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Stone MB, Yaseen ZS, Miller BJ, Richardville K, Kalaria SN, Kirsch I. Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis. BMJ 2022; 378:e067606. [PMID: 35918097 PMCID: PMC9344377 DOI: 10.1136/bmj-2021-067606] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To characterize individual participant level response distributions to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration from 1979 to 2016. DESIGN Individual participant data analysis. POPULATION 232 randomized, double blind, placebo controlled trials of drug monotherapy for major depressive disorder submitted by drug developers to the FDA between 1979 and 2016, comprising 73 388 adult and child participants meeting the inclusion criteria for efficacy studies on antidepressants. MAIN OUTCOME MEASURES Responses were converted to Hamilton Rating Scale for Depression (HAMD17) equivalent scores where other measures were used to assess efficacy. Multivariable analyses examined the effects of age, sex, baseline severity, and year of the study on improvements in depressive symptoms in the antidepressant and placebo groups. Response distributions were analyzed with finite mixture models. RESULTS The random effects mean difference between drug and placebo favored drug (1.75 points, 95% confidence interval 1.63 to 1.86). Differences between drug and placebo increased significantly (P<0.001) with greater baseline severity. After controlling for participant characteristics at baseline, no trends in treatment effect or placebo response over time were found. The best fitting model of response distributions was three normal distributions, with mean improvements from baseline to end of treatment of 16.0, 8.9, and 1.7 points. These distributions were designated Large, Non-specific, and Minimal responses, respectively. Participants who were treated with a drug were more likely to have a Large response (24.5% v 9.6%) and less likely to have a Minimal response (12.2.% v 21.5%). CONCLUSIONS The trimodal response distributions suggests that about 15% of participants have a substantial antidepressant effect beyond a placebo effect in clinical trials, highlighting the need for predictors of meaningful responses specific to drug treatment.
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Affiliation(s)
- Marc B Stone
- Division of Psychiatry, Office of Neuroscience, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Zimri S Yaseen
- Division of Psychiatry, Office of Neuroscience, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Brian J Miller
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kyle Richardville
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shamir N Kalaria
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Irving Kirsch
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Abstract
The dominant view within mental health services and research suggests that feeling depressed is a kind of medical illness, partially caused by various biological deficits which are somehow corrected by physical interventions. This article critically appraises evidence for the effectiveness and value of antidepressant drugs and electroconvulsive therapy (ECT), the two principle physical treatments recommended for depression. It also describes the negative effects of these interventions and raises concerns about how they impact the brain. We propose an alternative understanding that recognises depression as an emotional and meaningful response to unwanted life events and circumstances. This perspective demands that we address the social conditions that make depression likely and suggests that a combination of politics and common sense needs to guide us in providing help for one another when we are suffering in this way. This alternative view is increasingly endorsed around the world, including by the United Nations, the World Health Organization and service users who have suffered negative consequences of physical treatments that modify brain functions in ways that are not well-understood.
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Affiliation(s)
- John Read
- School of Psychology, University of East London, London E15 4LZ, UK
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Alpha-Glycerylphosphorylcholine Increases Motivation in Healthy Volunteers: A Single-Blind, Randomized, Placebo-Controlled Human Study. Nutrients 2021; 13:nu13062091. [PMID: 34207484 PMCID: PMC8235064 DOI: 10.3390/nu13062091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/02/2021] [Accepted: 06/16/2021] [Indexed: 11/17/2022] Open
Abstract
Alpha-glycerylphosphorylcholine (αGPC) is a precursor of acetylcholine and can increase acetylcholine concentration in the brain. In addition, αGPC has a role in cholinergic function as well as monoaminergic transmission, including dopaminergic and serotonergic systems. These monoaminergic systems are related to feelings and emotions, including motivation, reward processing, anxiety, and depression. However, the precise effects of αGPC on human feelings and emotions remain to be elucidated. In this study, we investigated changes in the subjective feelings of healthy volunteers using the KOKORO scale before and after administering αGPC. Thirty-nine volunteers participated in a single-blind, placebo-controlled design. Participants completed a KOKORO scale test to quantify self-reported emotional states, three times each day for two weeks preceding treatment and then for a further two weeks while self-administering treatment. αGPC treatment show a tendency to increase motivation during the intervention period. Furthermore, motivation at night was significantly higher in the αGPC group than in the placebo group (p < 0.05). However, αGPC did not show any effects on anxiety. These data suggest that αGPC can be used to increase motivation in healthy individuals.
