Systematic Review Of Non-pharmacological Interventions Research Articles

Preventing Violence against Healthcare Workers in Hospital Settings: A Systematic Review of Nonpharmacological Interventions

Aims and Objectives. To evaluate nonpharmacological interventions for preventing patient and visitor-perpetrated violence against healthcare workers within hospital settings. Background. Up to 92% of health workers experience some form of patient-perpetrated violence. The highest risk environments include emergency departments, acute care settings, and mental health units. Given such elevated rates of violence, current interventions have questionable efficacy or implementation challenges. Design. We conducted a systematic review conforming to PRISMA reporting requirements. We searched PubMed, CINAHL, PsycINFO, Scopus, and the Cochrane Library. Studies reporting interventions to prevent patient-initiated violence against healthcare workers in hospitals were included, and findings were synthesised. Results. Based on meeting eligibility criteria, twelve studies were included in the review. Most interventions reported an effect with eleven of the twelve studies describing changes in the incidence of violence postintervention. Most studies were evaluations of education and training programs (n = 7), followed by action plans (n = 2), and a reporting instrument, risk assessment tool, and legislation (n = 1). Conclusions. Insights into effective strategies to prevent hospital patient and visitor-initiated violence are necessary to develop guidelines for better aggression/violence deterrence. Violence prevention requires strong, evidence-based, and clinically applicable interventions that promote the safety and satisfaction of all healthcare workers. Relevance to Clinical Practice. Formulating effective and appropriate strategies that aid in early recognition, prevention, and management of aggression/violence will benefit all health workers. Patient and staff satisfaction will rise; healthcare workers will regain a sense of preparedness, and higher levels of safety will be achieved. Without these effective interventions being established, the magnitude of adverse outcomes from patient-perpetrated violence will continue in healthcare.

A systematic review of nonpharmacological interventions to reduce procedural anxiety among patients undergoing radiation therapy for cancer.

The primary objective was to assess the efficacy of nonpharmacological interventions delivered to adults with cancer, in the radiation oncology department, just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety. The secondary objectives were to assess the efficacy of these interventions in reducing physiological symptoms of procedural anxiety and anxiety-related treatment disruptions. Systematic review. Electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and Cochrane Central Register of Controlled Trials) were searched from inception up until February 2022. Population: Adult patients with cancer undergoing external beam radiation therapy. Nonpharmacological interventions delivered within the radiation therapy department. Comparison: standard care controls, or standard care plus an alternative intervention. level of self-reported procedural anxiety (primary), physiological symptoms of anxiety (secondary) and measures of anxiety-related treatment disruptions (secondary). Two reviewers independently extracted data. A meta-analysis was originally planned but deemed not feasible as the studies could not be confidently pooled for meta-analysis, due to the variability in the interventions, study designs and the generally low number of studies. Therefore, a narrative synthesis is presented. Screening of 2363 records identified nine studies that met inclusion criteria: six studies of music interventions, two of video-based patient education and one of aromatherapy. Overall, three studies received a global rating of strong methodological quality and low risk of bias. Three studies reported a significant effect of the intervention on reducing the primary outcome of self-reported procedural anxiety: two music interventions (both strong methodological quality), and one video-based patient education (moderate methodological quality). One of the studies (a music intervention) also reported a significant reduction in the secondary outcome of physiological symptoms of procedural anxiety (systolic blood pressure). The evidence for nonpharmacological interventions delivered to adults with cancer just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety is limited, with very few well-designed studies. There is a need for interventions for procedural anxiety during radiation therapy to be evaluated through rigorous randomised controlled trials.

