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Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to Services

III. Methods

The purpose of this literature review was to update, increase the rigor, and supercede a preliminary literature review published by SAMHSA in 2000 (Dorfman, 2000). This report includes a review of literature pertinent to the preventive interventions highlighted in the 2000 review, as well as the addition of other preventive interventions pertinent to health care delivery systems.

Scope of Review

Articles published between 1964 and 2003 were included in three separate searches, using different techniques for different time frames:

• Stage One: 1998–2002: Advanced Search on PubMed using nine specific search terms. (See details below.)
• Stage Two: 1964–2002: Search PubMed using articles listed in previous SAMHSA literature review (Dorfman, 2000) and PubMed’s “related articles.” (See Appendix A.)
• Stage Three: July 2002–October 2003: Ad hoc inclusion of selected recent, highly pertinent articles.

Stage One

First, a PubMed review was conducted for the period from January 1, 1998, to July 20, 2002, to identify new preventive interventions not discussed in the 2000 report. The specific terms used in the advanced search for the period from January 1998 to July 2002 are listed here:

1. Preventive health services OR preventive medicine OR preventive psychiatry OR primary prevention AND mental disorders NOT specific topics listed in items 2–9 below
2. Mass screening and mental disorders NOT in topics 3–9 below
3. Health education OR health promotion OR patient education AND mental disorders NOT topics 2, or 4–9
4. Home care services or home nursing AND mental disorders
5. Self-care and mental disorders (Note: there was no way to search separately on health risk appraisal in PubMed.)
6. Prenatal care OR perinatal care AND mental disorders
7. Disease management AND managed care AND mental disorders
8. Case management AND mental disorders
9. Psychoeducational (any reference where this term was used in title, abstract, or text; there is no MeSH term on this topic)

Because preliminary searching yielded more than 20,000 references by simple search techniques—with enormous numbers of duplicates and inappropriate references— advanced search techniques with the following criteria were used:

• Limits: All fields, 1998–July 20, 2002, English Human
• The term “mental disorders” was used to include all mental and behavioral disorder-related topics, including but not limited to substance use disorders, tobacco, alcohol, drug dependence, depression, schizophrenia, psychosis, anxiety state, adjustment reaction, hysteria, phobic disorder, obsessivecompulsive disorder, neurosis, hypochondriasis, somatization, malingering, personality disorder, disordered behavior
• Management of behavioral disorders to prevent onset or complications of major medical illnesses was considered in this literature review, as was psychoeducation to reduce postsurgical convalescence The results of this advanced search are summarized in Appendix A.

Stage Two

In the second stage, a more focused literature review was conducted for the period January 1964–July 2002 using PubMed to search for potentially omitted neutral or “negative studies” relative to the topics in the 2000 SAMHSA report and other items that may have been missed in the original literature search. This was accomplished using an alternative PubMed search technique; that is, listing the key studies used by Dorfman in the SAMHSA 2000 report, and then searching what Pub Med lists as “Related Articles.” The results of this search are listed in Appendix A.

Stage Three

Finally, selected additional references were added for publications published between July 2002 and October 2003. These studies were those so recent but so relevant to the objectives of this review that they were included, although a methodical review of this time period was not included.

The literature review also included an extensive set of publications provided by the SAMHSA office, various sets of national recommendations, and an extensive subsidiary set of literature searches, primarily based on the works cited in the documents noted above.

More than 3,000 papers, reports, recommendations, and Internet sites were reviewed, including 528 that are included in this report. Most represent randomized controlled trials, while the remainder provide background information and guidance relative to planning, implementation, and program evaluation.

Exclusions

This literature review was limited to preventive behavioral services best provided by health care systems. This excluded community, social, economic, generalpopulation education, and school-based and criminal justice interventions. Although worksite interventions (such as employee assistance programs) were not addressed in this monograph, worksite and productivity gains were included as benefits of some of the proposed interventions.

Because of the enormity of the literature, a number of topics were excluded from this review: AIDS-related issues; Alzheimer’s disease; attention deficit hyperactivity disorder; autism; delirium; dementia; eating disorders; encopresis; gambling; genetic testing and screening; homelessness; jet lag; mental retardation and developmental disorders (other than prenatal services and early childhood education); prison/jail; sexual issues and problems. Also excluded were adult misuse and abuse of prescription medications, care facilitation, and provision of support services to caregivers.

PubMed

The literature review conducted for this monograph used PubMed, a service of the National Library of Medicine. PubMed includes more than 14 million citations for biomedical articles, back to 1950. These citations are from MEDLINE and additional life science journals.

PubMed was used to cover the previous Grateful Med 11 databases used to prepare the 2000 SAMHSA report (Dorfman, 2000). (The previous 2000 SAMHSA report included 11 databases located on Grateful Med: MEDLINE, HealthSTAR, PREMEDLINE, AIDSLINE, AIDSDRUGS, AIDSTRIALS, DIRLINE, HISTLINE, HSRPROJ, OLDMEDLINE, and SDILINE [Dorfman, 2000].) It should be noted that Grateful Med was phased out in 2001 and replaced with PubMed. See www.nlm.nih.gov/pubs/techbull/jf01/jf01_igm_phaseout.html for details. Questions may be directed to custserv@nlm.nih.gov, or call 888-FIND-NLM.)