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Abstract
The aim of this review is to evaluate the placebo effect in the treatment of anxiety and depression. Antidepressants are supposed to work by fixing a chemical imbalance, specifically, a lack of serotonin or norepinephrine in the brain. However, analyses of the published and the unpublished clinical trial data are consistent in showing that most (if not all) of the benefits of antidepressants in the treatment of depression and anxiety are due to the placebo response, and the difference in improvement between drug and placebo is not clinically meaningful and may be due to breaking blind by both patients and clinicians. Although this conclusion has been the subject of intense controversy, the current article indicates that the data from all of the published meta-analyses report the same results. This is also true of recent meta-analysis of all of the antidepressant data submitted to the Food and Drug Administration (FDA) in the process of seeking drug approval. Also, contrary to previously published results, the new FDA analysis reveals that the placebo response has not increased over time. Other treatments (e.g., psychotherapy and physical exercise) produce the same benefits as antidepressants and do so without the side effects and health risks of the active drugs. Psychotherapy and placebo treatments also show a lower relapse rate than that reported for antidepressant medication.
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Schneier FR, Slifstein M, Whitton AE, Pizzagalli DA, Reinen J, McGrath PJ, Iosifescu DV, Abi-Dargham A. Dopamine Release in Antidepressant-Naive Major Depressive Disorder: A Multimodal [ 11C]-(+)-PHNO Positron Emission Tomography and Functional Magnetic Resonance Imaging Study. Biol Psychiatry 2018; 84:563-573. [PMID: 30041971 PMCID: PMC6347467 DOI: 10.1016/j.biopsych.2018.05.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/02/2018] [Accepted: 05/15/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Mesolimbic dopamine system dysfunction is believed to contribute to major depressive disorder (MDD), but molecular neuroimaging of striatal dopamine neurotransmission has yielded mixed results, possibly owing to limited sensitivity of antagonist radioligands used with positron emission tomography to assess dopamine release capacity. This study used an agonist radioligand with agonist challenge to assess dopamine release capacity and D2/D3 receptor availability in MDD. METHODS Twenty-six treatment-naive adults with MDD and 26 healthy comparison participants underwent functional magnetic resonance imaging during a probabilistic reinforcement task, and positron emission tomography with the D3-preferring ligand [11C]-(+)-PHNO, before and after oral dextroamphetamine. MDD participants then received pramipexole treatment for 6 weeks. RESULTS MDD participants had trend-level greater dopamine release capacity in the ventral striatum, as measured by percent change in baseline binding potential relative to nondisplaceable compartment (ΔBPND) (-34% vs. -30%; p = .072, d = 0.58) but no difference in D2/D3 receptor availability (BPND). Striatal and extrastriatal BPND and percent change in baseline BPND were not significantly associated with blood oxygen level-dependent response to reward prediction error in the ventral striatum, severity of depression and anhedonia, or antidepressant response to pramipexole (response rate = 72.7%). CONCLUSIONS [11C]-(+)-PHNO demonstrated high sensitivity to displacement by amphetamine-induced dopamine release, but dopamine release capacity and D2/D3 availability were not associated with ventral striatal activation to reward prediction error or clinical features, in this study powered to detect large effects. While a preponderance of indirect evidence implicates dopaminergic dysfunction in MDD, these findings suggest that presynaptic dopamine dysregulation may not be a feature of MDD or a prerequisite for treatment response to dopamine agonists.
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Affiliation(s)
- Franklin R Schneier
- Division of Clinical Therapeutics, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York; Department of Psychiatry, Columbia University Medical Center, New York, New York.
| | - Mark Slifstein
- Division of Translational Imaging, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York; Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - Alexis E Whitton
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont; Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts
| | - Diego A Pizzagalli
- Center for Depression, Anxiety and Stress Research, McLean Hospital, Belmont; Department of Psychiatry, Harvard Medical School, Cambridge, Massachusetts
| | - Jenna Reinen
- Department of Psychology, Columbia University Medical Center, New York, New York; Department of Psychology, Yale University, New Haven, Connecticut
| | - Patrick J McGrath
- Division of Clinical Therapeutics, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York; Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - Dan V Iosifescu
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anissa Abi-Dargham
- Division of Translational Imaging, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York; Department of Psychiatry, Columbia University Medical Center, New York, New York
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Zunhammer M, Ploner M, Engelbrecht C, Bock J, Kessner SS, Bingel U. The effects of treatment failure generalize across different routes of drug administration. Sci Transl Med 2017; 9:9/393/eaal2999. [DOI: 10.1126/scitranslmed.aal2999] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/17/2017] [Indexed: 12/12/2022]
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Dunlop BW, Kelley ME, Aponte-Rivera V, Mletzko-Crowe T, Kinkead B, Ritchie JC, Nemeroff CB, Edward Craighead W, Mayberg HS. Effects of Patient Preferences on Outcomes in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) Study. Am J Psychiatry 2017; 174:546-556. [PMID: 28335624 PMCID: PMC6690210 DOI: 10.1176/appi.ajp.2016.16050517] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The Predictors of Remission in Depression to Individual and Combined Treatments [PReDICT] study aimed to identify clinical and biological factors predictive of treatment outcomes in major depressive disorder among treatment-naive adults. The authors evaluated the efficacy of cognitive-behavioral therapy (CBT) and two antidepressant medications (escitalopram and duloxetine) in patients with major depression and examined the moderating effect of patients' treatment preferences on outcomes. METHOD Adults aged 18-65 with treatment-naive major depression were randomly assigned with equal likelihood to 12 weeks of treatment with escitalopram (10-20 mg/day), duloxetine (30-60 mg/day), or CBT (16 50-minute sessions). Prior to randomization, patients indicated whether they preferred medication or CBT or had no preference. The primary outcome was change in the 17-item Hamilton Depression Rating Scale (HAM-D), administered by raters blinded to treatment. RESULTS A total of 344 patients were randomly assigned, with a mean baseline HAM-D score of 19.8 (SD=3.8). The mean estimated overall decreases in HAM-D score did not significantly differ between treatments (CBT: 10.2, escitalopram: 11.1, duloxetine: 11.2). Last observation carried forward remission rates did not significantly differ between treatments (CBT: 41.9%, escitalopram: 46.7%, duloxetine: 54.7%). Patients matched to their preferred treatment were more likely to complete the trial but not more likely to achieve remission. CONCLUSIONS Treatment guidelines that recommend either an evidence-based psychotherapy or antidepressant medication for nonpsychotic major depression can be extended to treatment-naive patients. Treatment preferences among patients without prior treatment exposure do not significantly moderate symptomatic outcomes.
