When symptoms become side effects: Development of the side effect attribution scale (SEAS)

Patient reported tools for assessing potential medicine-related symptoms: A systematic review

BACKGROUND

Medicine-related symptom assessment tools have been developed to assist healthcare professionals in detecting potential medicine-related symptoms. This systematic review aimed to identify and evaluate the measurement properties of medicine-related symptom assessment tools.

METHOD

A systematic search was conducted in Ovid Medline, Ovid Embase, Ovid PsychInfo, and SCOPUS databases up to March 16, 2024. The primary studies that described either the development or measurement properties of a tool for identifying medicine-related symptoms were included. Screening and data extraction was done independently by two reviewers using Covidence. The methodological risk of bias and assessment results of reported measurement properties were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULT

Eleven studies met the inclusion criteria, reporting on nine unique tools. All included tools had sufficient content validity assessment results. The PHArmacotherapeutical Symptom Evaluation-20 (PHASE-20) had adequate to very good methodological quality internal consistency, construct validity, and reliability. The Patient-Reported Adverse Drug Event Questionnaire also showed adequate methodological quality with sufficient reliability, criterion validity, and construct validity but required over 30 min to complete. The PHASE-proxy exhibited adequate to very good methodological quality, with sufficient results in criterion validity, structural validity, internal consistency, and reliability. The Patient-Reported Outcome Measure Inquiry into Side-Effects showed sufficient content validity but lacked data on other measurement properties.

CONCLUSION

The majority of the identified tools were tested for one or more measurement properties. Among these tools, PHASE-20 is suitable for assessing medicine-related symptoms in elderly individuals who can participate independently, while PHASE-Proxy is for older adults with dementia or communication disabilities in nursing homes.

A pooled analysis of the side effects of non-invasive Transcutaneous Auricular Vagus Nerve Stimulation (taVNS)

Introduction

Transcutaneous auricular vagus nerve stimulation (taVNS) is a promising technique for modulating vagal afferent fibers non-invasively and has shown therapeutic potential in neurological, cognitive, and affective disorders. While previous research highlights its efficacy, the safety profile of taVNS has been less extensively examined.

Methods

This study therefore aimed to systematically investigate side effects of taVNS in a large pooled dataset consisting of n = 488 participants, utilizing a standardized questionnaire to assess ten reported side effects. Analyses included effects of stimulation type (interval vs. continuous), stimulation duration, stimulation intensity and participant characteristics (age and gender) as potential modulators.

Results

The findings support the safety of taVNS, with minimal and mild side effects reported across participants (M = 1.86, SD = 1.36). Although participants receiving sham stimulation were 32.4% less likely to report unpleasant feelings compared to participants receiving taVNS, this effect was driven primarily by low-end ratings (specifically, a rating of 1, indicating not at all when experiencing the corresponding side effect), thus suggesting limited clinical relevance. Interval stimulation notably reduced the likelihood of some side effects, particularly for neck pain, dizziness and unpleasant feelings, suggesting potential for optimizing taVNS protocols. Stimulation intensity and duration showed few statistically significant, but clinically minimal (i.e., very small) effects.

Conclusion

Overall, these findings demonstrate a favorable safety profile of taVNS, with mostly mild and transient effects, supporting its use as a suitable non-invasive tool in both research and clinical applications.

Side effects following administration of open-placebos: A randomized controlled trial

OBJECTIVE

To assess whether individuals reported more side effects and decreased mood after receiving an open-label placebo compared to a control group that received no treatment.

METHODS

We randomized participants to receive an open placebo or no treatment. The primary outcome was reported side effects on the Side effect Attribution Scale (SEAS) at 15 min and at 24-h. We also examined negative mood as a secondary outcome and whether psychological variables influenced symptom reporting.

RESULTS

At both 15 min and 24-h, participants who took the open-placebo reported a significantly higher number of symptoms (M = 2.03, SE = 0.42) than the control group (M = 1.14, SE = 0.20). Across both time points, participants who took the placebo also reported significantly greater negative mood (M = 6.28, SE = 0.27) than the control group (M = 5.59, SE = 0.16). There was no significant group by time interaction for symptoms or mood (ps > 0.32). Symptom reporting after taking the placebo was not correlated with baseline anxiety, perceived sensitivity to medicines, or modern health worries at either 15 min or 24-h (ps > 0.11).

CONCLUSIONS

The act of taking a treatment, even knowing it is a placebo, resulted in an increase in symptoms and negative mood reported immediately following pill-taking and 24 h later. These findings have implications for the use of open-label placebos and the prescription of medicines in general, as they suggest the process of taking a medicine may result in increased symptoms and an increase in negative mood.

TRIAL REGISTRATION

The trial was preregistered at the Australian New Zealand Clinical Trials Registry (12622001570774).

