The case for practical clinical trials in psychiatry

Navigating the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study: practical outcomes and implications for depression treatment in primary care

The Sequenced Treatment Alternatives to Relieve Depression (STAR( *)D) study addressed many clinically relevant issues on treatment of depressed outpatients. The study used an equipoise-stratified randomization scheme that enhanced the real-world expediency of treatment options studied. Because patients who had significant comorbid medical and psychiatric problems were included, and care was provided in the outpatient primary care setting as well as in outpatient psychiatric centers, findings are relevant to primary care physicians. The use of measurement-based treatment protocols promotes objectivity in a realm of often subjective clinical decision making. Although STAR( *)D was unable to provide specific treatment comparisons for patients at all study levels, it succeeded in defining the prevalence of treatment-resistant depression and is a model for further practical clinical outcomes studies.

Long-acting medications for the hyperkinetic disorders. A note on cost-effectiveness

New long-acting medications for attention-deficit/ hyperactivity disorder (ADHD) have become available, which combine certain advantages over conventional short-acting drugs with higher acquisition costs. Choices between these drugs should thus be driven by their clinical profiles and by an acceptable balance of increased costs and additional benefits. Accordingly, the notion of relative cost-effectiveness should be central to recommendations about the use of these drugs in practice. A recent technology assessment on behalf of the National Institute for Health and Clinical Excellence (NICE) did not identify differences between compounds in terms of clinical efficacy and described drug cost as the major driver of cost-effectiveness. The underlying economic model was restricted to a cost-utility analysis that used only a fraction of the available clinical evidence base and did not address the distinction between efficacy and effectiveness. Cost-effectiveness evaluations including the potential impact of improved treatment compliance indicate a relatively more attractive cost-effectiveness of long-acting medications than suggested by the NICE assessment. These evaluations provide health economic support to treatment recommendations recently published by the European Network for Hyperkinetic Disorders. Limitations of currently available economic evaluations include their short time horizon, and future research should assess treatment effects on long-term sequelae associated with ADHD.

Balancing efficacy and safety in treatment with antipsychotics

Balancing efficacy with tolerability and safety of prescribed treatments is critical to optimizing antipsychotic treatment outcomes in the mentally ill. Symptom control, symptom remission, and functional recovery are only realistic goals when treatments are both effective and well tolerated. The consideration of predictable differences in antipsychotic adverse-effect profiles is central to successful illness management. Minimizing adverse effects on alertness, motivation, cognition, sexual/reproductive functioning, and physical health enhances mental health outcomes, partly through improving treatment adherence. Neuroendocrine and metabolic side effects of antipsychotics for cardiovascular morbidity and mortality need to be addressed proactively and aggressively. In view of the widespread lack of primary care engagement and the adverse effects of psychotropic medications on cardiovascular health, psychiatric care providers should function as key facilitators of an integrated mental and physical health management approach. In addition to psychoeducation and healthy lifestyle counseling, clinicians can improve psychiatric and physical health by selecting medications carefully, routinely screening and monitoring for reversible cardiovascular risk factors, and playing an active role in the prevention and interdisciplinary management of cardiovascular risk factors and medical illness in the vulnerable mentally ill.

AACAP 2005 Research Forum: speeding the adoption of evidence-based practice in pediatric psychiatry

OBJECTIVES

At the 2005 Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), the Academy's Workgroup on Research conducted a Research Forum entitled "Increasing Research Literacy Through the Adoption of Evidence-Based Practice (EBP) in Pediatric Psychiatry."

METHOD

Forum participants focused on speeding the adoption of EBP across five areas: EBP as the preferred heuristic for teaching research literacy, use of EBP in training programs, dissemination of EBP in clinical practice, EBP in partnership with industry, and EBP as a framework for developing practice guidelines.

RESULTS

EBP provides an easy-to-understand method for accessing and evaluating the research literature and then applying this information to decisions about patient care. Although EBP has been gaining greater visibility in pediatric psychiatry, it is far from the preferred heuristic. To move the field toward fully embracing EBP will require greater understanding of what EBP is (and is not), educating mental health professionals in EBP skills, access to EBP resources, and a commitment to apply EBP to the conceptualization and design of research protocols and practice guidelines.

