the MYMOP2 profile score improved from 4.25 (IQR 3.50-5.00), with a mean change of 1.24 (95% CI 1.04, 1.44) from the first to the last consultation (p<0.001). Results were statistically significant both for completers (n=91) (p<0.001) and non-completers (n=107) (p<0.001) using last-observation-carried-forward, although completers did better than non-completers (p<0.001). The overall clinical significance of improvements was at least moderate. A repeated measures ANOVA test also showed statistically significant improvements (p<0.001). CONCLUSION: The MYMOP2 results add to a growing body of observational data which demonstrates that when patients with long term conditions come under homeopathic care their presenting symptoms and wellbeing often improve. Offering a low cost high impact intervention to extend the range of choice to patients and to support self-care could be an important part of the NHS.

Depression treated by homeopaths: a study protocol for a pragmatic cohort multiple randomised controlled trial.

BACKGROUND: The most commonly recommended treatments for depression are psychological/psychotherapeutic treatments, and antidepressant drugs. However, 38 percent of patients with depression do not use these recommended treatments. Some patients seek homeopathic treatment for depression, but insufficient evidence exists to conclude as to the effectiveness, cost-effectiveness and safety of treatment by homeopaths for patients with depression. The aim of this trial is to evaluate the acceptability and comparative clinical and cost-effectiveness of the offer of adjunctive treatment provided by homeopaths for patients with self-reported depression. METHOD: This pragmatic randomised controlled trial is embedded within the population based South Yorkshire Cohort (SYC) of whom nine percent self-report long-term depression. The SYC is designed to facilitate 'cohort multiple' randomised controlled trials (cmRCT). A self-completed questionnaire will be used to both screen and collect baseline data from potential trial participants. The primary outcome is PHQ-9. One-hundred-and-sixty-two participants will be randomly selected to the intervention group (Offer of treatment by a homeopath). The results of the Offer and the No Offer groups will be compared at 6 and 12 months using both an intention to treat (ITT) and complier average causal effect (CACE) analysis. Cost-effectiveness analysis will involve calculation of quality adjusted life year (QALY). In order to help interpret the quantitative findings a selection of up to 30 patients in the offer group will be invited to participate in qualitative interviews after the first consultation and after a minimum of 6 months. Interviews will be assessed by two researchers and results will be analysed using thematic analysis. Triangulation will be used to combine results from qualitative and quantitative methodologies at the interpretation stage, to see if results agree, offer complementary information on the same issue or contradict each other.

What is a competent homeopath and what do they need in their education? A qualitative study of educators' views.

INTRODUCTION: The rise of complementary and alternative medicine (CAM) professions has taken place alongside an increase in public use of CAM therapies. Some actions have been taken to establish educational standards, often focusing on educating competent professionals to ensure citizens' freedom to make choices for their own healthcare while at the same time ensuring their safety. However, in professions like homeopathy that are unregulated in most European countries, it is not clear what it means to be a competent homeopath. The aim of this study was to investigate educators' views on what a competent homeopath is and what they require in their education. METHODS: This was a qualitative study based on grounded theory methodology involving telephone interviews with 17 educators from different schools in 10 European countries. It used constant/simultaneous comparison and analysis to develop categories and properties of educational needs and theoretical constructs and to describe behaviour and social processes. The main questions asked of subjects were "What do you think is necessary in order to educate and train a competent homeopath?" and "How would you define a competent homeopath?" RESULTS: The educators defined a competent homeopath as a professional who, through her knowledge and skills together with an awareness of her bounds of competence, is able to help her patients in the best way possible. This is achieved through the processes of study and self-development, and is supported by a set of basic resources. Becoming and being a competent homeopath is underpinned by a set of basic attitudes. These attitudes include course providers and teachers being student-centred, and students and homeopaths being patient-centred. Openness on the part of students is important to learn and develop themselves, on the part of homeopaths when treating patients, and for teachers when working with students. Practitioners have a responsibility towards their patients and themselves, course providers and teachers have responsibility for providing students with effective and appropriate teaching and learning opportunities, and students have responsibility for their own learning and development. DISCUSSION: According to homeopathy educators' understanding, basic resources and processes contribute to the development of a competent homeopath, who possesses certain knowledge and skills, all underpinned by a set of basic attitudes.

Undergraduate homeopathy education in Europe and the influence of accreditation.

CONTEXT: The safety of patients consulting with practitioners of complementary and alternative medicine (CAM) partially depends on practitioners' competence, and thus the standard of undergraduate education. OBJECTIVES: Describe undergraduate homeopathy courses in Europe, student/graduate numbers and whether there were differences between recognised/accredited and non-recognised/non-accredited courses. METHODS: Cross sectional survey of current homeopathy undergraduate education in Europe in 2008. Data from 145 (94.8%) out of 153 identified courses were collected. Eighty-five (55.6%) responded to a questionnaire survey. For others some data was extracted from their websites. Only data from the questionnaire survey is used for the main analysis. FINDINGS: The average course in the questionnaire survey had 47 enrolled students and 142 graduates, and lasted 3.6 years part-time. An estimated 6500 students were enrolled and 21,000 had graduated from 153 identified European undergraduate homeopathy courses. Out of 85 courses most had entry requirements and provided medical education (N = 48) or required students to obtain this competence elsewhere (N = 33). The average number of teaching hours were 992 (95% confidence interval (CI) 814, 1170) overall, with 555 h (95%CI 496, 615) for homeopathy. Four out of five courses were recognised/accredited. Recognised/accredited part-time courses lasted significantly longer than non-recognised/non-accredited courses (difference 0.6 years, 95%CI 0.0-1.2, P = 0.040), and offered significantly larger numbers of teaching hours in homeopathy (difference 167 h, 95%CI 7-327, P = 0.041). CONCLUSIONS: About 6500 currently enrolled students are doing undergraduate homeopathy education in Europe and 21,000 have graduated from such courses over a period of about 30 years. Undergraduate homeopathy education in Europe is heterogeneous. Recognised/accredited courses are more extensive with more teaching hours.