Changing mindsets about methotrexate in the rheumatology clinic to reduce side effects and improve adherence: a randomized controlled trial

BACKGROUND

Patients' negative expectations about medication can exacerbate side effect burden leading to low adherence and persistence. A novel intervention involves targeting mindsets about non-severe symptoms; reframing them as encouraging signs of medication working.

PURPOSE

This study aimed to assess whether a brief symptom-mindset intervention can improve symptom experience and adherence in patients starting methotrexate to treat an inflammatory rheumatic disease.

METHODS

A randomized controlled trial was conducted with patients starting methotrexate. Participants were randomly assigned (1:1) to a mindset intervention or standard information control condition. Symptom mindset was assessed after 4 weeks to check intervention efficacy. The primary outcome was symptom experience after 4 weeks. Secondary outcomes were adherence and motivation to take methotrexate (4 weeks), as well as continuation and C-reactive protein (12 weeks).

RESULTS

Forty-seven participants were randomly assigned to the intervention (n = 24) or control group (n = 23). All participants completed the study. After 4 weeks, compared to the control group, intervention participants endorsed more positive symptom mindsets, experienced less symptom burden (mean difference -2.70 [95% CI, -4.50, -0.90] P = .005), fewer general symptoms (3.53 [-6.99, .79] P = .045) and a similar number of methotrexate-specific symptoms (-0.79 [-2.29, 0.71] P = .295). The intervention group had better motivation and adherence to methotrexate at 4 weeks and better continuation, and C-reactive protein at 12 weeks than the control group. There was no difference in side effect attribution.

CONCLUSIONS

In patients starting methotrexate, a mindset intervention reframing the role of non-severe side effects is a promising approach for improving symptom experience and early stage medication persistence.

Measuring the Influence of Side Effect Expectations, Beliefs, and Incident Side Effects on the Risk for Drug Discontinuation Among Individuals Starting New Medications, a Cross-sectional Study

Purpose

To measure the impact of beliefs, expectations, side effects, and their combined effects on the risk for medication nonpersistence.

Patients and methods

Using a cross-sectional design, individuals from Saskatchewan, Canada who started a new antihypertensive, cholesterol-lowering, or antihyperglycemic medication were surveyed about risk factors for nonpersistence including: (a) beliefs measured by a composite score of three questions asking about the threat of the condition, importance of the drug, and harm of the drug; (b) incident side effects attributed to treatment; and (c) expectations for side effects before starting treatment. Descriptive statistics and logistic regression models were used to quantify the influence of these risk factors on the outcome of nonpersistence. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.

Results

Among 3,029 respondents, 5.8% (n=177) reported nonpersistence within four months after starting the new drug. After adjustment for numerous covariates representing sociodemographics, health-care providers, medication experiences and beliefs, both negative beliefs (OR: 7.26, 95%CI: 4.98-10.59) and incident side effects (OR: 8.00, 95%CI: 5.49-11.68) were associated with the highest odds of nonpersistence with no evidence of interaction. In contrast, expectations for side effects before starting treatment exhibited an important interaction with incident side effects following treatment initiation. Among respondents with incident side effects (n=741, 24.5%), the risk for early nonpersistence was 11.5% if they indicated an expectation for side effects before starting the medication compared to 23.6% if they did not (adjusted OR: 0.38, 95%CI: 0.25-0.60).

Conclusion

Expectations for side effects may be a previously unrecognized but important marker of the probability to persist with treatment. A high percentage of new medication users appeared unprepared for the possibility of side effects from their new medication making them less resilient if side effects occur.

Really just a little prick? A meta-analysis on adverse events in placebo control groups of seasonal influenza vaccination RCTs

BACKGROUND

The Corona pandemic and ongoing mass vaccinations raise the question of the nocebo mechanisms involved. Since immunization is usually administered to healthy people as a preventive health measure, adverse events (AE) following immunization are less accepted and could contribute to vaccine hesitancy. Assuming that vaccinees experience nocebo responses, the aim of this meta-analysis was to investigate the effect sizes of solicited adverse events (or assumed reactogenicity) reported in placebo groups in RCTs on seasonal influenza vaccination.

METHODS

Literature search via PubMed, Web of Science, and CENTRAL was conducted considering gray literature. Only RCTs with placebo groups using pharmacologically inert substances (like saline) were included. Quality was assessed using Cochrane Collaboration's Risk of Bias Tool. Effect sizes were estimated using a random mixed effects model based on k = 31 studies covering 14,326 participants in placebo groups.

RESULTS

Reported solicited AEs in placebo groups showed significant effect sizes of proportions (ES_p). In k = 13 analyzed placebo groups, 35 % of the participants reported at least one solicited systemic AE (p = 0.007). The most common particular solicited systemic AEs were headache (k = 27; 17 %; p = 0.001), malaise (k = 13; 12 %; p = 0.004), and hyperhidrosis (k = 4; 12 %; p < 0.001) within one week after vaccination.

