Self-evaluations of antidepressants

Fluvoxamine: a selective serotonin re-uptake inhibitor for the treatment of obsessive-compulsive disorder

Fluvoxamine is the selective serotonin re-uptake inhibitor with the largest database in the treatment of obsessive-compulsive disorder, a severe, and often chronic, anxiety disorder associated with substantial impairment in functioning. The selective serotonin re-uptake inhibitors represent a first-line treatment in patients with obsessive-compulsive disorder. These agents work primarily by blocking the re-uptake of serotonin into the presynaptic nerve terminal, which is believed to be mediated by their effects on the serotonin transport system. In the last two decades, the anti-obsessional effect of fluvoxamine has been tested in several double-blind, placebo-controlled and active-comparison studies, demonstrating its superior efficacy over obsessions and compulsions compared with non-serotonergic antidepressants (i.e., desipramine) and equal efficacy to clomipramine (a tricyclic antidepressant with potent serotonin re-uptake inhibition) and other selective serotonin re-uptake inhibitors (paroxetine and citalopram). However, compared with clomipramine, the selective serotonin re-uptake inhibitor fluvoxamine showed fewer side effects and better tolerability. This reflects the poor affinity of this compound for adrenergic, muscarinic, cholinergic or histaminergic receptors.

Active placebos versus antidepressants for depression

BACKGROUND

Although there is a consensus that antidepressants are effective in depression, placebo effects are also thought to be substantial. Side effects of antidepressants may reveal the identity of medication to participants or investigators and thus may bias the results of conventional trials using inert placebos. Using an 'active' placebo which mimics some of the side effects of antidepressants may help to counteract this potential bias.

OBJECTIVES

To investigate the efficacy of antidepressants when compared with 'active' placebos.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety and Neurosis review groups's search strategy was used to search MEDLINE (1966-2000), PsychLIT (1980-2000) and EMBASE (1974-2000) and this was last done in July 2000. Reference lists from relevant articles and textbooks were searched and 12 specialist journals were handsearched up to 1996.

SELECTION CRITERIA

Randomised and quasi randomised controlled trials comparing antidepressants with active placebos in people with depression.

DATA COLLECTION AND ANALYSIS

Since many different outcome measures were used a standard measure of effect was calculated for each trial. A subgroup analysis of inpatient and outpatient trials was conducted. Two reviewers independently assessed whether each trial met inclusion criteria.

MAIN RESULTS

Nine studies involving 751 participants were included. Two of them produced effect sizes which showed a consistent and statistically significant difference in favour of the active drug. Combining all studies produced a pooled estimate of effect of 0.39 standard deviations (confidence interval, 0.24 to 0.54) in favour of the antidepressant measured by improvement in mood. There was high heterogeneity due to one strongly positive trial. Sensitivity analysis omitting this trial reduced the pooled effect to 0.17 (0.00 to 0.34). The pooled effect for inpatient and outpatient trials was highly sensitive to decisions about which combination of data was included but inpatient trials produced the lowest effects.

REVIEWER'S CONCLUSIONS

The more conservative estimates from the present analysis found that differences between antidepressants and active placebos were small. This suggests that unblinding effects may inflate the efficacy of antidepressants in trials using inert placebos. Further research into unblinding is warranted.

Are antidepressants overrated? A review of methodological problems in antidepressant trials

There are no signs that the rapidly escalating use of antidepressants is reducing the burden of depressive disorders. This may be due to the fact that the evidence base for antidepressants is weaker than is commonly assumed. There are a number of methodological problems that may bias the results of clinical trials. Unblinding may inflate the response of people taking an active drug when compared with those taking an inert placebo. Modern measurement techniques may exaggerate the benefit of drug treatment. Excluding some randomized subjects from analysis may inflate the apparent effect of antidepressant drugs and publication bias means that published studies may not represent an accurate picture of the effects of treatment. In trials of long-term treatment discontinuation-related effects may masquerade as clinical efficacy. A brief survey of evidence from controlled trials does not present a consistently positive picture. Two of the largest and most reputable trials found only negligible differences between tricyclic antidepressants and placebo. The evidence on whether antidepressants are specific treatments is also inconclusive. Many other drugs not classed as antidepressants have shown positive effects in depression in controlled clinical trials. It is suggested that the interests of the pharmaceutical industry and the psychiatric profession have helped to establish the notion of the efficacy and specificity of antidepressant drugs.

