- Email: [email protected]
Mental health and the 2012 US election
Comment
trained in public health or operated within the public health profession. A range of leadership styles were identified that aligned well with published tools.3 Common traits were identified: public health superheroes are exceptional “networker–connectors” capable of “putting the pieces of the jigsaw together”; they combine administrative excellence with a strong sense of professional welfare and actively develop the profession, articulate its shared values, and build for the future. Surprisingly, not all the nominated public health superheroes were exceptional communicators, and, as one respondent noted, had to “invest quite a bit of time in the ‘telling’ to get buy in from others”. Additionally, respondents voiced concern that the “corporatisation” of public health had stifled the ability of leaders to “speak out as independent advocates for the health of the population”. Our initial qualitative work has led us to recommend three approaches to better train and develop public health leaders. First, leadership programmes should be targeted to individuals who are moving from narrower management positions to public health leadership positions; such programmes can learn from evidence in areas outside of public health.4 Second, public health training needs a greater focus on understanding and applying constructs of power and authority in a range of settings to help develop skills that influence policy. However, this in itself is not possible without a coherent identity for public health, its values, and the sharing of
international lessons. Public health policy is increasingly multinational and many countries share similar problems, yet public health remains a small discipline in many countries. So, third, lessons and good practice should be shared regularly and widely. For leaders from within public health, refocusing public health training on leadership and helping people move up to the next leadership level is a priority (figure). For those who come from outside the profession, we need to better recruit level 5 leaders who can improve the performance of their own organisations and sectors whilst serving as allies for the public health agenda. *Matthew Day, Darren Shickle, Kevin Smith, Ken Zakariasen, Tom Oliver, Jacob Moskol Academic Unit of Public Health, University of Leeds, Leeds LS2 9LJ, UK (MD, DS, KS); Department of Public Health Sciences , University of Alberta, Edmonton Clinic Health Academy, AB, Canada (KZ); and School of Medicine and Public Health (TO) and Global Health Institute (JM), University of Wisconsin, Madison, WI, USA [email protected] We declare that we have no conflicts of interest. We thank all of the interviewees, the Worldwide Universities Network as the funding source for this project, and the UK Faculty of Public Health. 1 2 3 4
Horton R. 2011. Offline. Where is public health leadership in England? Lancet 2011; 378: 1060. Collins J. Good to great and the social sectors: a monograph to accompany good to great. London: Cornerstone/Random House Business Books, 2006. Posner BZ, Kouzes JM. Development and validation of the Leadership Practices Inventory. Educ Psychol Measurement 1988; 48: 483–96. Watkins MD. How managers become leaders. The seven seismic shifts of perspective and responsibility. Harv Bus Rev 2012; 90: 64–72.
Corbis
Mental health and the 2012 US election
See Editorial page 1203
1206
Nov 6, 2012 will be a milestone for health care in the USA.1,2 The national and local elections held that day will also have a lasting effect on psychiatric care, because they will affect how many people with mental illnesses will have access to care and how much care they will be able to access. About one in four adults (nearly 60 million people) in the USA has a diagnosable mental disorder in any given year, and one in 17 has a serious mental illness. Psychiatric disorders are the most common cause of disability in the country.3 People with serious mental illnesses need years, if not decades, of continued psychosocial and pharmacological treatment; consistency of care is necessary to avoid relapses that can
have devastating effects on patients and their families. However, fewer than 40% of patients with serious mental illnesses receive stable treatment in the USA.4 Millions of Americans with psychiatric disorders do not have adequate health insurance, and even those who have insurance are often deprived of needed treatments. These people, who do not have the support of rich or powerful lobbies, are always vulnerable to the politics of the moment. But the upcoming elections are special, and will help to decide if psychiatric patients will join the mainstream in getting the health care they need or if they will continue to be one of the most disenfranchised sectors of society. This Comment is not intended to endorse the platform of any political party, but rather to www.thelancet.com Vol 380 October 6, 2012
Comment