Methodological quality of systematic reviews on treatments for Alzheimer’s disease: a cross-sectional study

BackgroundCarefully conducted systematic reviews (SRs) can provide reliable evidence on the effectiveness of treatment strategies for Alzheimer’s disease (AD). Nevertheless, the reliability of SR results can be limited by methodological flaws. This cross-sectional study aimed to examine the methodological quality of SRs on AD treatments, along with potentially relevant factors.MethodsTo identify eligible SRs on AD treatments, four databases including the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, and PsycINFO were searched. The Assessing the Methodological Quality of Systematic Reviews 2 instrument was used for quality appraisal of SRs. Multivariable regression analyses were used to examine factors related to methodological quality.ResultsA total of 102 SRs were appraised. Four (3.90%) SRs were considered as high quality; 14 (13.7%), 48 (47.1%), and 36 (35.3%) were as moderate, low, and critically low quality, respectively. The following significant methodological limitations were identified: only 22.5% of SRs registered protocols a priori, 6.9% discussed the rationales of chosen study designs, 21.6% gave a list of excluded studies with reasons, and 23.5% documented funding sources of primary studies. Cochrane SRs (adjusted odds ratio (AOR): 31.9, 95% confidence interval (CI): 3.81–266.9) and SRs of pharmacological treatments (AOR: 3.96, 95%CI: 1.27–12.3) were related to the higher overall methodological quality of SRs.ConclusionMethodological quality of SRs on AD treatments is unsatisfactory, especially among non-Cochrane SRs and SRs of non-pharmacological interventions. Improvement in the following methodological domains requires particular attention due to poor performance: registering and publishing protocols a priori, justifying study design selection, providing a list of excluded studies, and reporting funding sources of primary studies.

A Systematic Review of Non-Pharmacological Interventions to Improve Gait Asymmetries in Neurological Populations

Gait asymmetries are commonly observed in neurological populations and linked to decreased gait velocity, balance decrements, increased fall risk, and heightened metabolic cost. Interventions designed to improve gait asymmetries have varying methods and results. The purpose of this systematic review was to investigate non-pharmacological interventions to improve gait asymmetries in neurological populations. Keyword searches were conducted using PubMed, CINAHL, and Academic Search Complete. The search yielded 14 studies for inclusion. Gait was assessed using 3D motion capture systems (n = 7), pressure-sensitive mats (e.g., GAITRite; n = 5), and positional sensors (n = 2). The gait variables most commonly analyzed for asymmetry were step length (n = 11), stance time (n = 9), and swing time (n = 5). Interventions to improve gait asymmetries predominantly used gait training techniques via a split-belt treadmill (n = 6), followed by insoles/orthoses (n = 3). The literature suggests that a wide range of methods can be used to improve spatiotemporal asymmetries. However, future research should further examine kinematic and kinetic gait asymmetries. Additionally, researchers should explore the necessary frequency and duration of various intervention strategies to achieve the greatest improvement in gait asymmetries, and to determine the best symmetry equation for quantifying gait asymmetries.

A Systematic Review of Non-pharmacological Interventions for Delirium Prevention in Elderly Inpatients

Purpose: The study was aimed to examine components and provider’s characteristics of non-pharmacological intervention that affect delirium prevention in elderly inpatients. Additional effects on delirium prevention based on identified characteristics were explored.Methods: Studies were searched by using seven electronic databases and examined through Preferred Reporting Items Systematic Review and Meta-Analysis (PRISMA) flow diagram. The Risk of Bias (ROB) and the Risk of Bias Assessment tool for Non-randomized Study (RoBANS) were used to evaluate the quality of each included study.Results: Seven studies were selected for the systematic review. Most of the selected studies had a low risk of bias. Interventions of each study and delirium outcome were heterogeneous. Each multi-component non-pharmacological intervention consisted on average of five interventions. Giving orientation and promoting early mobilization were included in every study. Interventions that included giving orientation, promoting early mobilization, and supporting nutrition significantly decreased delirium incidence. Moreover, when health care providers who have an intimate relationship with patients provided non-pharmacological interventions, delirium incidence has significantly decreased.Conclusion: Non-pharmacological intervention, such as giving orientation, promoting early mobilization, should be included to prevent delirium for elderly inpatients. It is important to include healthcare providers who have an intimate relationship or regular contact with patients in order to decrease delirium incidence.

