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Non-pharmacological strategies to prevent adrenal crisis during periods of psychological stress
Evidence review M
NICE Guideline, No. 243
1. Non-pharmacological interventions for psychological stress
1.1. Review question
What is the clinical and cost effectiveness of non-pharmacological strategies to prevent adrenal crisis during periods of psychological stress?
1.1.1. Introduction
Psychological stress may be a factor in precipitating or exacerbating adrenal crisis. A self-reported questionnaire-based study (White et al EJE) reported 1% of incidence of adrenal crisis being related to psychological stress. It is unclear how often this occurs as it is seen very rarely in clinical practice, and when it does is associated with severe sudden stress such as a bereavement. There is considerable variation in people’s experience of psychological stress and its contributing factors. Although some stress is a normal part of life for most people, people with adrenal insufficiency may benefit from reducing their risk of severe psychological stress and adjusting their medicines when these happen, to maintain their health and well-being. It is important to consider the impact of psychological stress as a triggering factor for adrenal crisis and to provide advice on non-pharmacological strategies including self-management strategies that may help reduce stress and avoid a crisis.
This review explores non-pharmacological strategies, such as patient support groups, talking therapies and advice to prevent adrenal crises during periods of psychological stress.
1.1.2. Summary of the protocol
For full details see the review protocol in Appendix A.
1.1.3. Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
1.1.4. Effectiveness evidence
1.1.4.1. Included studies
A search was conducted for randomised controlled trials (RCTs) and observational studies comparing non-pharmacological interventions for the management of psychological stress in people with adrenal insufficiency.
No relevant RCTs or observational studies were identified.
See also the study selection flow chart in Appendix C, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.
1.1.4.2. Excluded studies
See the excluded studies list in Appendix J.
1.1.5. Summary of studies included in the effectiveness evidence
No clinical studies were included.
1.1.6. Summary of the effectiveness evidence
No clinical studies were included.
1.1.7. Economic evidence
1.1.7.1. Included studies
No health economic studies were included.
1.1.7.2. Excluded studies
No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.
See also the health economic study selection flow chart in Appendix G.
1.1.8. Economic model
This area was not prioritised for new cost-effectiveness analysis.
1.1.9. Unit costs
Relevant unit costs are provided below to aid the consideration of cost-effectiveness.
1.2. The committee’s discussion and interpretation of the evidence
1.2.1. The outcomes that matter most
The committee considered all outcomes listed in the protocol to be critical and of equal importance in decision-making. These outcomes included mortality, Health-related quality of life, incidence of adrenal crisis, admission to hospital or ITU and psychological morbidities such as incidence of stress or PTSD.
1.2.2. The quality of the evidence
No evidence was identified for this review.
1.2.3. Benefits and harms
In the absence of any evidence, the committee wished to make consensus recommendations reflecting the best current practice. The aim of the recommendations is to highlight the significance of psychological and emotional stress as a triggering factor for adrenal crisis and to provide advice on non-pharmacological strategies to aid self-management of psychological stress and avoid an adrenal crisis.
The committee acknowledged the importance of condition-specific patient support groups and organisations in providing information and support particularly to newly diagnosed patients. Patient support groups and organisations can promote and signpost people to support services to help manage anxiety and stress, including increasing awareness of exploring adjustments that might be possible within the workplace or educational setting. The committee discussed, that newly diagnosed patients may not be aware or have the confidence to request support from organisations such as employers, schools, or universities to enable them to continue with everyday activities. The committee agreed it was important for people to know how to seek support if needed. The committee noted advising people and directing them on how they might access self-management strategies, such as exercise, or meditation can often help people in alleviating stress
The committee noted that people with adrenal insufficiency and diagnosed or undiagnosed anxiety or depression may need to be referred or advised to self-refer to NHS talking therapies or mental health services and decided to cross-refer to the recommendations in the NICE guideline on managing anxiety and depression.
1.2.4. Cost effectiveness and resource use
No economic evaluations were identified for this review; therefore, unit costs were presented to aid the committee’s consideration of cost-effectiveness. Unit costs were obtained for a range of healthcare professionals who may deliver non-pharmacological interventions listed in the protocol. In addition, the cost of Steroid Emergency Cards was also presented.
The committee made recommendations reflective of best practice that would be given in the form of information and advice, and in line with NICE guidelines on managing anxiety and depression. In instances where best practice is not currently implemented, these recommendations cover the provision of information which will likely only involve a couple of minutes of extra staff time on top of existing patient contact with healthcare professionals. The committee included a consider recommendation for referral or self-referral to NHS talking therapies or mental health services. These recommendations are in line with existing NICE guidelines for managing anxiety and depression, which will have considered cost-effectiveness and are considered current practice. Therefore, these recommendations are not expected to result in a significant resource impact.
1.2.5. Recommendations supported by this evidence review
This evidence review supports recommendations 1.5.4 – 1.5.5.
References
- 1.
- Jones K, Burns A. Unit costs of health and social care 2021. Canterbury. Personal Social Services Research Unit University of Kent, 2021. Available from: https://www
.pssru.ac .uk/project-pages/unit-costs /unit-costs-of-health-and-social-care-2021/ - 2.
- National Institute for Health and Care Excellence. Developing NICE guidelines: the manual. London. National Institute for Health and Care Excellence, 2014. Available from: https://www
.nice.org .uk/process/pmg20/chapter/introduction [PubMed: 26677490] - 3.