Synthesis of Literature Review Findings for Development of Monograph

The data synthesis was conducted as a multistep procedure. The first step concentrated on randomized and other controlled studies, the 2000 SAMHSA report (Dorfman, 2000), and the second and third editions of the Guide to Clinical Preventive Services, a report of the U.S. Preventive Services Task Force, as published in 1996 (USPSTF, 1996; USPSTF, 2003). The second step was taken to assess the rigor of the research studies and to gather as much data as possible to address cost, feasibility, time delay, and implementation-related issues. The final step was to format and organize the material in a manner that will help ease implementation in health care delivery systems.

The national guidance document most directly pertinent to this report is the third edition of the Guide to Clinical Preventive Services, a report of the U.S. Preventive Services Task Force, as published in 2003 (USPSTF, 2003). This third edition, which updates the second with newer scientific studies, is still evolving as new recommendations are posted on the Internet. Using literature review procedures more elaborate and more rigorous than feasible for this report, the Guide covers many but not all of the mental or substance abuse topics reviewed herein. For topics well covered in both reports, the findings and recommendations of the Guide are extensively duplicated, and then supplemented with findings in more recent literature and pertinent findings from older literature not included within the Guide. The newer guideline on depression is used in this SAMHSA report.

Quality and Types of Evidence

The following criteria are based on the 1996 second edition of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services (USPSTF, 1996)—

I: Evidence obtained from at least one properly designed, randomized controlled trial
II-1: Evidence obtained from well-designed controlled trials without randomization
II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group
II-3: Evidence obtained from multiple time series with or without the intervention, or dramatic results in uncontrolled experiments
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

This literature review focused on category I and II-1 studies for proof of efficacy. Special attention was given to studies showing no effect to determine whether the strength of these studies is sufficient to nullify those showing positive results, and to studies in other categories for the guidance they provide relative to program implementation issues. All readily available studies were reviewed, regardless of study design, to identify and address the program implementation issues of importance to translate results of the controlled studies into day-to-day health care practice. The discussion for the evidence base for each guideline addresses the strength of the most important studies and the strength of the overall evidence base.

Additional details on the methods used in development of this monograph are presented in Appendix A.

Synthesis of Findings

The first stage of searches yielded more than 20,000 articles; advanced searching narrowed that number to 3,436. Of those, 76 studies were randomized controlled trials (RCT), and of those RCT, only 49 were relevant. The second stage of searching, based on nine anchor studies from the previous SAMHSA report by Dorfman (2000), yielded 1,132 references, of which 340 were RCTs or meta-analyses. Analysis of those 340 articles revealed 58 were positive studies, while 11 were neutral or showed no effect of the intervention. The last stage encompassed about 38 recent articles, published in late 2002 through part of 2003, that were recent and relevant to the interventions under consideration.

Intervention topics were considered for inclusion in this report if they were preventive (i.e., not purely therapeutic; intended to prevent the occurrence or progression of a risk factor or illness), and behavioral in nature (involving substance misuse or a mental health condition, intended to impact medical or behavioral outcome), and appropriate for provision by health care delivery systems. Studies that were included for consideration met the USPSTF design criteria I through II-2 (see definitions above), and in one case, II-3, explained below.

After analysis of all the peer-reviewed, published studies generated through the search mechanism, most topics selected for “general” interventions to be delivered universally were required to have at least one or more RCTs. For interventions where no RCT existed, less rigorous literature was reviewed for consideration as a suggested service, and if used, targeted to selected patient groups, based on their risk factors. For example, the inclusion of screening for illicit drug use by pregnant women was based on less rigorous observational studies (classified as II-3) because no RCTs can be performed with this group due to ethical considerations. Similarly, since there were no RCTs for screening children for behavioral disorders or screening adolescents for the interventions, other well-designed, peerreviewed studies were considered.

If the literature was strong and the potential benefits outweighed the potential harmful effects, the intervention was included as a suggested guideline. Once the evidence was established that a screening procedure (for tobacco, alcohol, illicit drugs, depression, or behavioral disorders) was justified for one age-specific life cycle group, it was also considered for other age groups. For example, randomized trials exist for screening adults for depression, but not adolescents. The established basis for the service in adults encouraged a review of intervention literature on screening adolescents for depression as well.

After consideration of meta-analyses, randomized trials, and well-designed, nonrandomized controlled trials, studies with negative or neutral results were analyzed. This was followed by consideration of all other available literature on the intervention. These steps were taken to identify determinants of success and failure of implementations. While many studies were synthesized into a balanced review of each intervention, only those studies that qualified as a major trial, large meta-analysis, or published research that provided specific guidance about implementation were included as references.

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