Underage drinking in the UK: changing trends, impact and interventions. A rapid evidence synthesis.

The UK is a high prevalence country for underage alcohol use. We conducted an evidence synthesis to examine (1) the changing trends in underage drinking in the UK compared to Europe and the USA, (2) the impact of underage drinking in terms of hospital admissions, (3) the association between underage drinking and violent youth offending, and (4) the evidence base for the effectiveness of alcohol harm reduction interventions aimed at children and adolescents under the age of 18 years. The following databases were searched from November 2002 until November 2012: Cochrane Database of Systematic Reviews, National Institute for Health and Clinical Excellence, The Evidence for Policy and Practice Information, DARE, Medline, The Campbell Collaboration, CINAHL, Criminal Justice Abstracts, Psych INFO and Social Care Online. Our findings revealed changes in the way children drink in the UK and how much they drink. Alcohol related harms are increasing in the UK despite overall population levels of consumption reducing in this age group. Girls aged 15-16 years report binge drinking and drunkenness more than boys. Girls are also more likely than boys to be admitted to hospital for alcohol related harm. The evidence suggests a strong association between heavy episodic binge drinking and violent youth offending. Only 7 out of 45 randomised controlled trials (RCTs) identified for this review included children and adolescents under the age of 18 years. Most were delivered in the emergency department (ED) and involved a brief intervention. All were characterised by a wide age range of participants, heterogeneous samples and high rates of refusal and attrition. The authors conclude that whilst the ED might be the best place to identify children and adolescents at risk of harm related to alcohol use it might not be the best place to deliver an intervention. Issues related to a lack of engagement with alcohol harm reduction interventions have been previously overlooked and warrant further investigation.

Training to recognise the early signs of recurrence in schizophrenia.

BACKGROUND: Schizophrenia has a lifetime prevalence of less than one per cent. Studies have indicated that early symptoms that are idiosyncratic to the person with schizophrenia (early warning signs) often precede acute psychotic relapse. Early warning signs interventions propose that learning to detect and manage early warning signs of impending relapse might prevent or delay acute psychotic relapse. OBJECTIVES: To compare the effectiveness of early warning signs interventions plus treatment as usual involving and not involving a psychological therapy on time to relapse, hospitalisation, functioning, negative and positive symptomatology. SEARCH METHODS: Search databases included the Cochrane Schizophrenia Group Trials Register (July 2007 and May 2012) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were reviewed for inclusion. We inspected the UK National Research Registe and contacted relevant pharmaceutical companies and authors of trials for additional information. SELECTION CRITERIA: We included all randomised clinical trials (RCTs) comparing early warning signs interventions plus treatment as usual to treatment as usual for people with schizophrenia or other non-affective psychosis DATA COLLECTION AND ANALYSIS: We assessed included studies for quality and extracted data. If more than 50% of participants were lost to follow-up, the study was excluded. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI), for continuous outcomes, we calculated mean differences (MD) with standard errors estimated, and for time to event outcomes we calculated Cox proportional hazards ratios (HRs) and associated 95 % CI. We assessed risk of bias for included studies and assessed overall study quality using the GRADE approach. MAIN RESULTS: Thirty-two RCTs and two cluster-RCTs that randomised 3554 people satisfied criteria for inclusion. Only one study examined the effects of early warning signs interventions without additional psychological interventions, and many of the outcomes for this review were not reported or poorly-reported. Significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; RR 0.53, 95% CI 0.36 to 0.79; 15 RCTs, 1502 participants; very low quality evidence). Time to relapse did not significantly differ between intervention groups (6 RCTs, 550 participants; very low quality evidence). Risk of re-hospitalisation was significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR 0.48, 95% CI 0.35 to 0.66; 15 RCTS, 1457 participants; very low quality evidence). Time to re-hospitalisation did not significantly differ between intervention groups (6 RCTs; 1149 participants; very low quality evidence). Participants' satisfaction with care and economic costs were inconclusive because of a lack of evidence. AUTHORS' CONCLUSIONS: This review indicates that early warning signs interventions may have a positive effect on the proportions of people re-hospitalised and on rates of relapse, but not on time to recurrence. However, the overall quality of the evidence was very low, indicating that we do not know if early warning signs interventions will have similar effects outside trials and that it is very likely that further research will alter these estimates. Moreover, the early warning signs interventions were used along side other psychological interventions, and we do not know if they would be effective on their own. They may be cost-effective due to reduced hospitalisation and relapse rates, but before mental health services consider routinely providing psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia, further research is required to provide evidence of high or moderate quality regarding the efficacy of early warning signs interventions added to usual care without additional psychological interventions, or to clarify the kinds of additional psychological interventions that might aid its efficacy. Future RCTs should be adequately-powered, and designed to minimise the risk of bias and be transparently reported. They should also systematically evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.