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MacCallum PE, Cooze JB, Ward J, Moore KA, Blundell J. Evaluating the effects of single, multiple, and delayed systemic rapamycin injections to contextual fear reconsolidation: Implications for the neurobiology of memory and the treatment of PTSD-like re-experiencing. Behav Brain Res 2024; 461:114855. [PMID: 38185381 DOI: 10.1016/j.bbr.2024.114855] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/18/2023] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
The mechanistic target of rapamycin (mTOR) kinase is known to mediate the formation and persistence of aversive memories. Rapamycin, an mTOR inhibitor, administered around the time of reactivation blocks retrieval-induced mTOR activity and de novo protein synthesis in the brains of rodents, while correspondingly diminishing subsequent fear memory. The goal of the current experiments was to further explore rapamycin's effects on fear memory persistence. First, we examined whether mTOR blockade at different time-points after reactivation attenuates subsequent contextual fear memory. We show that rapamycin treatment 3 or 12 h post-reactivation disrupts memory persistence. Second, we examined whether consecutive days of reactivation paired with rapamycin had additive effects over a single pairing at disrupting a contextual fear memory. We show that additional reactivation-rapamycin pairings exacerbates the reconsolidation impairment. Finally, we examined if impaired reconsolidation of a contextual fear memory from rapamycin treatment had any after-effects on learning and recalling a new fear association. We show that rapamycin-impaired reconsolidation does not affect new learning or recall and protects against fear generalization. Our findings improve our understanding of mTOR- dependent fear memory processes, as well as provide insight into potentially novel treatment options for stress-related psychopathologies such as posttraumatic stress disorder.
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Affiliation(s)
- Phillip E MacCallum
- Department of Psychology, Memorial University of Newfoundland, 232 Elizabeth Ave, St. John's, Newfoundland and Labrador A1B 3X9, Canada
| | - Jane B Cooze
- Department of Psychology, Memorial University of Newfoundland, 232 Elizabeth Ave, St. John's, Newfoundland and Labrador A1B 3X9, Canada
| | - Joshua Ward
- Department of Psychology, Memorial University of Newfoundland, 232 Elizabeth Ave, St. John's, Newfoundland and Labrador A1B 3X9, Canada
| | - Kelsey Am Moore
- Department of Psychology, Memorial University of Newfoundland, 232 Elizabeth Ave, St. John's, Newfoundland and Labrador A1B 3X9, Canada
| | - Jacqueline Blundell
- Department of Psychology, Memorial University of Newfoundland, 232 Elizabeth Ave, St. John's, Newfoundland and Labrador A1B 3X9, Canada.
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Li G, Liu Y, Zhang J, DeMauro SB, Meng Q, Mbuagbaw L, Schmidt B, Kirpalani H, Thabane L. Missing Outcome Data in Recent Perinatal and Neonatal Clinical Trials. Pediatrics 2024; 153:e2023063101. [PMID: 38389453 DOI: 10.1542/peds.2023-063101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 02/24/2024] Open
Abstract
Missing outcome data in clinical trials may jeopardize the validity of the trial results and inferences for clinical practice. Although sick and preterm newborns are treated as a captive patient population during their stay in the NICUs, their long-term outcomes are often ascertained after discharge. This greatly increases the risk of attrition. We surveyed recently published perinatal and neonatal randomized trials in 7 high-impact general medical and pediatric journals to review the handling of missing primary outcome data and any choice of imputation methods. Of 87 eligible trials in this survey, 77 (89%) had incomplete primary outcome data. The missing outcome data were not discussed at all in 9 reports (12%). Most study teams restricted their main analysis to participants with complete information for the primary outcome (61 trials; 79%). Only 38 of the 77 teams (49%) performed sensitivity analyses using a variety of imputation methods. We conclude that the handling of missing primary outcome data was frequently inadequate in recent randomized perinatal and neonatal trials. To improve future approaches to missing outcome data, we discuss the strengths and limitations of different imputation methods, the appropriate estimation of sample size, and how to deal with data withdrawal. However, the best strategy to reduce bias from missing outcome data in perinatal and neonatal trials remains prevention. Investigators should anticipate and preempt missing data through careful study design, and closely monitor all incoming primary outcome data for completeness during the conduct of the trial.