A Systematic Review of Non-Pharmacological Interventions to Prevent Delirium at Intensive Care Units

Objective: It was aimed to systematically review non-pharmacological interventions used to prevent delirium at intensive care units. Methods: A search was conducted for publications in the period of 2013-2020 by using keywords determined based on Medical Subjects Headings and Embase Tree on the databases of Cochrane, CINAHL, PsyInfo, PubMed and EMBASE. Quasi-experimental, experimental and randomized-controlled studies were included in the review. Results: Thirteen studies meeting the criteria of this review were determined. The studies were categorized under the titles of multi-component, patient education, hormone intervention, physical environment, therapeutic intervention, automated preventive system, quitting daily sedation and exercise. It was determined that the interventions had important effects regarding delirium management, but only the multi-component intervention application was significant. Conclusion: According to results of this systematic review, it is recommended to use multi-component interventions in delirium treatment.

Overview of systematic reviews of non-pharmacological interventions in women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a major contributor to subfertility, diabetes and cardiovascular disease in women. The role of non-pharmacological interventions to prevent these outcomes has been reported in many systematic reviews, but robust conclusions have not been made due to variations in the scope, quality and findings of these reviews. Our aim was to provide an overview of existing evidence on the effects of non-pharmacological interventions in women with PCOS on fertility and non-fertility outcomes by a review of existing systematic reviews. We reviewed systematic reviews of randomized trials that have evaluated the effects of non-pharmacological interventions, such as lifestyle interventions, nutritional supplements or alternative medicine therapies in women with PCOS on fertility, endocrine, glycaemic and weight-related outcomes. We assessed the quality of systematic reviews with the AMSTAR tool, and reported the outcomes with regard to: fertility (live birth, clinical pregnancy, ovulation and menstrual cycle regularization); endocrine outcomes (Ferriman-Gallwey score, free androgen index, free testosterone and total testosterone levels); and glycaemic (fasting blood insulin, fasting blood glucose, homoeostatic model assessment) and weight-related (BMI) outcomes. We assessed the strength of evidence for significant outcomes as per the grading of recommendations assessment, development and evaluation (GRADE) system. We found twelve eligible systematic reviews which included between three (143 women) and 27 randomized trials (2093 women). Four reviews assessed the effects of lifestyle interventions (diet, physical activity and/or behavioural interventions); four evaluated nutritional supplements (one each on n-acetylcysteine, omega-3 fatty acids, inositol and vitamin D); and four studied alternative medical therapies (Chinese herbal medicine and acupuncture). All of the included reviews were of high quality and scored between 8 and 11 with the AMSTAR tool (with a maximum score of 11).Randomized evidence is lacking for live birth rate. N-acetylcysteine, inositol and the addition of alternative medicine to ovulation induction agents show preliminary potential to improve fertility (odds ratios (OR) for clinical pregnancy rate range from 1.99 to 4.83). Lifestyle interventions show benefits in improving hirsutism (mean difference (MD): -1.01 to -1.19). Lifestyle interventions (MD: -1.10 to -2.02), inositol (MD: -2.1) and acupuncture (MD: -1.90 to -3.43) all show some evidence of improvement in glycaemic outcomes and there is some evidence of reduced BMI with lifestyle interventions (MD: -0.15 to -1.12). All of these outcomes scored either low or very low quality of evidence on the GRADE score. Lifestyle interventions in women with PCOS appear to improve glycaemic results, androgenic symptoms and anthropometric outcomes. The role of inositol and N-acetylcysteine in women with PCOS needs further evaluation. Large primary trials on all interventions are needed for an agreed set of core outcomes.

Ageing well with chronic musculoskeletal pain: protocol for a systematic review of non-pharmacological interventions aimed at reducing pain in an ageing population

Background: Chronic musculoskeletal pain in the elderly is highly prevalent, with osteoarthritis, low back pain, neck pain and other musculoskeletal disorders as the leading contributors to pain chronicity and disability. Previous reviews identifying effective components of non-pharmacological interventions for treating chronic pain have either few studies or the included studies examine outcome over a limited time span. This systematic review will investigate the effectiveness and components of interventions associated with management of chronic musculoskeletal pain in older adults (≥65 years).Methods/Design: This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Randomised controlled trials of non-pharmacological interventions aimed at reducing pain in older adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, Web of Science and PEDro. Two review authors will independently screen articles retrieved from the search for eligibility, and extract relevant data on methodological issues. A narrative synthesis will be completed if there are insufficient data for a meta-analysis. The narrative synthesis will summarise the current state of knowledge, interventions, study designs and robustness of evidence.Discussion: Findings of the study will inform support programs and interventions to assist people aging with pain, carers and other supporters and practitioners.Systematic review registration: PROSPERO 2017:CRD42017074173.