CONCLUSIONS

Pediatric psychiatry would benefit from a principled commitment to follow other areas of medicine in adopting EBP.

The status of pharmacotherapy for autism spectrum disorders

The use of pharmacologic agents as a component of treatment for children and adults with autism spectrum disorders is common and a substantial body of literature describing controlled and open-label clinical trials now exists to guide clinical practice. Empiric evidence of efficacy of risperidone, methylphenidate and some selective serotonin re-uptake inhibitors for maladaptive behaviors commonly associated with autism spectrum disorders has increased substantially in recent years. Preliminary controlled trials of valproate, atomoxetine, alpha-2 adrenergic agonists and olanzapine are promising. In addition to traditional psychotropic medications, investigators have examined the potential role of a variety of agents with glutamatergic or cholinergic mechanisms, and the results warrant further investigation. Although psychotropic medications are effective in treating some important associated behaviors, evidence of significant impact on the core features of autism spectrum disorders is very limited.

Current clinical research environment: focus on psychiatry

The introduction of international guidelines on Good Clinical Practices (GCP) in 1996, immediately followed by the publication of Resolution CNS 196/96 in Brazil, created a great opportunity for Brazilian research centers to participate in international trials. Such studies must be strictly monitored in order to assure compliance with the regulations, as well as with the standards of patient safety. Clear agreement among the investigator, the sponsor and the institution carrying out the study must be previously defined in order to avoid any conflicts of interest during or after the study. Operational aspects, such as the time needed to gain regulatory approval of the study design, strategies for patient recruitment/retention and appropriate logistics, are also important. In 2005, the Brazilian National Clinical Research Network was established, bringing together a number of research centers in teaching hospitals. The objective was to subsidize public clinical research with state-of-the-art practices and appropriate technical/scientific training programs. The development of research protocols that prioritize public health care needs in Brazil is other fundamental goal of this network. This article addresses general aspects of clinical research, as well as some specific issues in psychiatry. Improving the health and quality of life of the global population is certainly the major objective of all of the work done in this area.

Thirty years of clinical experience with carbamazepine in the treatment of bipolar illness: principles and practice

Carbamazepine began to be studied in a systematic fashion in the 1970s and became more widely used in the treatment of bipolar disorder in the 1980s. Interest in carbamazepine has been renewed by (i) the recent US FDA approval of a long-acting preparation for the treatment of acute mania; (ii) studies suggesting some efficacy in bipolar depression; and (iii) evidence of prophylactic efficacy in some difficult-to-treat subtypes of bipolar illness. A series of double-blind controlled studies of the drug were conducted at the US National Institute of Mental Health from the mid-1970s to the mid-1990s. This review summarises our experience in the context of the current literature on the clinical efficacy, adverse effects and pharmacokinetic interactions of carbamazepine. Carbamazepine has an important and still evolving place in the treatment of acute mania and long-term prophylaxis. It may be useful in individuals with symptoms that are not responsive to other treatments and in some subtypes of bipolar disorder that are not typically responsive to a more traditional agent such as lithium. These subtypes might include those patients with bipolar II disorder, dysphoric mania, substance abuse co-morbidity, mood incongruent delusions, and a negative family history of bipolar illness in first-degree relatives. In addition, carbamazepine may be useful in patients who do not adequately tolerate other interventions as a result of adverse effects, such as weight gain, tremor, diabetes insipidus or polycystic ovarian syndrome. We review our clinical and research experience with carbamazepine alone and in combination with lithium, valproic acid and other agents in complex combination treatment of bipolar illness. More precise clinical and biological predictors and correlates of individual clinical responsiveness to carbamazepine and other mood stabilisers are eagerly awaited.

[Evidence-based medicine: methods and critics]

The evaluation of professional practices is now obligatory. Evidence-Based Medicine, defined as the use of current best evidence in making well-informed decisions, could play a major role for that purpose, as it allows an objective evaluation of the clinical practices by the use of there commendations it gives rise to. The aim of that study was to describe the EBM decision procedure with examples in anaesthesia, and to present its limits, particularly due to the problems of hierarchies of evidence.