Concordance between self-report and clinician's assessment of depression

In order to assess differences between self-assessment and clinician's assessment of depression, 64 depressed in-patients were assessed for depressive symptomatology at admission (D0), 10 days (D10) and 28 days (D28) after the beginning of antidepressant treatment, using the Inventory for Depressive Symptomatology Clinician Rated (IDS-C) and the Inventory for Depressive Symptomatology Self-Rated (IDS-SR). Associated symptoms (SCL-90R) were assessed at D0 and personality dimensions (TCI) at D28. Although agreement was high between IDS-C and IDS-SR total scores, D0, D0-D10 and D0-D28 total scores were significantly different between IDS-C and IDS-SR, showing a higher sensitivity to change for IDS-C as compared to IDS-SR. Differences between IDS-C and IDS-SR were due mostly to mood items and not to somatic items. Discrepancies between self-assessment and clinician's assessment of depressive symptomatology were linked neither to age, sex, familial status, single/recurrent and length of episode, nor to depression severity, but to associated symptoms and, to a lesser extent, personality dimensions: patients over-estimating their depressive symptomatology change relative to the psychiatrist tended to score high on phobic anxiety, Cooperativeness (especially Social Acceptance) and Self-Transcendence (especially Self-forgetfulness) and vice-versa.

Cognitive function in hypertensives treated with atenolol or propranolol

STUDY OBJECTIVE

To test reports that beta blockers, particularly lipophilic forms, impair cognitive function and cause psychiatric disturbances.

DESIGN

Randomized, double-blind, controlled crossover trial with eight-week treatment periods.

PATIENTS

Sequential sample of 42 male veterans, with untreated diastolic blood pressures (DBP) between 90 and 110 mmHg, aged 35-64 years.

INTERVENTIONS

Propranolol-LA, 80-mg tablets, or atenolol, 50-mg tablets, were given daily, incremented by one tablet at weekly intervals until DBP less than or equal to 90 mmHg. Hydrochlorothiazide was added, if necessary.

MAIN RESULTS

Repeated-measures ANOVA was performed on all cognitive tests. Cognitive test performance was not affected by beta blocker therapy in seven of nine tests and was enhanced on Trail Making Test. Performance was impaired only on Digit Cancellation. Neither Speilberger's State Trait Anxiety Inventory nor the Beck Depression Inventory was affected by either beta blocker.

CONCLUSIONS

Atenolol or propranolol therapy does not impair cognitive function or contribute significantly to psychiatric side effects.

Problems with the differentiation of anxiety and depression

This paper discusses the problems of differentiating anxiety and depression. Assessment of these two clinical states is particularly difficult since they are typically intermingled. Theoretical analysis of the current use of the constructs and a sound psychometric approach can disentangle them. Unfortunately, the most widely used assessment methods do not measure anxiety and depression independently.

Different rates of improvement of different symptoms in combined pharmacological and behavioral treatment of agoraphobia

This study was designed to see whether the high vs low serum level of imipramine influenced the outcome of in vivo exposure therapy on patients with agoraphobia. Thirty-six subjects completed the Hopkins Symptom Checklist-90 one week before treatment and weekly throughout treatment. Both groups demonstrated equal improvement. It was noted that the rate of improvement differed for different symptom subscales: (1) Hostility, Paranoia and Psychotic symptom ratings improved over the first three weeks of treatment, (2) Interpersonal Sensitivity, Anxiety and Depression ratings improved throughout the first seven weeks of treatment and (3) Phobic Anxiety, Somatization and Obsessive Compulsure symptom ratings continued to improve throughout the entire 12 week course of treatment. Responsive vs nonresponsive subjects could be significantly differentiated after one week of treatment on the basis of their responses to the Psychoticism subscale.

Stress management for multiple sclerosis patients

The purpose of the study was to explore the utility of stress-reduction techniques within a population of hospitalized multiple sclerosis patients. Four stress-management groups, each composed of 8 to 10 patients, were formed with each participant receiving a pre- and posttest battery focusing on emotional/mood factors (the Profile of Mood States). Group sessions were held once/weekly for 13 wk. Relaxation, cognitive, and behavioral strategies were incorporated into the program. The findings indicate that stress-management techniques were effective in the reduction of psychological distress. Significant decreases were noted in scores on depression and anxiety and significant increase on vigor.