Depressed patients treated by homeopaths: a randomised controlled trial using the "cohort multiple randomised controlled trial" (cmRCT) design.

BACKGROUND: Despite controversy regarding homeopathy, some patients consult homeopaths for depression. Evidence is required to determine whether this is an effective, acceptable and safe intervention for these patients. METHODS: A pragmatic trial using the "cohort multiple randomised controlled trial" design was used to test the effectiveness of adjunctive treatment by homeopaths compared to usual care alone, over a period of 12 months in patients with self-reported depression. One third of patients were randomly selected for an offer of treatment provided by a homeopath. The primary outcome measure was the Patient Health Questionnaire (PHQ-9) at 6 months. Secondary outcomes included depression scores at 12 months; and the Generalised Anxiety Disorder (GAD-7) outcome at 6 and 12 months. RESULTS: The trial over-recruited by 17% with a total of 566 patients. Forty percent took up the offer and received treatment. An intention-to-treat analysis of the offer group at 6 months reported a 1.4-point lower mean depression score than the no offer group (95% CI 0.2, 2.5, p = 0.019), with a small standardized treatment effect size (d = 0.30). Using instrumental variables analysis, a moderate treatment effect size in favour of those treated was found (d = 0.57) with a between group difference of 2.6 points (95% CI 0.5, 4.7, p = 0.018). Results were maintained at 12 months. Secondary analyses showed similar results. Similar results were found for anxiety (GAD-7). No evidence suggested any important risk involved with the intervention. CONCLUSION: This trial provides preliminary support for both the acceptability and the effectiveness of treatment by a homeopath for patients with self-reported depression. Our results provide support for further pragmatic research to provide more precise estimates of treatment effect. TRIAL REGISTRATION: ISRCTN registry, ISRCTN02484593 . Registered on 7 January 2013.

Economic evaluations of homeopathy: a review.

CONTEXT: Economic evaluations of commonly used complementary and alternative medicine (CAM) therapies such as homeopathy are needed to contribute to the evidence base on which policy makers, clinicians, health-care payers, as well as patients base their health-care decisions in an era of constrained resources. OBJECTIVES: To review and assess existing economic evaluations of homeopathy. METHODS: Literature search was made to retrieve relevant publications using AMED, the Cochrane Library, CRD (DARE, NHS EED, HTA), EMBASE, MEDLINE, and the journal Homeopathy (former British Homoeopathic Journal). A hand search of relevant publications was carried out. Homeopathy researchers were contacted. Identified publications were independently assessed by two authors. RESULTS: Fifteen relevant articles reported on 14 economic evaluations of homeopathy. Thirteen studies reported numbers of patients: a total of 3,500 patients received homeopathic treatment (median 97, interquartile range 48-268), and 10 studies reported on control group participants (median 57, IQR 40-362). Eight out of 14 studies found improvements in patients' health together with cost savings. Four studies found that improvements in homeopathy patients were at least as good as in control group patients, at comparable costs. Two studies found improvements similar to conventional treatment, but at higher costs. Studies were highly heterogeneous and had several methodological weaknesses. CONCLUSIONS: Although the identified evidence of the costs and potential benefits of homeopathy seemed promising, studies were highly heterogeneous and had several methodological weaknesses. It is therefore not possible to draw firm conclusions based on existing economic evaluations of homeopathy. Recommendations for future research are presented.

Antibiotics and the development of resistant microorganisms. Can homeopathy be an alternative?

Antibiotic resistance is a global public health problem. Once confined primarily to hospitals it is now increasingly common in primary care. The prevalence of resistant bacteria is rising, and organisms resistant to almost all antibiotics have been identified. The main causes are indiscriminate prescribing and the use of antibiotics in animal feeds and other agricultural applications. Policies to restrict use of antibiotics have had limited success. Homeopathy may have a role to play in combating the development of antibiotic resistance. Clinical research suggests that homeopathy is effective in the treatment of upper respiratory tract infections in children, a frequent cause of inappropriate antibiotic prescribing. The EU recommends the use of homeopathy in organic animal husbandry, and it is used by significant numbers of farmers. At present there is little data on the effectiveness of homeopathy in this setting. Further research should be done.

Antibiotics and the development of resistant microorganisms. Can homeopathy be an alternative?

Antibiotic resistance is a global public health problem. Once confined primarily to hospitals it is now increasingly common in primary care. The prevalence of resistant bacteria is rising, and... (AU)