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Affiliation(s)
- Guowei Li
- Center for Clinical Epidemiology and Methodology
- Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Yingxin Liu
- Center for Clinical Epidemiology and Methodology
| | - Jingyi Zhang
- Center for Clinical Epidemiology and Methodology
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Qiong Meng
- Department of Pediatrics, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Lawrence Mbuagbaw
- Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Evidence, and Impact; Department of Health Research Methods
- Anesthesia
- Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon, Central Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Barbara Schmidt
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Evidence, and Impact; Department of Health Research Methods
| | - Haresh Kirpalani
- Emeritus Professor Pediatrics at University Pennsylvania, Philadelphia, PA
- Emeritus Professor Pediatrics McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Evidence, and Impact; Department of Health Research Methods
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- University of Johannesburg, Johannesburg, South Africa
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Schaub AC, Schneider E, Vazquez-Castellanos JF, Schweinfurth N, Kettelhack C, Doll JPK, Yamanbaeva G, Mählmann L, Brand S, Beglinger C, Borgwardt S, Raes J, Schmidt A, Lang UE. Clinical, gut microbial and neural effects of a probiotic add-on therapy in depressed patients: a randomized controlled trial. Transl Psychiatry 2022; 12:227. [PMID: 35654766 PMCID: PMC9163095 DOI: 10.1038/s41398-022-01977-z] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 12/18/2022] Open
Abstract
A promising new treatment approach for major depressive disorder (MDD) targets the microbiota-gut-brain (MGB) axis, which is linked to physiological and behavioral functions affected in MDD. This is the first randomized controlled trial to determine whether short-term, high-dose probiotic supplementation reduces depressive symptoms along with gut microbial and neural changes in depressed patients. Patients with current depressive episodes took either a multi-strain probiotic supplement or placebo over 31 days additionally to treatment-as-usual. Assessments took place before, immediately after and again four weeks after the intervention. The Hamilton Depression Rating Sale (HAM-D) was assessed as primary outcome. Quantitative microbiome profiling and neuroimaging was used to detect changes along the MGB axis. In the sample that completed the intervention (probiotics N = 21, placebo N = 26), HAM-D scores decreased over time and interactions between time and group indicated a stronger decrease in the probiotics relative to the placebo group. Probiotics maintained microbial diversity and increased the abundance of the genus Lactobacillus, indicating the effectivity of the probiotics to increase specific taxa. The increase of the Lactobacillus was associated with decreased depressive symptoms in the probiotics group. Finally, putamen activation in response to neutral faces was significantly decreased after the probiotic intervention. Our data imply that an add-on probiotic treatment ameliorates depressive symptoms (HAM-D) along with changes in the gut microbiota and brain, which highlights the role of the MGB axis in MDD and emphasizes the potential of microbiota-related treatment approaches as accessible, pragmatic, and non-stigmatizing therapies in MDD. Trial Registration: www.clinicaltrials.gov , identifier: NCT02957591.
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Affiliation(s)
| | - Else Schneider
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
| | - Jorge F Vazquez-Castellanos
- Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven-University of Leuven, Leuven, Belgium
- VIB Center for Microbiology, Leuven, Belgium
| | - Nina Schweinfurth
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
| | - Cedric Kettelhack
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
| | - Jessica P K Doll
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
| | | | - Laura Mählmann
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
| | - Serge Brand
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, 6719851115, Iran
- Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, 6715847141, Iran
- Department of Sport, Exercise and Health, Division of Sport Science and Psychosocial Health, University of Basel, 4052, Basel, Switzerland
- School of Medicine, Tehran University of Medical Sciences, Tehran, 1416753955, Iran
| | | | - Stefan Borgwardt
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Jeroen Raes
- Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven-University of Leuven, Leuven, Belgium
- VIB Center for Microbiology, Leuven, Belgium
| | - André Schmidt
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland.
| | - Undine E Lang
- University of Basel, Department of Psychiatry (UPK), Basel, Switzerland
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Feasibility of Combining Transcranial Direct Current Stimulation and Active Fully Embodied Virtual Reality for Visual Height Intolerance: A Double-Blind Randomized Controlled Study. J Clin Med 2022; 11:jcm11020345. [PMID: 35054039 PMCID: PMC8779186 DOI: 10.3390/jcm11020345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Transcranial Direct Current Stimulation (tDCS) and Virtual Reality Exposure Therapy (VRET) are individually increasingly used in psychiatric research. OBJECTIVE/HYPOTHESIS Our study aimed to investigate the feasibility of combining tDCS and wireless 360° full immersive active and embodied VRET to reduce height-induced anxiety. METHODS We carried out a pilot randomized, double-blind, controlled study associating VRET (two 20 min sessions with a 48 h interval, during which, participants had to cross a plank at rising heights in a building in construction) with online tDCS (targeting the ventromedial prefrontal cortex) in 28 participants. The primary outcomes were the sense of presence level and the tolerability. The secondary outcomes were the anxiety level (Subjective Unit of Discomfort) and the salivary cortisol concentration. RESULTS We confirmed the feasibility of the association between tDCS and fully embodied VRET associated with a good sense of presence without noticeable adverse effects. In both groups, a significant reduction in the fear of height was observed after two sessions, with only a small effect size of add-on tDCS (0.1) according to the SUD. The variations of cortisol concentration differed in the tDCS and sham groups. CONCLUSION Our study confirmed the feasibility of the association between wireless online tDCS and active, fully embodied VRET. The optimal tDCS paradigm remains to be determined in this context to increase effect size and then adequately power future clinical studies assessing synergies between both techniques.