provide an outline of how the two main parties’ positions will affect the health of people with psychiatric disorders. For psychiatry, the fate of President Barack Obama’s signature Patient Protection and Affordable Care Act (ACA)5 is key. The US Supreme Court recently upheld the law with one caveat—it allowed individual states to opt out of the requirement for provision of health care to uninsured people with low incomes. Many poor people with mental illnesses who do not meet the strict financial threshold for federal Medicare depend on state-provided Medicaid for their health care. Therefore, state elections will also affect health-care reform. Most Democrats support much of the ACA, whereas Republicans generally oppose several of its key provisions. People with psychiatric diseases are much more likely to be unemployed, poor, and uninsured than the general population. The ACA “promises to give Americans something they have never had before: near-universal health insurance” for physical and psychiatric disorders, irrespective of the ability to pay for insurance coverage.6 A serious issue for psychiatric patients is social stigma, which has led to discriminatory healthinsurance practices. People with mental illnesses and substance-use disorders face ungenerous annual and lifetime caps on coverage, increased deductibles, or no coverage at all.6 The most meaningful attempt to rectify this gross injustice was the Mental Health Parity and Addiction Equity Act of 2008,7 which was approved by a bipartisan majority. This act mandated that psychiatric disorders be covered in the same way as other illnesses. However, it did not require every insurance plan to offer benefits for mental health and substance-use disorders, and did not create a mechanism to monitor enforcement. Consequently, parity remains a dream for many people with mental disorders. The ACA prohibits denial of coverage based on pre-existing mental or substance-use disorders, bans lifetime or annual dollar limits, and allows single individuals younger than 26 years to remain on their parents’ insurance—an important benefit for those people who develop psychiatric illness in youth.5 These measures will help to provide access to health care for many people who do not currently have it. Whereas the Democratic platform supports the ACA,8 the Republican platform is committed to its repeal.9 The Republican Party has indicated that it would retain a ban on exclusions of pre-existing disorders and a prohibition www.thelancet.com Vol 380 October 6, 2012
on dropping coverage because of illness, and would extend coverage for dependants until age 26 years. These initiatives are encouraging. However, many currently uninsured people who would be covered by the ACA could remain uninsured because of the Republicans’ focus on cost cutting. Thus, at least in the short run, overturning or substantially weakening the ACA would have an adverse effect on mental health care.10 The Republican Party emphasises personal empowerment, and believes that balancing the government budget will improve the overall economy, which would lead to increased job creation and so improved health-care access for all. However, people with serious mental illnesses need extra help to get appropriate jobs and adequate insurance to end the vicious cycle of psychopathology and poverty. The Massachusetts health-care insurance reform law of 2006 is a state-level version of the ACA, signed by then-Governor Mitt Romney (who, as the Republican presidential candidate, opposes the ACA at national level). The Massachusetts law mandates that nearly every resident of the state obtain a minimum standard of health-insurance coverage, and provides free insurance for poor residents. During the first four years of the reform, the proportion of uninsured state residents fell from 6% to 2%. Although some critics have complained of increased health-care spending, the state government has reported better overall self-assessed health and improvements in physical health, mental health, and functional limitations.11,12 Political opposition to the ACA is not limited to insurance. The law also includes support for research into and treatment for depression, comparative effectiveness research, and community mental health centres, all of which could be eliminated if the law is repealed. The present House Republican Funding Bill13 would also terminate the Agency for Healthcare Research and Quality, and the new patient-centred outcomes research it oversees. Budgets for the National Institutes of Health and the Centers for Disease Control and Prevention would be unchanged or reduced, which would mean limits on research and training. Personally, I am greatly frustrated by the failure to implement parity of mental health coverage.6 How can any sensible person believe that mental illnesses, which are disorders of the brain, are any less deserving of treatment than those that affect the lungs or liver? The average lifespan of someone with a serious mental illness 1207
Comment
is 20 years shorter than that of the general population, and the gap has widened during recent decades. As an old age psychiatrist, I also worry about the rapidly growing numbers of older people with mental illnesses, who suffer from the dual stigma of old age and mental illness, and have disproportionately high rates of suicide.14 Research has shown that preventive psychiatry, even in older people, is not an oxymoron;15 however, we are not even providing basic care for many mentally ill individuals. When will the US health-care system agree to allocate the resources needed to improve mental health care to prevent avoidable morbidity and mortality in patients with psychiatric disorders? Any discussion of the effect of election results on mental health care must note that long-term effects of elections cannot be predicted with certainty. Politicians can and do change their positions after winning (or losing). Also, in our increasingly interconnected world, unrelated factors such as economic crises in other countries might have substantial effects on US health-care reform. We can only hope that, in the end, basic principles of fairness, compassion, and care for all will win the day.