Heterogeneity of treatment effects in schizophrenia

The treatment of mental illness presents an opportunity to examine the heterogeneity of treatment effects. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial was sponsored by the National Institute of Mental Health (NIMH) to evaluate the effectiveness of antipsychotic medications for schizophrenia in broad patient populations and in scenarios representative of standard clinical practice. Trial inclusion criteria were broad and exclusion criteria were minimal, allowing for a heterogeneous study population. The majority of patients in each phase 1 treatment group discontinued their randomly assigned treatment owing to inadequate efficacy, intolerable side effects, or other reasons. Phase 2 of CATIE featured 2 treatment pathways (efficacy and tolerability) with randomized follow-up medication based on the reason for discontinuation of the previous antipsychotic drug. Outcome differences between treatment groups and variable responses to medications across the study suggest why multiple medication trials are common and may be necessary in the treatment of schizophrenia. Collectively, the CATIE results highlight variable response in the treatment of schizophrenia and demonstrate the need for individualized therapy based on variations in drug efficacy and tolerability among patients.

Research in child and adolescent psychopharmacology: recent accomplishments and new challenges

RATIONALE

Research in pediatric psychopharmacology has expanded considerably in the last 10 years. Still, controversy remains about the effectiveness and safety of commonly used psychotropics and their role in child treatment, thus pointing to the need for more in-depth and targeted investigations.

OBJECTIVES

To review recent accomplishments and current limitations of pediatric psychopharmacology, and discuss approaches to further research.

METHODS

Selective review of the relevant literature and research in progress.

RESULTS

Controlled clinical trials have been conducted in many common psychiatric disorders in children and adolescents, thus providing a basis on which evidence-based treatment guidelines can be constructed. Little innovation has, however, occurred in treatment development and testing. Safety concerns are prominent and have a major influence on clinical practice and drug utilization.

CONCLUSIONS

While a research infrastructure has been successfully built for conducting pediatric clinical trials, important aspects such as long-term treatment effects, optimal sequencing and individualization of interventions, and integration of neuroscience findings into innovative, theory-driven treatment development remain to be addressed.

The Treatment for Adolescents with Depression Study (TADS): methods and message at 12 weeks

Funded by the National Institute of Mental Health, the Treatment for Adolescents With Depression Study (TADS) is intended to evaluate the short-term (12 weeks) and longer-term (36 weeks) effectiveness of four treatments for adolescents with DSM-IV major depressive disorder: clinical management with fluoxetine (FLX), cognitive-behavioral therapy (CBT), FLX and CBT combined (COMB), and clinical management with placebo (PBO). We previously reported that COMB and FLX were more effective in reducing depression than CBT or PBO after 12 weeks of acute treatment. In this special section of the Journal, separate articles extend these findings to the impact of TADS treatments on remission, speed of response, function and quality of life, predictors of outcome, and safety during the first 12 weeks of treatment. To set the stage for the special section, we briefly review the rationale, design, and methods of the TADS; describe the TADS sample to which the TADS findings generalize; using all of the currently available data, summarize the intent-to-treat outcomes across multiple endpoints at 12 weeks; and consider the public health value of the TADS findings in the context of design decisions and methodological limitations of the TADS, including some that may have advantaged the combined treatment condition. Reflecting the ordering of effect sizes at week 12--COMB (0.98) > FLX (0.68) > CBT (-0.03)--combined treatment proved superior to PBO on 15 of 16 endpoints, to CBT on 14 of 16 endpoints, and to FLX on 8 of 16 endpoints, whereas FLX was superior to CBT on 8 of 14 and to PBO on 7 of 16 measures. CBT did not differ from PBO on any measure. Despite the fact that suicidality improved markedly across all of the treatment conditions, suicidal events were twice as common in patients treated with FLX alone than with COMB or CBT alone, perhaps indicating that CBT protects against suicidal events. Thus, combined treatment appears to accelerate recovery relative to CBT and, for some outcomes, FLX alone, while minimizing the risk of suicidality relative to FLX alone. Taking benefit and risk into account, we conclude that the combination of FLX and CBT appears superior to either monotherapy as a treatment for moderate to severe major depressive disorder in adolescents.