- Simpson H. New NHS Steroid Emergency Card: Available to order. Endocrinologist. 2020; (137)
Appendices
Appendix A. Review protocols
A.1. Review protocol for non-pharmacological management during periods of psychological stress (PDF, 195K)
A.2. Health economic review protocol (PDF, 134K)
Appendix B. Literature search strategies
The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.2
For more information, please see the Methodology review published as part of the accompanying documents for this guideline.
B.1. Clinical search literature search strategy
Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies as these concepts may not be indexed or described in the title or abstract and are therefore difficult to retrieve. Search filters were applied to the search where appropriate.
Download PDF (251K)
B.2. Health Economics literature search strategy
Health economic evidence was identified by conducting searches using terms for a broad Adrenal Insufficiency population. The following databases were searched: NHS Economic Evaluation Database (NHS EED - this ceased to be updated after 31st March 2015), Health Technology Assessment database (HTA - this ceased to be updated from 31st March 2018) and The International Network of Agencies for Health Technology Assessment (INAHTA). Searches for recent evidence were run on Medline and Embase from 2014 onwards.
Download PDF (166K)
Appendix C. Effectiveness evidence study selection
Download PDF (98K)
Appendix D. Effectiveness evidence
No clinical effectiveness evidence was identified.
Appendix E. Forest plots
No forest plots included in this review.
Appendix F. GRADE
No evidence was identified in this review.
Appendix G. Economic evidence study selection
Download PDF (172K)
Appendix H. Economic evidence tables
None.
Appendix I. Health economic model
No original economic modelling was undertaken for this review question.
Appendix J. Excluded studies
J.1. Clinical studies
Table 7Studies excluded from the clinical review
| Study | Reasons for exclusion |
|---|---|
| Burger-Stritt, Stephanie, Eff, Annemarie, Quinkler, Marcus et al (2020) Standardised patient education in adrenal insufficiency: a prospective multi-centre evaluation. European journal of endocrinology 183(2): 119–127 [PubMed: 32580144] | - Study does not address our clinical question |
| Halpin, K.L.; Paprocki, E.L.; McDonough, R.J. (2019) Utilizing health information technology to improve the recognition and management of life-threatening adrenal crisis in the pediatric emergency department: Medical alert identification in the 21st century. Journal of Pediatric Endocrinology and Metabolism 32(5): 513–518 [PubMed: 31042645] | - Study does not address our clinical question |
| Repping-Wuts, H.J.W.J., Stikkelbroeck, N.M.M.L., Noordzij, A. et al (2013) A glucocorticoid education group meeting: An effective strategy for improving self-management to prevent adrenal crisis. European Journal of Endocrinology 169(1): 17–22 [PubMed: 23636446] | - Study design not relevant to this review protocol |
| Vidmar, Alaina P, Weber, Jonathan F, Monzavi, Roshanak et al (2018) Improved medical-alert ID ownership and utilization in youth with congenital adrenal hyperplasia following a parent educational intervention. Journal of pediatric endocrinology & metabolism : JPEM 31(2): 213–219 [PMC free article: PMC7140978] [PubMed: 29315077] | - Study does not address our clinical question |
J.2. Health Economic studies
None.
Tables
Table 1PICO characteristics of review question
| Population |
Inclusion: People with adrenal insufficiency (primary, secondary, or tertiary) who are diagnosed or presumed adrenal insufficiency including the following groups: Strata:
Exclusion: None specified. |
| Interventions |
|
| Comparisons |
|
| Outcomes |
All outcomes are considered equally important for decision making and therefore have all been rated as critical:
Follow up: Medium 6 months to a year If evidence only available for less than 6 months this will be included and downgraded for indirectness |
| Study design |
Systematic reviews of RCTs and RCTs will be considered for inclusion. Cross-over trials will also be considered for inclusion regardless of washout period. If insufficient RCT evidence is available, a search for non-randomised studies will be considered if they have conducted a multivariate analysis adjusting for at least 3–4 of the following key confounders:
Published NMAs and IPDs will be considered for inclusion. |
Table 2Staff costs associated with non-pharmacological interventions
| Resource | Cost per hour |
|---|---|
| Nurse | |
| Band 5 | £43.78 |
| Band 6 | £53.87 |
| Band 7 | £64.27 |
| Pharmacist | |
| Band 6 | £54.71 |
| Band 7 | £65.73 |
| Psychologist | |
| Band 5 | £52.72 |
| Band 6 | £63.74 |
| Band 7 | £73.03 |
| Band 8a | £85.81 |
| Band 8b | £101.47 |
| Psychiatrist | |
| Speciality register (48-hour week) | £68.89 |
| Speciality register (56-hour week) | £58.96 |
| Associate specialist | £144.22 |
| Consultant | £152.65 |
Source: PSSRU 2020/211 including qualification costs (and excluding individual productivity costs)
Table 3Other costs associated with non-pharmacological interventions
| Resource | Unit costs |
|---|---|
| Steroid emergency card (100 cards) | £2.65 |
Source: Society for Endocrinology,3 cost excludes VAT
Final
Evidence reviews underpinning recommendations 1.5.4 to 1.5.5 in the NICE guideline
This evidence review was developed by NICE
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.