1 2 3
4 5
6
7
8
9 10 11
12
13
Dilip V Jeste Department of Psychiatry, University of California, San Diego, CA 92093–0664, USA [email protected] I am president of the American Psychiatric Association. I declare that I have no conflicts of interest.
14
15
Blumenthal D. A watershed election for health care. N Engl J Med 2011; 365: 2047–49. Jones DK. The fate of health care reform—what to expect in 2012. N Engl J Med 2012; 366: e7. National Institute of Mental Health. The numbers count: mental disorders in America. http://www.nimh.nih.gov/health/publications/the-numberscount-mental-disorders-in-america/index.shtml (accessed July 30, 2012). Kessler RC, Berglund PA, Bruce ML, et al. The prevalence and correlates of untreated serious mental illness. Health Serv Res 2001; 36: 987–1007. The Patient Protection and Affordable Care Act. 111th Congress Public Law 148. http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/ PLAW-111publ148.htm (accessed July 30, 2012). Friedman R. Good news for mental illness in health law. The New York Times July 9, 2012. http://www.nytimes.com/2012/07/10/health/policy/ health-care-law-offers-wider-benefits-for-treating-mental-illness.html (accessed Aug 6, 2012). US Department of Labor. Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). http://www.dol.gov/ebsa/newsroom/fsmhpaea.html (accessed Aug 6, 2012). 2012 Democratic National Convention. Moving American forward: 2012 Democratic national platform. http://assets.dstatic.org/ dnc-platform/2012-National-Platform.pdf (accessed Aug 21, 2012). 2012 Republican Party platform. http://whitehouse12.com/ republican-party-platform/ (accessed Aug 31, 2012). Moran M. Affordable Care Act has benefits for people with psychiatric illness. Psychiatric News 2012; 47: 1a–27. Massachusetts Taxpayer Foundation. Massachusetts health reform spending, 2006–2011: an update on the “budget buster” myth. Boston, MA: Massachusetts Taxpayer Foundation. http://www.masstaxpayers.org/ sites/masstaxpayers.org/files/Health%20Reform%20Report.pdf (accessed Sept 3, 2012). Courtemanche CJ, Zapata D. Does universal coverage improve health? The Massachusetts experience (NBER Working Paper No 17893, March 2012). http://papers.nber.org/papers/w17893?ntw (accessed Aug 31, 2012). House of Representatives Report No 112 (112th Congress, 2nd Session), 2012. http://appropriations. house·90v/uploadedfiles/bills-112hr-sc-apfy13-laborhhsed.pdf (accessed Aug 20, 2012). Jeste DV, Alexopoulos GS, Bartels SJ, et al. Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next two decades. Arch Gen Psychiatry 1999; 56: 848–53. Jeste DV, Bell CC. Preface—prevention in mental health: lifespan perspective. Psychiatr Clin North Am 2011; 34: xiii–xvi.
Assessment of stent retrievers in acute ischaemic stroke Published Online August 26, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61302-6 See Articles pages 1231 and 1241
1208
There has been healthy scepticism about the use of mechanical clot retrieval devices in the treatment of acute ischaemic stroke. Such devices give higher rates of recanalisation than does counterpart treatment with intravenous recombinant tissue plasminogen activator (rt-PA), but might not be associated with improvements in outcome for patients.1 Analysis of the National Inpatient Sample of almost 4000 patients who received endovascular clot retrieval therapy for acute ischaemic stroke showed that about 75% had either died in hospital or were discharged to long-term care facilities.2 A data synthesis of neurothrombectomy studies in acute ischaemic stroke concluded that although the devices provide intriguing treatment options, there was little evidence to support their use in routine practice,
and adequately powered randomised controlled trials were needed to prove at least equivalency or noninferiority between treatment strategies or devices.3 These and other findings culminated in the American College of Chest Physicians’ 2012 evidence-based guideline statement, which suggested against the use of mechanical thrombectomy for acute ischaemic stroke.4 Finally, another blow to the advocacy for use of mechanical retrieval devices was the recent early termination for futility in terms of efficacy of the Interventional Management of Stroke (IMS) III trial.5 In view of the limitations in efficacy of intravenous rt-PA in acute ischaemic stroke, researchers have been looking for better techniques to achieve recanalisation of major cerebral arteries and, importantly, reperfusion www.thelancet.com Vol 380 October 6, 2012