CONCLUSION

The results show significant solicited AEs in placebo groups, indicating substantial nocebo responses after vaccination. Based on the fact that most vaccination programs include similar groups of healthy people, we expect that comparable nocebo effects occur during other campaigns. Health care professionals should be aware of the nocebo response and take action to prevent or decrease the burden of adverse events following immunization. Fear of side effects must be addressed early in order to diminish vaccine hesitancy. Prospero identifier: CRD42020156287, October 2019.

Psychological factors associated with reporting side effects following COVID-19 vaccination: A prospective cohort study (CoVAccS - Wave 3)

OBJECTIVE

To investigate symptom reporting following the first and second COVID-19 vaccine doses, attribution of symptoms to the vaccine, and factors associated with symptom reporting.

METHODS

Prospective cohort study (T1: 13-15 January 2021, T2: 4-15 October 2021). Participants were aged 18 years or older, living in the UK. Personal, clinical, and psychological factors were investigated at T1. Symptoms were reported at T2. We used logistic regression analyses to investigate associations.

RESULTS

After the first COVID-19 vaccine dose, 74.1% (95% CI 71.4% to 76.7%, n = 762/1028) of participants reported at least one injection-site symptom, while 65.0% (95% CI 62.0% to 67.9%, n = 669/1029) reported at least one other (non-injection-site) symptom. Symptom reporting was associated with being a woman and younger. After the second dose, 52.9% (95% CI 49.8% to 56.0%, n = 532/1005) of participants reported at least one injection-site symptom and 43.7% (95% CI 40.7% to 46.8%, n = 440/1006) reported at least one other (non-injection-site) symptom. Symptom reporting was associated with having reported symptoms after the first dose, having an illness that put one at higher risk of COVID-19 (non-injection-site symptoms only), and not believing that one had enough information about COVID-19 to make an informed decision about vaccination (injection-site symptoms only).

CONCLUSIONS

Women and younger people were more likely to report symptoms from vaccination. People who had reported symptoms from previous doses were also more likely to report symptoms subsequently, although symptom reporting following the second vaccine was lower than following the first vaccine. Few psychological factors were associated with symptom reporting.

Increasing and dampening the nocebo response following medicine-taking: A randomised controlled trial

OBJECTIVE

The nocebo effect is the adverse effects of treatment that cannot be attributed to a medicine. We investigated if we could increase or decrease nocebo responding following medicine taking. A nocebo explanation to reduce side effects was compared with a negative medication news item designed to increase side effects and a control condition.

METHODS

108 healthy participants enrolled in a between-subjects study purportedly testing the effect of lamotrigine (actually placebo) on mood and cognition. Participants were randomised to watch either a video explaining the nocebo effect; a negative media item on lamotrigine, or control video prior to receiving the tablet. Side effects were assessed at 45-min and 48-h.

RESULTS

The negative media group reported significantly more side effects (M = 0.78, SD = 1.53) than the control group (M = 0.46, SD = 1.80, p = .035) at the end of session and a greater proportion of the negative media group (33%) reported at least one side effect compared to the nocebo explanation (11%) and control group (11%, p = .020). The nocebo explanation group reported significantly fewer side effects (M = 0.38, SD = 1.16) than the control group (M = 1.37, SD = 2.98, p = .038) at the 48-h follow-up.

CONCLUSION

Explaining the nocebo effect may be a beneficial addition to standard medicine information for reducing side effect reporting. Negative media coverage about a drug is likely to generate increased side effects. Future research should examine the benefit of nocebo explanation in patients starting new medicines.

Adverse Effects on Work and Daily Life Interference among Healthcare Workers after the First and Second ChAdOx1 and BNT162b2 COVID-19 Vaccine Doses

In this study, we assessed the adverse effects and the work and daily life interference associated with each dose of the ChAdOx1 and BNT162b2 COVID-19 vaccines. Questionnaires were distributed to workers after they received both doses; only those who worked the day after receiving the vaccine were included in the analysis. Overall, 368 ChAdOx1-vaccinated and 27 BNT162b2-vaccinated participants were included. Among the ChAdOx1-vaccinated participants, the incidence of adverse effects was significantly lower after the second dose than after the first dose. Among the BNT162b2-vaccinated participants, however, no differences in adverse effects or work and daily life interference were found between the doses. After the first and second dose, the numeric scale score (0–10) for interference with work was 3.9 ± 2.9 and 1.6 ± 1.9 for the ChAdOx1 and 3.2 ± 2.5 and 3.6 ± 3.0 for the BNT162b2 vaccine, respectively. A similar trend was observed for interference with daily life. Factors associated with work and daily life interference in the multivariate model were age, vaccine dose (first or second), and the interaction term of vaccine type and dose. These results could be used to inform the general population of the adverse effects associated with these vaccinations.