Issues in selecting outcome measures to assess functional recovery after stroke

Most patients who survive a stroke experience some degree of physical recovery. Selecting the appropriate outcome measure to assess physical recovery is a difficult task, given the heterogeneity of stroke etiology, symptoms, severity, and even recovery itself. Despite these complexities, a number of strategies can facilitate the selection of functional outcome measures in stroke clinical trial research and practice. Clinical relevance in stroke outcome measures can be optimized by incorporating a framework of health and disability, such as the International Classification of Functioning, Disability, and Health (ICF). The ICF provides the conceptual basis for measurement and policy formulations for disability and health assessment. All outcome measures selected should also have sound psychometric properties. The essential psychometric properties are reliability, validity, responsiveness, sensibility, and established minimal clinically important difference. It is also important to establish the purpose of the measurement (discriminative, predictive, or evaluative) and to determine whether the purpose of the study is to evaluate the efficacy or effectiveness of an intervention. In addition, when selecting outcome measures and time of assessment, the natural history of stroke and stroke severity must be regarded. Finally, methods for acquiring data must also be considered. We present a comprehensive overview of the issues in selecting stroke outcome measures and characterize existing measures relative to these issues.

Bias in psychopathology research

PURPOSE OF REVIEW

Biases are frequently invoked in psychopathology research, either as core features of particular forms of psychopathology or as errors and distortions that affect psychiatric assessment, diagnosis, treatment, and research methodology. This review provides an overview of recent research on the forms of bias that are commonly examined in the field.

RECENT FINDINGS

Recent research has made a number of advances in the analysis of cognitive and affective biases underpinning psychopathology: the effect of rating and other biases on psychiatric assessment and diagnosis; the role of race and gender in psychiatric practice; financial and institutional influences on psychiatric services; and several biases affecting research methodology, study design, and statistical inference.

SUMMARY

Bias has several distinct meanings, and encompasses a disparate set of phenomena, so no over-arching conclusion about the place of bias in psychopathology research can be drawn. Recent work, however, makes solid progress toward a better understanding of systematic distortions and how they can be recognized and reduced.

Comparative effectiveness of second-generation antipsychotics and haloperidol in acute schizophrenia

BACKGROUND

There is little information on the comparative effectiveness of second-generation antipsychotic agents.

AIMS

To determine if any of five second-generation antipsychotics or haloperidol is more effective in treating acutely ill patients with schizophrenia, schizoaffective disorder or schizophreniform disorder.

METHOD

A sample of 327 newly admitted patients were randomised to open-label treatment with aripiprazole, haloperidol, olanzapine, quetiapine, risperidone or ziprasidone for a minimum of 3 weeks. Measures of effectiveness were improvement in mental status so that the patient no longer required acute in-patient care, and changes in Brief Psychiatric Rating Scale (BPRS) scores.

RESULTS

By the first measure, haloperidol (89%), olanzapine (92%) and risperidone (88%) were significantly more effective than aripiprazole (64%), quetiapine (64%) and ziprasidone (64%). Changes in BPRS ratings were not significant among treatments.

CONCLUSIONS

Haloperidol, olanzapine and risperidone are superior to aripiprazole, quetiapine and ziprasidone for the acute treatment of psychosis in hospitalised patients with schizophrenia, schizoaffective disorder or schizophreniform disorder.

Homocysteine-reducing strategies improve symptoms in chronic schizophrenic patients with hyperhomocysteinemia

BACKGROUND

An elevated homocysteine level is reported to be a risk factor for several diseases, including Alzheimer's and cerebrovascular disease. Recently, several studies have reported that homocysteine levels are elevated in many schizophrenic patients. Homocysteine levels can be lowered by oral folic acid, B-12, and pyridoxine.

METHODS

Forty-two schizophrenic patients with plasma homocysteine levels >15 micromol/L were treated with these vitamins for 3 months and placebo for 3 months in a study with a randomized, double-blind, placebo-controlled, crossover design.