trained in public health or operated within the public health profession. A range of leadership styles were identified that aligned well with published tools.3 Common traits were identified: public health superheroes are exceptional “networker–connectors” capable of “putting the pieces of the jigsaw together”; they combine administrative excellence with a strong sense of professional welfare and actively develop the profession, articulate its shared values, and build for the future. Surprisingly, not all the nominated public health superheroes were exceptional communicators, and, as one respondent noted, had to “invest quite a bit of time in the ‘telling’ to get buy in from others”. Additionally, respondents voiced concern that the “corporatisation” of public health had stifled the ability of leaders to “speak out as independent advocates for the health of the population”. Our initial qualitative work has led us to recommend three approaches to better train and develop public health leaders. First, leadership programmes should be targeted to individuals who are moving from narrower management positions to public health leadership positions; such programmes can learn from evidence in areas outside of public health.4 Second, public health training needs a greater focus on understanding and applying constructs of power and authority in a range of settings to help develop skills that influence policy. However, this in itself is not possible without a coherent identity for public health, its values, and the sharing of
international lessons. Public health policy is increasingly multinational and many countries share similar problems, yet public health remains a small discipline in many countries. So, third, lessons and good practice should be shared regularly and widely. For leaders from within public health, refocusing public health training on leadership and helping people move up to the next leadership level is a priority (figure). For those who come from outside the profession, we need to better recruit level 5 leaders who can improve the performance of their own organisations and sectors whilst serving as allies for the public health agenda. *Matthew Day, Darren Shickle, Kevin Smith, Ken Zakariasen, Tom Oliver, Jacob Moskol Academic Unit of Public Health, University of Leeds, Leeds LS2 9LJ, UK (MD, DS, KS); Department of Public Health Sciences , University of Alberta, Edmonton Clinic Health Academy, AB, Canada (KZ); and School of Medicine and Public Health (TO) and Global Health Institute (JM), University of Wisconsin, Madison, WI, USA [email protected] We declare that we have no conflicts of interest. We thank all of the interviewees, the Worldwide Universities Network as the funding source for this project, and the UK Faculty of Public Health. 1 2 3 4
Horton R. 2011. Offline. Where is public health leadership in England? Lancet 2011; 378: 1060. Collins J. Good to great and the social sectors: a monograph to accompany good to great. London: Cornerstone/Random House Business Books, 2006. Posner BZ, Kouzes JM. Development and validation of the Leadership Practices Inventory. Educ Psychol Measurement 1988; 48: 483–96. Watkins MD. How managers become leaders. The seven seismic shifts of perspective and responsibility. Harv Bus Rev 2012; 90: 64–72.
Corbis
Mental health and the 2012 US election
See Editorial page 1203
1206
Nov 6, 2012 will be a milestone for health care in the USA.1,2 The national and local elections held that day will also have a lasting effect on psychiatric care, because they will affect how many people with mental illnesses will have access to care and how much care they will be able to access. About one in four adults (nearly 60 million people) in the USA has a diagnosable mental disorder in any given year, and one in 17 has a serious mental illness. Psychiatric disorders are the most common cause of disability in the country.3 People with serious mental illnesses need years, if not decades, of continued psychosocial and pharmacological treatment; consistency of care is necessary to avoid relapses that can
have devastating effects on patients and their families. However, fewer than 40% of patients with serious mental illnesses receive stable treatment in the USA.4 Millions of Americans with psychiatric disorders do not have adequate health insurance, and even those who have insurance are often deprived of needed treatments. These people, who do not have the support of rich or powerful lobbies, are always vulnerable to the politics of the moment. But the upcoming elections are special, and will help to decide if psychiatric patients will join the mainstream in getting the health care they need or if they will continue to be one of the most disenfranchised sectors of society. This Comment is not intended to endorse the platform of any political party, but rather to www.thelancet.com Vol 380 October 6, 2012
Comment
provide an outline of how the two main parties’ positions will affect the health of people with psychiatric disorders. For psychiatry, the fate of President Barack Obama’s signature Patient Protection and Affordable Care Act (ACA)5 is key. The US Supreme Court recently upheld the law with one caveat—it allowed individual states to opt out of the requirement for provision of health care to uninsured people with low incomes. Many poor people with mental illnesses who do not meet the strict financial threshold for federal Medicare depend on state-provided Medicaid for their health care. Therefore, state elections will also affect health-care reform. Most Democrats support much of the ACA, whereas Republicans generally oppose several of its key provisions. People with psychiatric diseases are much more likely to be unemployed, poor, and uninsured than the general population. The ACA “promises to give Americans something they have never had before: near-universal health insurance” for physical and