A systematic review of non-pharmacological interventions for BPSD in nursing home residents with dementia: from a perspective of ergonomics.

Non-pharmacological interventions for Behavioral and Psychological Symptoms of Dementia (BPSD) have been developed; however, a systematic review on the effectiveness of this type of intervention from a perspective of ergonomics is lacking. According to ergonomics, the capabilities of Persons with Dementia (PwD) should be considered in the interventions for the outcomes to be reliable. We aimed to systematically review the non-pharmacological interventions for BPSD in nursing home residents with an additional assessment criterion based on ergonomics, specifically, capability consideration. The electronic databases MEDLINE, EMBASE, and PsycINFO were searched for non-pharmacological interventions treating BPSD in nursing homes. The interventions were categorized according to the capabilities of PwD required to participate. Study quality was assessed by National Health and Medical Research Council (NHMRC) evidence hierarchy and the capability consideration. Sixty-four clinical trials met the inclusion criteria; 41 trials reported a significant reduction in at least one BPSD symptom; 20 trials reported no significant reduction in BPSD symptoms; three trials reported adverse effects after the intervention. Interventions were categorized into sensory-, cognition-, and movement-oriented. Capabilities of PwD were not considered in 28 trials, especially for sensory capabilities. The majority of the clinical trials reported a significant reduction in BPSD. The quality of evidence for nonpharmacological interventions in these trials is low due to the lack of capability consideration, data inhomogeneity, and inadequate study design and reporting. Future studies should focus on improving the quality of evidence by including capability consideration and examining if a relationship between capability consideration and effectiveness of non-pharmacological interventions exists.

A systematic review of non-pharmacological interventions to improve nighttime sleep among residents of long-term care settings

BackgroundDisturbances in sleep and circadian rhythms are common among residents of long-term care facilities. In this systematic review, we aim to identify and evaluate the literature documenting the outcomes associated with non-pharmacological interventions to improve nighttime sleep among long-term care residents.MethodsThe Preferred Reporting Items for Systematic Reviews guided searches of five databases (MEDLINE, Embase, CINAHL, Scopus, and Cochrane Library) for articles reporting results of experimental or quasi-experimental studies conducted in long-term care settings (nursing homes, assisted-living facilities, or group homes) in which nighttime sleep was subjectively or objectively measured as a primary outcome. We categorized each intervention by its intended use and how it was administered.ResultsOf the 54 included studies evaluating the effects of 25 different non-pharmacological interventions, more than half employed a randomized controlled trial design (n = 30); the others used a pre-post design with (n = 11) or without (n = 13) a comparison group. The majority of randomized controlled trials were at low risk for most types of bias, and most other studies met the standard quality criteria. The interventions were categorized as environmental interventions (n = 14), complementary health practices (n = 12), social/physical stimulation (n = 11), clinical care practices (n = 3), or mind-body practices (n = 3). Although there was no clear pattern of positive findings, three interventions had the most promising results: increased daytime light exposure, nighttime use of melatonin, and acupressure.ConclusionsNon-pharmacological interventions have the potential to improve sleep for residents of long-term care facilities. Further research is needed to better standardize such interventions and provide clear implementation guidelines using cost-effective practices.

A Systematic Review of Nonpharmacological Interventions for Moderate to Severe Dementia: A Study Protocol for a Systematic Review and Meta-Analysis.

The study is designed as a systematic review on nonpharmacological interventions for patients with moderate to severe dementia. This review will be conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The following databases will be searched: Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, KoreaMED, KMbase, and KISS. The primary outcome will include the effect of the interventions on activities of daily living and behavioral and psychological symptoms of dementia. The literature search will be conducted based on search strategies designed for each database. The reviewers will independently assess the identified studies and extract the data. The risk of bias will be assessed and a meta-analysis will be conducted in accordance with the methodology for meta-analysis described in the Cochrane handbook. This systematic review will provide clinicians and policy makers with reliable evidence for developing and implementing nonpharmacological interventions for moderate to severe patients with dementia.