RESULTS

Homocysteine levels declined with vitamin therapy compared with placebo in all patients except for one noncompliant subject. Clinical symptoms of schizophrenia as measured by the Positive and Negative Syndrome Scale declined significantly with active treatment compared with placebo. Neuropsychological test results overall, and Wisconsin Card Sort (Categories Completed) test results in particular, were significantly better after vitamin treatment than after placebo.

CONCLUSIONS

A subgroup of schizophrenic patients with hyperhomocysteinemia might benefit from the simple addition of B vitamins.

Clinical trials in schizophrenia with results for the real world

Most clinical data for antipsychotics come from studies designed to test the efficacy and safety of the drugs under ideal conditions, in limited subgroups of patients. In contrast, practical clinical trials (PCTs) are designed to test the effectiveness of different treatment options under conditions that more accurately reflect actual clinical practice. Consequently, PCTs are able to provide information that can be utilized by healthcare providers and other decision makers. Characteristics of PCTs include a clinically relevant question, a representative sample of patients and practice settings, sufficient power to identify modest relevant effects, randomization to protect against bias, uncertainty regarding the outcome of treatment, assessment and treatment protocols that enact best clinical practices, simple and relevant outcomes, and limited subject and investigator burden. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) research program is an example of a PCT. The CATIE study illustrates how PCTs, when properly designed, might be helpful in informing clinical decision making. Because the CATIE study was designed to reflect the effectiveness of antipsychotics under naturalistic clinical conditions, its results should have particular applicability to the arena of clinical practice. This article provides a discussion of the differences between efficacy and effectiveness studies. In assessing the practical utility of results from the CATIE study, much can be learned on how to shape future studies of effectiveness so as to better generate data that are applicable to the "real world."

Child and adolescent psychopharmacology in the new millennium: a workshop for academia, industry, and government

OBJECTIVE

To give academic researchers, government officials, and industry scientists an opportunity to assess the state of pediatric psychopharmacology and identify challenges facing professionals in the field.

METHOD

Increased federal spending and the introduction of pediatric exclusivity led to large increases in pediatric psychopharmacology research in the 1990s. Despite the increase in research, concerns exist about methods and incentives for making new medications available for use in pediatric psychiatric disorders. In recognition of these concerns, the Duke Clinical Research Institute held a roundtable in September 2004. Participants from the National Institutes of Health, regulatory agencies, academia, and the pharmaceutical industry spoke about the effects of government regulations such as the U.S. Food and Drug Administration Modernization Act and the Pediatric Research Equity Act on pediatric research from academic, clinical, and industry perspectives, and bioethical considerations of such research.

CONCLUSIONS

To ensure development of new drugs for treating psychiatric disorders in children and adolescents, we must address the challenges posed by the regulatory environment governing pediatric psychopharmacology research. Strategies were identified for improving the evidence base for psychopharmacologic interventions in youth before widespread use and for more effectively defining a research agenda for the future.

Clinical trials for antipsychotic drugs: design conventions, dilemmas and innovations

More than 50 years after the introduction of modern pharmacotherapies for schizophrenia, there remains a tremendous need for therapeutic advances. A second generation of antipsychotic drugs, introduced over the past 15 years, has provided uncertain advantages over the first-generation drugs. This paper reviews the designs of studies that evaluate the effectiveness of putative antipsychotic drugs. Data from the trials needed to achieve regulatory approval do not meet all the needs of clinicians and policy makers. Practical and large, simple trials that evaluate the comparative effectiveness of antipsychotic drugs in real-world settings can help to meet these needs once a drug has reached the market.

Selective serotonin reuptake inhibitors in pediatric depression: is the balance between benefits and risks favorable?