psychiatric disorders, irrespective of the ability to pay for insurance coverage.6 A serious issue for psychiatric patients is social stigma, which has led to discriminatory healthinsurance practices. People with mental illnesses and substance-use disorders face ungenerous annual and lifetime caps on coverage, increased deductibles, or no coverage at all.6 The most meaningful attempt to rectify this gross injustice was the Mental Health Parity and Addiction Equity Act of 2008,7 which was approved by a bipartisan majority. This act mandated that psychiatric disorders be covered in the same way as other illnesses. However, it did not require every insurance plan to offer benefits for mental health and substance-use disorders, and did not create a mechanism to monitor enforcement. Consequently, parity remains a dream for many people with mental disorders. The ACA prohibits denial of coverage based on pre-existing mental or substance-use disorders, bans lifetime or annual dollar limits, and allows single individuals younger than 26 years to remain on their parents’ insurance—an important benefit for those people who develop psychiatric illness in youth.5 These measures will help to provide access to health care for many people who do not currently have it. Whereas the Democratic platform supports the ACA,8 the Republican platform is committed to its repeal.9 The Republican Party has indicated that it would retain a ban on exclusions of pre-existing disorders and a prohibition www.thelancet.com Vol 380 October 6, 2012
on dropping coverage because of illness, and would extend coverage for dependants until age 26 years. These initiatives are encouraging. However, many currently uninsured people who would be covered by the ACA could remain uninsured because of the Republicans’ focus on cost cutting. Thus, at least in the short run, overturning or substantially weakening the ACA would have an adverse effect on mental health care.10 The Republican Party emphasises personal empowerment, and believes that balancing the government budget will improve the overall economy, which would lead to increased job creation and so improved health-care access for all. However, people with serious mental illnesses need extra help to get appropriate jobs and adequate insurance to end the vicious cycle of psychopathology and poverty. The Massachusetts health-care insurance reform law of 2006 is a state-level version of the ACA, signed by then-Governor Mitt Romney (who, as the Republican presidential candidate, opposes the ACA at national level). The Massachusetts law mandates that nearly every resident of the state obtain a minimum standard of health-insurance coverage, and provides free insurance for poor residents. During the first four years of the reform, the proportion of uninsured state residents fell from 6% to 2%. Although some critics have complained of increased health-care spending, the state government has reported better overall self-assessed health and improvements in physical health, mental health, and functional limitations.11,12 Political opposition to the ACA is not limited to insurance. The law also includes support for research into and treatment for depression, comparative effectiveness research, and community mental health centres, all of which could be eliminated if the law is repealed. The present House Republican Funding Bill13 would also terminate the Agency for Healthcare Research and Quality, and the new patient-centred outcomes research it oversees. Budgets for the National Institutes of Health and the Centers for Disease Control and Prevention would be unchanged or reduced, which would mean limits on research and training. Personally, I am greatly frustrated by the failure to implement parity of mental health coverage.6 How can any sensible person believe that mental illnesses, which are disorders of the brain, are any less deserving of treatment than those that affect the lungs or liver? The average lifespan of someone with a serious mental illness 1207
Comment
is 20 years shorter than that of the general population, and the gap has widened during recent decades. As an old age psychiatrist, I also worry about the rapidly growing numbers of older people with mental illnesses, who suffer from the dual stigma of old age and mental illness, and have disproportionately high rates of suicide.14 Research has shown that preventive psychiatry, even in older people, is not an oxymoron;15 however, we are not even providing basic care for many mentally ill individuals. When will the US health-care system agree to allocate the resources needed to improve mental health care to prevent avoidable morbidity and mortality in patients with psychiatric disorders? Any discussion of the effect of election results on mental health care must note that long-term effects of elections cannot be predicted with certainty. Politicians can and do change their positions after winning (or losing). Also, in our increasingly interconnected world, unrelated factors such as economic crises in other countries might have substantial effects on US health-care reform. We can only hope that, in the end, basic principles of fairness, compassion, and care for all will win the day.
