Possibly no baseline severity effect for antidepressants versus placebo but for antipsychotics. Why?

Drug development in psychopharmacology: Insights from evolutionary psychiatry

In the last decade, no other branch of clinical pharmacology has been subject to as much criticism of failed innovation and unsatisfactory effectiveness as psychopharmacology. Evolutionary psychiatry can offer original insights on the problems that complicate pharmacological research. Considering that invalid phenotyping is a major obstacle to drug development, an evolutionary perspective suggests targeting clinical phenotypes related to evolved behavior systems because they are more likely to map onto the underlying biology than constructs based on predetermined diagnostic criteria. Because of their emphasis on symptom remission, pharmacological studies of psychiatric populations rarely include functional capacities as the primary outcome measure and neglect the impact of social context on the effects of psychiatric drugs. Evolutionary psychiatry explains why it is appropriate to replace symptoms with functional capacities as the primary target of psychiatric therapies and why social context should be a major focus of studies assessing the effectiveness of drugs currently used and new drugs under development. When the focus of research shifts to those questions that go beyond the "disease-based" concept of drug action, evolutionary psychiatry clearly emerges as a reference framework to assess drug effectiveness and to optimize clinicians' decisions about prescribing, deprescribing, and non-prescribing.

Can we increase the subjective well-being of the general population? An umbrella review of the evidence

INTRODUCTION

Subjective well-being (SWB) refers to being satisfied with one's life, having positive affect and having little negative affect. We may understand it as a subjective definition of good life, or in colloquial terms "happiness", and it has been associated with several important benefits such as lower mortality. In the last decades, several randomized controlled trials (RCT) have investigated the efficacy of several interventions in increasing SWB in the general population but results from different disciplines have not been integrated.

METHODS

We conducted an umbrella review of systematic reviews and meta-analyses of RCT that assess the efficacy of any kind of interventions in increasing SWB in the general population, including both positive psychology interventions (PPI) and other interventions. We (re)calculated the meta-analytic statistics needed to objectively assess the quality of the evidence of the efficacy of each type of intervention in improving each component of SWB according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

There was moderate-quality evidence that PPI might induce small decreases of negative affect, and low-quality evidence that they might induce moderate increases of positive affect. We found similar results for those PPI specifically consisting in conducting acts of kindness (especially spending money on or giving items to others), for which there was low-quality evidence that they might induces small increases of life satisfaction, but not for PPI specifically consisting in practicing gratitude. Quality of the evidence of the efficacy for the other interventions included in the umbrella review (yoga, resilience training, physical activity, leisure, control enhancement, psychoeducation, and miscellaneous) was very low.

CONCLUSION

There is some evidence that PPI, and specially conducting acts of kindness such as spending money on others, may increase the SWB of the general population. The quality of the evidence of the efficacy for other interventions (e.g., yoga, physical activity, or leisure) is still very low. Registration number: PROSPERO CRD42020111681.

Personalise antidepressant treatment for unipolar depression combining individual choices, risks and big data (PETRUSHKA): rationale and protocol

Introduction

Matching treatment to specific patients is too often a matter of trial and error, while treatment efficacy should be optimised by limiting risks and costs and by incorporating patients’ preferences. Factors influencing an individual’s drug response in major depressive disorder may include a number of clinical variables (such as previous treatments, severity of illness, concomitant anxiety etc) as well demographics (for instance, age, weight, social support and family history). Our project, funded by the National Institute of Health Research, is aimed at developing and subsequently testing a precision medicine approach to the pharmacological treatment of major depressive disorder in adults, which can be used in everyday clinical settings.

Methods and analysis

We will jointly synthesise data from patients with major depressive disorder, obtained from diverse datasets, including randomised trials as well as observational, real-world studies. We will summarise the highest quality and most up-to-date scientific evidence about comparative effectiveness and tolerability (adverse effects) of antidepressants for major depressive disorder, develop and externally validate prediction models to produce stratified treatment recommendations. Results from this analysis will subsequently inform a web-based platform and build a decision support tool combining the stratified recommendations with clinicians and patients’ preferences, to adapt the tool, increase its’ reliability and tailor treatment indications to the individual-patient level. We will then test whether use of the tool relative to treatment as usual in real-world clinical settings leads to enhanced treatment adherence and response, is acceptable to clinicians and patients, and is economically viable in the UK National Health Service.

Discussion

This is a clinically oriented study, coordinated by an international team of experts, with important implications for patients treated in real-world setting. This project will form a test-case that, if effective, will be extended to non-pharmacological treatments (either face-to-face or internet-delivered), to other populations and disorders in psychiatry (for instance, children and adolescents, or schizophrenia and treatment-resistant depression) and to other fields of medicine.