Non-pharmacological Interventions to Treat Clinical Symptoms in Patients with Dementia

Previous systematic reviews of non-pharmacological interventions for clinical symptoms in dementia patients have confirmed the effectiveness of cognitive stimulation therapy (CST) for cognitive impairment, exercise therapy for activities of daily living, and music therapy and behavior management techniques for behavioral and psychological symptoms of dementia (BPSD). A Japanese version of CST has been developed and is available, but standardized exercise therapy and music therapy have not been developed. It is also important for informal and formal caregivers to learn behavior management techniques. Thus, attempts are being made to promote the use of behavior management techniques in Japan. It is further important to incorporate non-pharmacological interventions into the daily life of dementia patients and to prevent the development of BPSD. In Japan, these interventions are usually provided in care services for elderly people and are covered by the Japanese long-term insurance system. Thus, it is advisable for dementia patients to start using these care services before they develop BPSD. The effectiveness of non-pharmacological interventions in patients with diseases causing dementia other than Alzheimer's disease has not yet been assessed.

Review of systematic reviews of non-pharmacological interventions to improve quality of life in cancer survivors

ObjectivesOver two million people in the UK are living with and beyond cancer. A third report diminished quality of life.DesignA review of published systematic reviews to identify effective non-pharmacological interventions...

Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. The SENATOR-OnTop series

ObjectiveTo provide an overview of non-pharmacological interventions for behavioural and psychological symptoms in dementia (BPSD).DesignSystematic overview of reviews.Data sourcesPubMed, EMBASE, Cochrane Database of Systematic Reviews, CINAHL and PsycINFO (2009–March 2015).Eligibility...

Effectiveness of Non-Pharmacological Interventions to Prevent Falls in Older People: A Systematic Overview. The SENATOR Project ONTOP Series.

BackgroundFalls are common events in older people, which cause considerable morbidity and mortality. Non-pharmacological interventions are an important approach to prevent falls. There are a large number of systematic reviews of non-pharmacological interventions, whose evidence needs to be synthesized in order to facilitate evidence-based clinical decision making.ObjectivesTo systematically examine reviews and meta-analyses that evaluated non-pharmacological interventions to prevent falls in older adults in the community, care facilities and hospitals.MethodsWe searched the electronic databases Pubmed, the Cochrane Database of Systematic Reviews, EMBASE, CINAHL, PsycINFO, PEDRO and TRIP from January 2009 to March 2015, for systematic reviews that included at least one comparative study, evaluating any non-pharmacological intervention, to prevent falls amongst older adults. The quality of the reviews was assessed using AMSTAR and ProFaNE taxonomy was used to organize the interventions.ResultsFifty-nine systematic reviews were identified which consisted of single, multiple and multifactorial non-pharmacological interventions to prevent falls in older people. The most frequent ProFaNE defined interventions were exercises either alone or combined with other interventions, followed by environment/assistive technology interventions comprising environmental modifications, assistive and protective aids, staff education and vision assessment/correction. Knowledge was the third principle class of interventions as patient education. Exercise and multifactorial interventions were the most effective treatments to reduce falls in older adults, although not all types of exercise were equally effective in all subjects and in all settings. Effective exercise programs combined balance and strength training. Reviews with a higher AMSTAR score were more likely to contain more primary studies, to be updated and to perform meta-analysis.ConclusionsThe aim of this overview of reviews of non-pharmacological interventions to prevent falls in older people in different settings, is to support clinicians and other healthcare workers with clinical decision-making by providing a comprehensive perspective of findings.

Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a systematic review of quantitative and qualitative research.