1 2 3
4 5
6
7
8
9 10 11
12
13
Dilip V Jeste Department of Psychiatry, University of California, San Diego, CA 92093–0664, USA [email protected] I am president of the American Psychiatric Association. I declare that I have no conflicts of interest.
14
15
Blumenthal D. A watershed election for health care. N Engl J Med 2011; 365: 2047–49. Jones DK. The fate of health care reform—what to expect in 2012. N Engl J Med 2012; 366: e7. National Institute of Mental Health. The numbers count: mental disorders in America. http://www.nimh.nih.gov/health/publications/the-numberscount-mental-disorders-in-america/index.shtml (accessed July 30, 2012). Kessler RC, Berglund PA, Bruce ML, et al. The prevalence and correlates of untreated serious mental illness. Health Serv Res 2001; 36: 987–1007. The Patient Protection and Affordable Care Act. 111th Congress Public Law 148. http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/ PLAW-111publ148.htm (accessed July 30, 2012). Friedman R. Good news for mental illness in health law. The New York Times July 9, 2012. http://www.nytimes.com/2012/07/10/health/policy/ health-care-law-offers-wider-benefits-for-treating-mental-illness.html (accessed Aug 6, 2012). US Department of Labor. Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). http://www.dol.gov/ebsa/newsroom/fsmhpaea.html (accessed Aug 6, 2012). 2012 Democratic National Convention. Moving American forward: 2012 Democratic national platform. http://assets.dstatic.org/ dnc-platform/2012-National-Platform.pdf (accessed Aug 21, 2012). 2012 Republican Party platform. http://whitehouse12.com/ republican-party-platform/ (accessed Aug 31, 2012). Moran M. Affordable Care Act has benefits for people with psychiatric illness. Psychiatric News 2012; 47: 1a–27. Massachusetts Taxpayer Foundation. Massachusetts health reform spending, 2006–2011: an update on the “budget buster” myth. Boston, MA: Massachusetts Taxpayer Foundation. http://www.masstaxpayers.org/ sites/masstaxpayers.org/files/Health%20Reform%20Report.pdf (accessed Sept 3, 2012). Courtemanche CJ, Zapata D. Does universal coverage improve health? The Massachusetts experience (NBER Working Paper No 17893, March 2012). http://papers.nber.org/papers/w17893?ntw (accessed Aug 31, 2012). House of Representatives Report No 112 (112th Congress, 2nd Session), 2012. http://appropriations. house·90v/uploadedfiles/bills-112hr-sc-apfy13-laborhhsed.pdf (accessed Aug 20, 2012). Jeste DV, Alexopoulos GS, Bartels SJ, et al. Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next two decades. Arch Gen Psychiatry 1999; 56: 848–53. Jeste DV, Bell CC. Preface—prevention in mental health: lifespan perspective. Psychiatr Clin North Am 2011; 34: xiii–xvi.
Assessment of stent retrievers in acute ischaemic stroke Published Online August 26, 2012 http://dx.doi.org/10.1016/ S0140-6736(12)61302-6 See Articles pages 1231 and 1241
1208
There has been healthy scepticism about the use of mechanical clot retrieval devices in the treatment of acute ischaemic stroke. Such devices give higher rates of recanalisation than does counterpart treatment with intravenous recombinant tissue plasminogen activator (rt-PA), but might not be associated with improvements in outcome for patients.1 Analysis of the National Inpatient Sample of almost 4000 patients who received endovascular clot retrieval therapy for acute ischaemic stroke showed that about 75% had either died in hospital or were discharged to long-term care facilities.2 A data synthesis of neurothrombectomy studies in acute ischaemic stroke concluded that although the devices provide intriguing treatment options, there was little evidence to support their use in routine practice,
and adequately powered randomised controlled trials were needed to prove at least equivalency or noninferiority between treatment strategies or devices.3 These and other findings culminated in the American College of Chest Physicians’ 2012 evidence-based guideline statement, which suggested against the use of mechanical thrombectomy for acute ischaemic stroke.4 Finally, another blow to the advocacy for use of mechanical retrieval devices was the recent early termination for futility in terms of efficacy of the Interventional Management of Stroke (IMS) III trial.5 In view of the limitations in efficacy of intravenous rt-PA in acute ischaemic stroke, researchers have been looking for better techniques to achieve recanalisation of major cerebral arteries and, importantly, reperfusion www.thelancet.com Vol 380 October 6, 2012