Recent controversies surrounding the use of selective serotonin reuptake inhibitors (SSRIs) have highlighted the need to reassess potential benefits, as well as potential risks of this class of medications in the treatment of pediatric depression. The recent availability of data from meta-analyses of published and unpublished antidepressant trials, epidemiological studies, and the Treatment for Adolescents with Depression Study (TADS) has facilitated a reanalysis of this risk/benefit relationship. Despite reviewing similar data, various regulatory agencies have arrived at rather disparate conclusions regarding the data, resulting in continued controversy. Although all groups appear to agree that careful assessment, education regarding risks, and closer monitoring are essential for SSRIs, only the U.S. Food and Drug Administration (FDA) and the U.K. Medicine and Health Care Products Regulatory Agency maintain that an acceptable risk/benefit relationship exists for fluoxetine. The European Medicines Agency concluded that the SSRIs should not be used in the treatment of depression in children and adolescents. The authors of this review have taken into consideration many of these same data and offer a critical discussion of the pros and cons of SSRIs in pediatric depression. The authors have concluded that SSRIs -- in particular, fluoxetine -- do have a role in the treatment of pediatric depression.

Treatment benefit and the risk of suicidality in multicenter, randomized, controlled trials of sertraline in children and adolescents

OBJECTIVE

The aim of this study was to examine the balance between the benefits of treatment and the risk of suicidality in children and adolescents in multicenter, randomized, controlled trials of sertraline versus placebo.

METHOD

The published literature was searched for multicenter, randomized, placebo-controlled trials of sertraline for pediatric mental disorders. Four trials were identified: Two (pooled) in pediatric major depressive disorder (MDD; Wagner 2003) and two in obsessive-compulsive disorder (OCD; March et al. 1998; POTS Team 2004). Using intent-to-treat (ITT) analysis populations, the authors calculated the number needed to treat (NNT) for response and remission and the number needed to harm (NNH) for suicidality, and their ratio, for each clinical trial.

RESULTS

NNTs ranged from 2 to 10, indicating clinically meaningful benefits. Benefit was greater for OCD than for MDD, and for adolescents as compared with children in MDD. No age effect was apparent for OCD. Suicidality was reported in 8 patients (5 assigned to sertraline and 3 assigned to placebo). All but 1 (a placebo-treated patient in the Pfizer OCD trial) were enrolled in the sertraline MDD trial. The NNH for suicidality in MDD was 64. Treatment emergent suicidality was more common in children (NNH 28.7) than in adolescents (NNH 706.3). Because no patient developed suicidality in sertraline-treated OCD patients, the NNH for sertraline in OCD approaches infinity.

CONCLUSIONS

With the stipulation that doctor and patient preferences necessarily play a critical role in the choice of treatment, NNT to NNH ratios indicate a positive benefit-to-risk ratio for sertraline in adolescents with MDD and in patients of all ages with OCD.

An update on publicly funded multisite trials in pediatric psychopharmacology

In the last 10 years, the National Institute of Mental Health has funded a number of multisite clinical trials in pediatric psychopharmacology. Trials have been completed or are in progress in attention-deficit hyperactivity disorder, depression, autism, schizophrenia, bipolar disorder, obsessive-compulsive disorder, and other anxiety disorders. Direct comparison between different treatment modalities, such as pharmacotherapy and psychotherapy, alone or in combination, has been the focus of a number of these studies, to inform clinicians and families of the relative therapeutic benefits of alternative interventions. This article presents a brief overview of these studies.

Clotiapine compared with chlorpromazine in chronic schizophrenia

OBJECTIVES

Clotiapine is a classic neuroleptic with a chemical structure similar to clozapine. It was said that patients unresponsive to other neuroleptics respond to clotiapine although it causes extrapyramidal syndromes (EPS) like other typical neuroleptics. We conducted a study of clotiapine vs. chlorpromazine in severe chronic active psychotic hospitalized schizophrenia patients.

METHODS

The design was double-blind crossover of clotiapine vs chlorpromazine. No washout was necessary from previous neuroleptic treatment, and flexible overlap with the study medication was individualized for each patient. Patients were treated after reaching neuroleptic monotherapy for 3 months with clotiapine and 3 months with chlorpromazine, in random order. Medication was supplied in identical capsules of 100 mg chlorpromazine or 40 mg of clotiapine. Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression (CGI) were rated every 2 weeks and Nurse's Observation Scale for Inpatient Evaluation (NOSIE) every month.