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Affiliation(s)
- Boadie W. Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Mary E. Kelley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Vivianne Aponte-Rivera
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Tanja Mletzko-Crowe
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Becky Kinkead
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - James C. Ritchie
- Department of Clinical Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Charles B. Nemeroff
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - W. Edward Craighead
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.,Department of Psychology, Emory University, Atlanta, GA, USA
| | - Helen S. Mayberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Hsu JH, Mulsant BH, Lenze EJ, Karp JF, Lavretsky H, Roose SP, Reynolds CF, Blumberger DM. Impact of Prior Treatment on Remission of Late-Life Depression with Venlafaxine and Subsequent Aripiprazole or Placebo Augmentation. Am J Geriatr Psychiatry 2016; 24:918-22. [PMID: 27538352 PMCID: PMC5026879 DOI: 10.1016/j.jagp.2016.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Treatment history can inform clinical decisions about subsequent treatment choices. The authors examined the impact of prior antidepressant treatment on treatment outcomes with venlafaxine only and then with augmentation with aripiprazole or placebo in depressed older adults. METHODS The authors analyzed outcome data from a randomized, placebo-controlled clinical trial of aripiprazole augmentation in depressed older adults. The study consisted of an open-label lead-in phase with venlafaxine XR, followed by a placebo-controlled phase of aripiprazole augmentation. Treatment history was assessed with the Antidepressant Treatment History Form. RESULTS Documented prior treatment failure predicted a reduced remission rate with venlafaxine. However, aripiprazole augmentation was efficacious in those with prior treatment failure (42.6% remission with aripiprazole versus 25.8% with placebo; χ(2) = 3.87 df = 1, p = 0.049). CONCLUSION Aripiprazole augmentation is an efficacious strategy in older depressed adults who fail to remit with two or more adequate antidepressant trials, including a course of venlafaxine.
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Affiliation(s)
- Jonathan H. Hsu
- Campbell Family Research Institute, Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto
| | - Benoit H. Mulsant
- Campbell Family Research Institute, Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto
| | - Eric J. Lenze
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine
| | - Jordan F. Karp
- University of Pittsburgh School of Medicine, Pittsburgh, PA,VAPHS Geriatric Research, Education, and Clinical Center, Pittsburgh, PA
| | - Helen Lavretsky
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Steven P. Roose
- Columbia University and the New York State Psychiatric Institute, New York, NY
| | | | - Daniel M. Blumberger
- Campbell Family Research Institute, Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto
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Leuchter AF, Hunter AM, Tartter M, Cook IA. Authors' reply. Br J Psychiatry 2015; 207:561-2. [PMID: 26628700 DOI: 10.1192/bjp.207.6.561b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Andrew F Leuchter
- Andrew F. Leuchter, Semel Institute for Neuroscience and Human Behavior at UCLA, Director of Neuromodulation Division, Los Angeles, USA. ; Aimee M. Hunter, Molly Tartter, Ian A. Cook, UCLA, Los Angeles, USA
| | - Aimee M Hunter
- Andrew F. Leuchter, Semel Institute for Neuroscience and Human Behavior at UCLA, Director of Neuromodulation Division, Los Angeles, USA. ; Aimee M. Hunter, Molly Tartter, Ian A. Cook, UCLA, Los Angeles, USA
| | - Molly Tartter
- Andrew F. Leuchter, Semel Institute for Neuroscience and Human Behavior at UCLA, Director of Neuromodulation Division, Los Angeles, USA. ; Aimee M. Hunter, Molly Tartter, Ian A. Cook, UCLA, Los Angeles, USA
| | - Ian A Cook
- Andrew F. Leuchter, Semel Institute for Neuroscience and Human Behavior at UCLA, Director of Neuromodulation Division, Los Angeles, USA. ; Aimee M. Hunter, Molly Tartter, Ian A. Cook, UCLA, Los Angeles, USA
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