Use of headache rating scales: a multiaxial approach

The basic principles of the rating scale procedure have been outlined, including the Likert scale, the Guilford criteria for item definitions, and the Guttman and Rasch criteria for item combinations. With these criteria, headache rates among the core symptoms of anxiety and depression. Next, we have discussed one of the prevailing scales for headache, the Waters Headache Questionnaire (WHQ), with a multiaxial approach. The WHQ thus contains a severity axis, a diagnostic axis, and a personality axis. Previous studies on the validity of the WHQ, including factor analysis, have shown that migraine and muscular headaches are not mutually exclusive categories. Studies to validate a two-dimensional diagnostic system of migraine and non-migraine headache by Rasch models are discussed. In the field of personality it was suggested, when using questionnaires like the WHQ, to focus on the concepts of acquiescence and dissimulation. Supplemental axes such as "severity of psychosocial stressors" and "social functioning" or "quality of life" should be considered in future research.

Early decision in clinical trials when the treatment differences are small. Experience of a controlled trial in head trauma

In a long-term clinical trial, it is customary to review the results of the data periodically. Two possible situations suggesting a possible early decision in hypothesis testing may arise. First, the difference in outcome may be sufficiently convincing without further evidence from additional data. Second, the difference may be such that it is not likely to be significant even if additional data are collected. This article is mainly concerned with a method for reaching a decision under the second situation, in particular when inadequate patient acquisition has occurred. A predicted distribution of likely future outcomes on the basis of data already accumulated is used to evaluate what might happen if the trial were carried on to the designed end. The method is intended for the case where the outcome variable is dichotomous and the two groups are compared for the difference in proportions.

Self-rating data as a selecting factor in clinical trials of psychotropic drugs

In psychiatry the relationship between rating by others and self-rating has been discussed again and again. The question has been raised as to the influence of complete data material (all patients with self-rating and rating by others) on results, in comparison to results where patients without self-rating are not taken into evaluation. This question was answered by conducting a double-blind study which included two pharmacologically active substances (amitriptylinoxide and trazodone) and two sub-samples of patients (patients with rating by others and self-rating, and patients with rating by others alone). The trial was performed in a total of 57 in-patients suffering from endogenous depression (ICD 296.1) who received drug treatment for 21 days. The effect was assessed multi-methodically. While no differences between the two drugs were seen in the sub-sample "self-rating and rating by others", amitriptylinoxide proved to be superior to trazodone in the sub-sample "rating by others". On the basis of these findings the use of rating by others and self-rating procedures will be considered.

The prediction of treatment outcome at a multidisciplinary pain center

The purpose of this study was to determine if some commonly used admission variables could predict treatment outcome on a multidisciplinary pain center. Specifically, it was designed as a prospective study of an index proposed by Maruta et al. The subjects were 104 patients. The 4 outcome measures used were staff judgment, patient judgment, change in pain scores and change in mood. With the exception of a negative correlation with age, none of the other variables predicted outcome. The index of Maruta did not predict outcome.

Some adaptive strategies for inadequate sample acquisition in veterans administration cooperative clinical trials

A major concern of any clinical trial is being able to recruit sufficient patients of the proper type so that reliable answers can be obtained for the hypotheses being tested. This article considers patient recruitment in seven VA cooperative studies and the adaptive strategies used for inadequate sample acquisition. These strategies are: (1) the re-evaluation of the required sample size; (2) the addition of new hospitals; (3) the replacement of poor recruiting hospitals; (4) the extension of the patient intake period; and (5) the modification of the patient exclusion-inclusion criteria. When there is no expectation of achieving the required sample size in a reasonable time, the study is terminated. Although each of the five strategies will increase the likelihood of successfully completing a study should a recruitment problem occur, preventing these problems from occurring should be a major concern during the planning of a study.

The effects of chlordiazepoxide on self-rated depression, anxiety, and well-being

The main purpose of this study was to compare sensitivity of several self-rating scales to drug effects in anxious and depressed patients. Twenty-two distressed nonpsychotic outpatients completed a double-blind crossover trial of chlordiazepoxide and placebo. All self-rating scales of depression, anxiety, somatic symptoms, and feelings of inadequacy discriminated significantly between chlordiazepoxide and placebo. The decrease in self-rated depression was about equal to the decrease in self-rated anxiety. Subscales describing well-being were more sensitive to drug effects than subscales describing symptoms. A questionnaire (The Symptom Questionnaire) and one of the self-rating scales (Symptom Rating Test) were more sensitive than global self-rating scales, global observer-rating scales, and the Hamilton Anxiety Rating Scale. Some of the self-rating scales discriminated significantly between drug and placebo even when the sample size was reduced to two subsamples of eight patients each. High and significant positive correlations between two scales did not indicate equal sensitivity in discriminating between drug and placebo.