BackgroundCritically ill patients have an increased risk of developing delirium during their intensive care stay. To date, pharmacological interventions have not been shown to be effective for delirium management but non-pharmacological interventions have shown some promise. The aim of this systematic review is to identify effective non-pharmacological interventions for reducing the incidence or the duration of delirium in critically ill patients.MethodsWe will search MEDLINE, EMBASE, CINAHL, Web of Science, AMED, psycINFO and the Cochrane Library. We will include studies of critically ill adults and children. We will include randomised trials and controlled trials which measure the effectiveness of one or more non-pharmacological interventions in reducing incidence or duration of delirium in critically ill patients. We will also include qualitative studies that provide an insight into patients and their families’ experiences of delirium and non-pharmacological interventions. Two independent reviewers will assess studies for eligibility, extract data and appraise quality. We will conduct meta-analyses if possible or present results narratively. Qualitative studies will also be reviewed by two independent reviewers, and a specially designed quality assessment tool incorporating the CASP framework and the POPAY framework will be used to assess quality.DiscussionAlthough non-pharmacological interventions have been studied in populations outside of intensive care units and multicomponent interventions have successfully reduced incidence and duration of delirium, no systematic review of non-pharmacological interventions specifically targeting delirium in critically ill patients have been undertaken to date. This systematic review will provide evidence for the development of a multicomponent intervention for delirium management of critically ill patients that can be tested in a subsequent multicentre randomised trial.Systematic review registrationPROSPERO CRD42015016625Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0254-0) contains supplementary material, which is available to authorized users.

A systematic review of non-pharmacological interventions for primary Sjögren's syndrome.

Objective. To evaluate the effects of non-pharmacological interventions for primary SS (pSS) on outcomes falling within the World Health Organization International Classification of Functioning Disability and Health domains.Methods. We searched the following databases from inception to September 2014: Cochrane Database of Systematic Reviews; Medline; Embase; PsychINFO; CINAHL; and clinical trials registers. We included randomized controlled trials of any non-pharmacological intervention. Two authors independently reviewed titles and abstracts against the inclusion/exclusion criteria and independently assessed trial quality and extracted data.Results. A total of 1463 studies were identified, from which 17 full text articles were screened and 5 studies were included in the review; a total of 130 participants were randomized. The included studies investigated the effectiveness of an oral lubricating device for dry mouth, acupuncture for dry mouth, lacrimal punctum plugs for dry eyes and psychodynamic group therapy for coping with symptoms. Overall, the studies were of low quality and at high risk of bias. Although one study showed punctum plugs to improve dry eyes, the sample size was relatively small.Conclusion. Further high-quality studies to evaluate non-pharmacological interventions for PSS are needed.

O2.05: A review of systematic reviews of non-pharmacological interventions to prevent and treat delirium in older patients. The SENATOR project ONTOP series

O2.05: A review of systematic reviews of non-pharmacological interventions to prevent and treat delirium in older patients. The SENATOR project ONTOP series

204. A Systematic Review of Non-Pharmacological Interventions for Primary Sjögren’s Syndrome

204. A Systematic Review of Non-Pharmacological Interventions for Primary Sjögren’s Syndrome

Apathy after acquired brain impairment: A systematic review of non-pharmacological interventions

Apathy commonly occurs after acquired brain impairment. It is characterised by impaired initiative, diminished activity, and lack of concern; formally delineated as a decrease in cognitive, behavioural and emotional components of goal-directed activity. The impact is widespread, hampering rehabilitation and outcome. This systematic review identifies and assesses the efficacy of non-pharmacological treatments for apathy following four types of acquired brain impairment (traumatic brain injury, dementia, cerebrovascular accident, encephalitis). Nine databases were searched. Studies were reviewed according to the following criteria: age over 16 years, acquired brain impairment, non-pharmacological intervention for apathy, and data reported on treatment efficacy. The methodological quality of the studies was assessed. Searches yielded 1754 articles, with 28 meeting criteria. Methodological quality ranged greatly. The majority of trials involved the dementia population. Cognitive interventions were the most frequent mode of treatment. For those with severe impairments, the strongest evidence suggested music therapy and for milder impairment, the strongest evidence was for cognitive rehabilitation. This review reveals a need for more high quality, methodologically rigorous treatment studies for apathy, particularly within the milder ranges of impairment. Initially, however, a uniform operational definition needs to be utilised in all research studies to minimise variability. Additionally, employing a standardised outcome measure specific to apathy would greatly enhance comparison among treatments.