RESULTS

Fifty-eight patients were randomized. Forty-three patients completed at least one phase of the study, and thirty-three completed both phases. Because of the small number of hostel patients and the very high dropout rate in the hostel patients, data analysis was done separately for inpatients and hostel patients. Clotiapine was significantly superior to chlorpromazine in 26 inpatients completing the crossover, on the PANSS, NOSIE and CGI. Clotiapine was also superior to chlorpromazine in an analysis of the parallel inpatient groups in the first three months before the crossover.

CONCLUSION

Some classic neuroleptic compounds may have superiority to chlorpromazine in a "clozapine-like" manner, despite a typical profile for EPS.

Clinical trial design in schizophrenia: implications for clinical decisions

PURPOSE OF REVIEW

Results from clinical trials do not necessarily provide information for decisions in clinical practice. This review aims to present strengths and limitations of different methodological types of clinical trials and to offer an overview of how knowledge from clinical trails can be distilled for clinical practice. Selected key questions in the treatment of schizophrenia are presented, with a focus on the possibilities and restrictions of translating trial results into real-world practice.

RECENT FINDINGS

Randomized controlled trials are the gold standard for proving efficacy of a diagnostic or therapeutic procedure. They have a high degree of internal validity and a clear-cut message when conducted to good-quality standards but suffer from a lack of generalizability (external validity). Effectiveness studies evaluate effects of treatments under conditions approximating usual care. They may include patient-centred outcomes or health economic evaluations. According to the type of trial, specific problems arise in the interpretation of results. Typical examples are given for the treatment of acute exacerbations of schizophrenia, for relapse prevention and for the treatment of cognitive impairment.

SUMMARY

Clinical decisions have to be made upon the best knowledge. Therefore, well conducted studies addressing all major issues from all relevant perspectives are needed. The assessment of a treatment regimen for clinical utility requires both efficacy and effectiveness studies. An understanding of the design, analysis and conventions of both study types is essential for the interpretation of results and their translation to the clinical decision-making process.

Public welfare agenda or corporate research agenda?

As things stand today, whether we like it or not, industry funding is on the upswing. The whole enterprise of medicine in booming, and it makes sense for industry to invest more and more of one's millions into it. The pharmaceutical industry has become the single largest direct funding agency of medical research in countries like Canada, the United Kingdom and the United States.Since the goals of industry and academia differ, it seems that conflicts of interest are inevitable at times. The crucial decision is whether the public welfare agenda of academia, or the corporate research agenda of industry, should occupy center stage when they conflict.There is enough evidence to show that funding by industry is very systematic, and results that are supportive of the safety and efficacy of sponsor's products alone get the funds. It is no surprise, therefore, that one finds very few negative drug trials reports published, and whatever are, are likely to be by rival companies to serve their commercial interests.Renewed and continued funding by industry decides the future prospects of many academic researchers. At the same time there is now evidence that pharmaceutical companies attempt suppression of research findings, may be selective in publishing results, and may delay or stymie publication of unfavourable results. This is a major area of concern for all conscientious researchers and industry watchers.Industry commonly decides which clinical research/trial gets done, not academia, much though the latter may wish to believe otherwise. It finds willing researchers to carry this out. This can be one area of concern. Another area of pressing concern is when industry decides to both design and control publication of research.It makes sense for researchers to refuse to allow commercial interests to rule research reporting. Research having been reported, the commercial implications of such reporting is industry's concern. But, doctoring of findings to suit commerce is to be resisted at all costs. In this even pliant researchers need have no fear, for if they indeed publish what will work, the concerned sponsor will benefit in the long run. The only decision academia has to make is refuse to comply with predestined conclusions of sponsors for the 'thirty pieces of silver'. Instead do genuine research and make sixty for themselves.The useful rule of thumb is: Keep the critical antenna on, especially with regard to drug trials, and more especially their methodology, and study closely the conflict of interest disclosed, and if possible undisclosed, before you jump on the band wagon to herald the next great wonder drug.There are three important lessons to be learnt by academia in all academia-industry relationships:i)LESSON NUMBER ONE: incorporate the right to publish contrary findings in the research contract itself. Which means, it makes great sense for academia to concentrate on the language and contractual provisions of sponsored research, to read the fine print very closely, and protect their research interests in case of conflict.ii)LESSON NUMBER TWO: a number of lawsuits successfully brought up against industry recently reflect earnest attempts by patient welfare bodies and others to remedy the tilt. It will result in a newfound confidence in academia that augurs well for academia industry relationship in the long run. Hence the second lesson for academia: do not get browbeaten by threats of legal actioniii)LESSON NUMBER THREE: Academia should keep itself involved right from inception of the clinical trial through to ultimate publication. And this must be an integral part of the written contract.The time to repeat cliches about the exciting future of the academia-industry connect is past. A concerted effort to lay a strong foundation of the relationship on practical ethical grounds has become mandatory.

