Media update

Emergency Contraception: Advance Provision Does Not Reduce Pregnancy Rates or Increase Unprotected Sex

Providing emergency contraception to women in advance of need does not reduce pregnancy rates, despite increased use and faster use after unprotected sexual intercourse. These are the findings according to a new review published in The Cochrane Library.

Women who take emergency contraception up to five days after unprotected sex are less likely to become pregnant. But there are many reasons why women may not be able to access emergency contraception within this time frame. In some countries, for instance, emergency contraceptives are not available over the counter and it can be difficult to arrange an appointment with a doctor on public holidays or weekends. One proposed solution is to provide women with a set of emergency contraceptive pills to keep for immediate use, should it be needed.

The review included 11 trials and involved a total of 7,695 women from the US, China, India and Sweden. The researchers looked at the effect of advance provision of emergency contraception on rates of pregnancy and sexually transmitted infections (STIs), as well as on sexual behaviour and contraceptive use. They found that women with advance access to emergency contraception had similar rates of pregnancy as women who did not receive the medication in advance. Women given emergency contraception in advance were no more likely to have unprotected sex, to contract STIs, or to change their use of other contraceptive methods. However, women with advance provision did take the medication an average of 13 hours sooner after sex, and were more likely to use emergency contraception at all.

“Our review suggests that strategies for advance provision of emergency contraception which have been tested to date do not appear to reduce unintended pregnancy at the population level,” says lead researcher Chelsea Polis of the Johns Hopkins Bloomberg School of Public Health. “At the same time, advance provision does not appear to increase the risk of unprotected sex or sexually transmitted infections, and does not change use of other contraceptive methods.”

“Some women may not use emergency contraception when needed, even if they have it in advance. Like condoms, emergency contraception will not work if it is not used,” says Polis. “Women should still be given information about and easy access to emergency contraception, because it is a safe and effective way to prevent unintended pregnancies for individual women who will use it when needed.”

Full citation: Polis CB, Grimes DA, Schaffer K, Blanchard K, Glasier A, Harper C. Advance Provision of Emergency Contraception for Pregnancy Prevention (Review). Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD005497. DOI: 10.1002/14651858.CD005497.pub2.
Notes: Dr. Polis can be reached on cpolis@jhsph.edu or please contact Jennifer Beal on medicalnews@wiley.com.

Severe Acid Reflux: Stomach Wraps Effective in Short to Medium Term

Stomach wrap operations may be more effective than acid suppression tablets in the treatment of severe acid reflux, according to a new Cochrane Systematic Review. The study shows a more pronounced improvement in symptoms shortly after surgery than with drug treatment.

Gastro-oesophageal reflux disease (GORD) is a common chronic disease in which acid reflux causes heartburn, acid regurgitation, vomiting and difficulty swallowing. GORD can be treated by changes to diet and acid suppression tablets, but in the most severe cases a surgical operation called a fundoplication can be carried out. This involves wrapping part of the stomach around the lower part of the gullet. However, it is not certain whether this procedure is more effective than medication.

The authors reviewed data from four trials, which together involved 1232 participants. Their conclusions relate to findings from follow-up up to one year after treatment. They found that fundoplication operations performed by keyhole surgery were more effective at reducing the symptoms of GORD over this timescale, but that there was little data available to indicate potential benefits over longer timescales.

“There is evidence to suggest that, at least in the short to medium term, surgery is more effective than tablets for treatment of GORD,” says lead researcher Samantha Wileman of the Health Services Research Unit at the University of Aberdeen in the UK. “But surgery does carry a risk and whether this is outweighed by the benefits in the long term is still not certain.”

“Previous research, prior to the development of keyhole surgery for GORD, has suggested that the benefits of surgery for GORD are not sustained over time, highlighting the importance for future keyhole fundoplication studies to include longer term follow-up,” says Wileman. “We also need to know more about the clinical and cost implications of long term medication versus surgery.”

Full citation: Wileman SM, McCann S, Grant AM, Krukowski ZH, Bruce J. Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD003243. DOI: 10.1002/14651858.CD003243.pub2
Notes: To arrange an interview with Samantha Wileman, please contact Jennifer Phillips at the University of Aberdeen Communications Office on: +44 (0)1224-273174 or j.phillips@abdn.ac.uk.

Depression: Antidepressants Beneficial in Physically Ill Patients

Antidepressants are effective against depression in patients suffering from physical illnesses, according to a new systematic review by Cochrane researchers at King’s Health Partners Academic Health Sciences Centre in the UK. The researchers found the drugs were more effective than placebos at treating depression in these patients.

