Note from the National Guideline Clearinghouse (NGC): The National Institute for Health and Clinical Excellence (NICE) commissioned an independent academic centre to perform a systematic literature review on the technology considered in this appraisal and prepare an assessment report. The assessment report for this technology appraisal was prepared by the West Midlands Health Technology Assessment Collaboration, University of Birmingham (see the "Availability of Companion Documents" field).
Clinical Effectiveness
Identification of Studies
A scoping search based on the Aggressive Research Intelligence Facility (ARIF) search protocol was undertaken to identify systematic reviews and background material (see Appendix 1 of the Assessment Report [see the "Availability of Companion Documents" field]).
For the main clinical effectiveness review the following sources were searched:
- Bibliographic databases: Cochrane Library (Wiley) 2006 Issue 4 (CENTRAL); MEDLINE (Ovid) 1966 to November Week 3 2006; MEDLINE (Ovid) In-Process and Other Non-Indexed Citations 4 December 2006; EMBASE (Ovid) 1980 to 2006 Week 48; CINAHL (Ovid) 1982 to November Week 4 2006; PsycINFO (Ovid) 1967 to November Week 4 2006.
- Citations of relevant studies.
- Research registries of ongoing trials included the National Research Register, Current Controlled Trials, and Clinical Trials.gov.
- Relevant internet resources.
- Hand search of appropriate journals-(Magnetic Resonance in Medicine (1985 to 2007), NMR in Biomedicine (1985 to 2007)), American Journal of Psychiatry (1985-2007).
- Further information from contact with relevant experts.
Details of all search strategies may be found in Appendix 2 of the Assessment Report (see the "Availability of Companion Documents" field). No language or date restrictions were applied. All citations were exported, or entered by hand, into Reference Manager version 11 (ISI, Carlsband, CA, USA).
Additional searches were carried out on the comparative sensitivity of computed tomography (CT) and magnetic resonance imaging (MRI) scanning, which were used to inform part of the economic evaluation (see section 6.2.1.3 of the Assessment Report [see the "Availability of Companion Documents" field]).
Inclusion and Exclusion Criteria and Process
Three reviewers independently scanned all titles and abstracts identified by the searches for inclusion. The full text was obtained for potentially relevant articles. Publications in foreign languages were assessed using the English abstract where available or a translator was used. Studies were included in the review of effectiveness if they met the following criteria:
Population: adults or children presenting with psychosis, particularly a first episode of psychosis (FEP). Psychosis was considered to be a first episode if the study described psychosis as new, first or of recent onset, a new or first hospital admission for psychosis, first contact with any medical services for psychosis, or antipsychotic treatment naïve. In cases where it was unclear whether the population were presenting with a first episode, the study was included and clearly marked as such.
Judgement on whether a condition was considered to be psychotic was made according to Appendix 3 of the Assessment Report (see "Availability of Companion Documents" field) following clinical input.
Studies investigating populations of mixed psychiatric patients that had a subgroup of psychotic patients were included if other criteria were met.
In order to capture the subgroup of psychotic patients with a possible psychiatric misdiagnosis, or those who were experiencing a change in their pre-existing psychotic disorder, the reviewers also looked for studies evaluating:
- Patients who had a prior diagnosis of a psychotic disorder but were failing to respond to treatment
- Patients who had a prior diagnosis of a psychotic disorder, had previously responded to antipsychotic treatment but had a recent deterioration in their condition.
Intervention (diagnostic investigation): MRI or CT with or without contrast media.
Comparator: current standard National Health Service (NHS) practice without MRI or CT neuroimaging, or before MRI or CT neuroimaging.
Outcomes: See the "Major Outcomes Considered" field.
Study design: Any design that gave diagnostic yield, including prospective or retrospective before and after studies, were included.
Exclusion criteria: Studies employing functional imaging techniques such as magnetic resonance spectroscopy, diffusion weighted MRI, diffusion tensor imaging, perfusion MRI, or positron emission tomography (PET) were excluded.
Studies were excluded where the primary aim of the study was to investigate the cerebral morphometry (such as shape, size or volume measurements) associated with psychosis or a specific psychotic illness.
Individual case reports were excluded.
Cost Effectiveness
Search Strategy and Numbers of Papers Found
A comprehensive search for literature on the cost and cost-effectiveness of structural neuroimaging in first episode psychosis was carried out. The strategies in full may be found in Appendix 2 of the Assessment Report (see the "Availability of Companion Documents" field).
Studies on costs, quality of life, cost effectiveness and modelling were identified from the following sources:
- Bibliographic databases: MEDLINE (Ovid) 1966 to November Week 3 2006; EMBASE (Ovid) 1980 to 2006 Week 47, Cochrane Library (Wiley) 2006 Issue 4; (CENTRAL) DARE and NHS EED and the Office of Health Economics HEED database November 2006 issue.
- Industry submissions
- Internet sites of national economic units
Searches were not be limited by date and there were no language restrictions.
A total of 967 abstracts were identified. Of these, 46 were regarded as potentially relevant and full papers were requested. It was found that no papers reported directly on the cost-effectiveness of neuroimaging in patients with first-episode psychosis. As a consequence, the inclusion criteria were broadened to encompass papers that reported use of neuroimaging within the mental health clinical area more generally as it was felt that this would still provide useful information to inform the overall economic evaluation. For the quality of life (QoL) papers, all papers reporting utility-based QoL values within the mental health clinical field were also included.
Refer to the Assessment Report (see the "Availability of Companion Documents" field) for more details.