The connection between academia and industry

The growing commercialization of research with its effect on the ethical conduct of researchers, and the advancement of scientific knowledge with its effect on the welfare or otherwise of patients, are areas of pressing concern today and need a serious, thorough study. Biomedical research, and its forward march, is becoming increasingly dependent on industry-academia proximity, both commercial and geographic. A realization of the commercial value of academic biomedical research coupled with its rapid and efficient utilization by industry is the major propelling force here. A number of well-intentioned writers in the field look to the whole development with optimism. But this partnership is a double-edged sword, for it carries with it the potential of an exciting future as much as the prospect of misappropriation and malevolence. Moreover, such partnerships have sometimes eroded public trust in the research enterprise itself.Connected to the growing clout of industry in institutions is concern about thecommercialization of research and resolving the 'patient or product' loyalty.There is ambivalence about industry funding and influence in academia, and a consequent 'approach-avoidance' conflict. If academia has to provide the patients and research talent, industry necessarily has to provide the finances and other facilities based on it. This is an invariable and essential agreement between the two parties that they can walk out of only at their own peril. The profound ethical concerns that industry funded research has brought center-stage need a close look, especially as they impact patients, research subjects, public trust, marketability of products, and research and professional credibility.How can the intermediate goal of industry (patient welfare) serve the purpose of the final goal of academia is the basic struggle for conscientious research institutions /associations. And how best the goal of maximizing profits can be best served, albeit suitably camouflaged as patient welfare throughout, is the concern of the pharmaceutical industry.A very great potential conflict of interest lies in the fact that academia needs the sophisticated instruments that only big funding can provide, while at the same time resists the attempts of the fund provider to set the agenda of research, protocol, design, publication, the works. Conflicts arise at many steps and levels of functioning, and are related to the expectations, competing interests, and conflicting priorities of the different entities involved, whether they are the academic medical centers, the funding agencies, the patients and their families, or the investors and venture capitalists.The public expects access to new treatments. Its appetite for innovation has been bolstered by the constant attention given by the press to new treatments and by the implicit promise from researchers of continuing advances. Similarly, patients demand privacy and control over information about themselves.It makes greater sense for genuine researchers to associate with large long-term industry players who have a track record of genuine hard-core discoveries, even if the process is slow (maybe), and the funding less (may not be).The element of control venture capitalists exert over the pharmaceutical industry is an under researched area for obvious reasons. But it needs further probing, for that will lay bare the pulls and pressures under which industry works.It makes sense for ethically minded researchers and institutions not to fall in the trap of stocks and equity investments in industry, howsoever attractive they appear, and get rid of them as soon as possible if they have them. If at all they want, it makes more sense to own stocks of larger well established concerns, for the stock upheavals being less, the pressure of the market-place, and of venture sharks, is likely to be lower too.While active participation by the researcher in the commercialization process may be greatly desired by industry, ostensibly in the name of creating value, academia must realize it is a bait it might find hard to swallow in the long run. It makes more sense for the researcher and institution to forego such temptations and/or walk out of such investments as soon as possible.While mainstream medicine and research are booming, as is connected industry, concerns about professional commitment to patient welfare are growing too. Increasing corporate influence is challenging certain long held and fundamental values of patient care, which will have far reaching implications for biomedical care and the future progress of mainstream medicine.