One of the most neglected areas of healthcare research is the effects of physical illness on an individual’s mental health. Research suggests that more than ten percent of patients suffering from physical diseases also suffer from depression. For reasons that are not entirely clear, depression may amplify the symptoms of physical disease and increase the risk of these patients dying. Studies suggest that doctors are less likely to prescribe antidepressants to people who are physically ill because they are unsure if they are helpful for these patients. Therefore, it is important to know whether antidepressants can be effective in people with physical illness.

The review included 51 studies comparing antidepressants to placebos. Most studies trialled selective serotonin reuptake inhibitors or tricyclic antidepressants. A total of 3603 patients were involved, suffering from physical illnesses including stroke, HIV/AIDS, Parkinson’s disease and cancer. The researchers found that antidepressants were more effective than placebos, although patients receiving antidepressants were more likely to experience adverse effects, including sexual dysfunction and dry mouth. For every six people receiving treatment, one more could be expected to benefit at between six and eight weeks if they were taking antidepressants.

Lead author Lauren Rayner of King’s College London said, “Although trials were small, they do seem to indicate a genuine benefit associated with antidepressants. However, patients with more severe physical illness and more severely depressed patients were not included in the trials. It is possible that those with more severe illness don’t respond so well to treatment with antidepressants. This is something that should be addressed in further studies.”

Senior investigator Professor Matthew Hotopf, Institute of Psychiatry, King’s College London added: “As a clinician I see many patients struggling with the effects of physical disease on their mental health. Doctors should take into account patients’ preferences, symptoms and possible interactions with any other medications they are taking when prescribing antidepressants to physically ill patients”. He concludes: “This is a critical area of research which will help doctors maximise a patient’s treatment and recovery from the mental and physical symptoms of illness.”

“This research is very important for millions of patients and families who are experiencing physical illness, including the most advanced stages of disease,” said Professor Irene Higginson, senior investigator and Head of the Cicely Saunders Institute, King’s College London. “Until now many doctors and nurses were worried that these treatments did not work well in people with physical illness. This result shows that they are usually of benefit. Already we are using the results to inform a new European Guideline for doctors and nurses on the management of depression.”

Full citation: Rayner L, Price A, Evans A, Valsraj K, Higginson IJ, Hotopf M. Antidepressants for depression in physically ill people. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD007503. DOI: 10.1002/14651858.CD007503.pub2
Notes: King’s Health Partners Academic Health Sciences Centre is a pioneering collaboration between King’s College London, and Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley NHS Foundation Trusts. For more information, visit www.kingshealthpartners.org.
To arrange an interview with an author of this review, please contact Louise Pratt at King's College London Pres Office on +44 20 7848 5378 or louise.a.pratt@kcl.ac.uk.

Notes for editors
1. About The Cochrane Library

The Cochrane Library contains high quality health care information, including the Cochrane Database of Systematic Reviews, from the Cochrane Collaboration. Cochrane Systematic Reviews bring together research on the effects of health care and are considered the gold standard for determining the relative effectiveness of different interventions. The Cochrane Collaboration (http://www.cochrane.org) is a UK registered international charity and the world's leading producer of systematic Reviews. It has been demonstrated that Cochrane Systematic Reviews are of comparable or better quality and are updated more often than the reviews published in print journals (Wen J et al; The reporting quality of meta-analyses improves: a random sampling study. Journal of Clinical Epidemiology 2008; 61: 770-775).
From 2010 The Cochrane Library will move from quarterly to monthly publication.
The Cochrane Library is published by Wiley-Blackwell on behalf of the Cochrane Collaboration.
The Cochrane Library Podcasts: a collection of podcasts on a selection of Cochrane Reviews by authors of reviews in this issue will be available from www.cochrane.org/podcasts.

2. Accessing The Cochrane Library
The Cochrane Library can be accessed at www.thecochranelibrary.com. Guest users may access abstracts and plain language summaries for all reviews in the database, and members of the media may request full access to the contents of the Library. For further information, see contact details below. A number of countries, including countries in the World Bank’s list of low-income economies (countries with a gross national income (GNI) per capita of less than $1000), have national provisions by which some or all of their residents are able to access The Cochrane Library for free. To find out more, please visit tinyurl.com/CochraneAccess.

3. About Wiley-Blackwell
Wiley-Blackwell is the international scientific, technical, medical, and scholarly publishing business of John Wiley & Sons, with strengths in every major academic and professional field and partnerships with many of the world’s leading societies. Wiley-Blackwell publishes nearly 1,500 peer reviewed journals and 1,500+ new books annually in print and online, as well as databases, major reference works and laboratory protocols. For more information, please visit www.wileyblackwell.com or www.interscience.wiley.com.