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Systematic review and meta analysis of differential attrition between active and control arms in randomized controlled trials of lifestyle interventions in chronic disease. BMC Med Res Methodol 2021; 21:122. [PMID: 34126934 PMCID: PMC8204467 DOI: 10.1186/s12874-021-01313-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/30/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Attrition is a major obstacle for lifestyle interventions sustained for the medium-to-long term and can have significant consequences on the internal validity of a trial. When the degree of attrition differs between active and control arms this is termed differential attrition and is an important consideration during initial stages of trial planning. OBJECTIVES The primary research question of this study was: what is the differential attrition between treatment arms in lifestyle interventions for prevalent chronic diseases? METHODS We performed a systematic review and meta-analysis of 23 studies involving a lifestyle intervention component in cohorts with chronic diseases. The search accessed three databases: Scopus, Medline Ovid and Web of Science. Attrition between treatment arms was analysed using a random-effects model and examined the relationship between the relative attrition and potential moderators, such as time to final follow-up, time to first follow-up, type of disease, type of control, type of intervention and length of treatment. RESULTS The pooled risk ratio was 1.00 (95% CI 0.97 - 1.03) and only one study fell outside this range. A univariable association was described between the pooled risk ration and length (years) to final follow-up, which did not remain in the multivariable model. CONCLUSIONS Ultimately, we found no evidence of differential attrition in medium-to-long term lifestyle intervention studies for chronic disease, increasing confidence in conducting such studies with minimal potential of attrition bias. TRIAL REGISTRATION PROSPERO registration number CRD42018084495 .
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The prevalence of depressive and anxiety symptoms and their associations with quality of life among clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. Transl Psychiatry 2021; 11:75. [PMID: 33500389 PMCID: PMC7835649 DOI: 10.1038/s41398-021-01196-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/12/2020] [Accepted: 12/15/2020] [Indexed: 01/30/2023] Open
Abstract
The impact of the COVID-19 pandemic on clinically stable older patients with psychiatric disorders is unclear. This study examined the prevalence of depressive and anxiety symptoms, and their associations with quality of life (QOL) in clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. This was a multicenter, cross-sectional study. Depressive and anxiety symptoms, insomnia, pain, and QOL were assessed with standardized instruments. A total of 1063 patients were included. The prevalence of depressive and anxiety symptoms, and combined depressive and anxiety symptoms were 62.3% (95%CI = 59.4-65.2%), 52.4% (95%CI = 49.3-55.4%), and 45.9% (95%CI = 42.9-48.9%), respectively. Patients with depressive and anxiety symptoms had significantly lower QOL than those without (P < 0.01). Binary logistic regression analyses revealed that having depressive symptoms was positively associated with more severe insomnia (OR = 1.29, P < 0.01) and pain (OR = 1.14, P < 0.01), and was negatively associated with other psychiatric diagnoses (except for major depressive disorder, schizophrenia, and organic mental disorder; OR = 0.50, P < 0.01), while having anxiety symptoms was positively associated with severe physical diseases (OR = 1.57, P = 0.02), poor adherence to treatment (OR = 1.50, P < 0.01), and more severe insomnia (OR = 1.15, P < 0.01) and pain (OR = 1.11, P < 0.01). Having combined depression and anxiety symptoms was positively associated with poor adherence to treatment (OR = 1.42, P = 0.02) and more severe insomnia (OR = 1.19, P < 0.01) and pain (OR = 1.15, P < 0.01), and was negatively associated with the diagnosis of schizophrenia (OR = 0.50, P = 0.04) and others (OR = 0.53, P < 0.01). Depressive and anxiety symptoms were common in clinically stable older patients with psychiatric disorders during the COVID-19 pandemic. Considering the negative impact of these symptoms on QOL, regular screening and appropriate treatment are recommended for this population.
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Differentiating "types" of treatment dropout: Nonstarters in an RCT of prolonged exposure versus sertraline. Behav Res Ther 2020; 135:103750. [PMID: 33035741 DOI: 10.1016/j.brat.2020.103750] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/20/2020] [Accepted: 10/02/2020] [Indexed: 11/23/2022]
Abstract
Despite effective interventions for posttraumatic stress disorder (PTSD), many patients prematurely drop out. Differentiating "types" of dropout at various stages of treatment may improve our ability to predict and prevent attrition. Using data from a doubly randomized preference trial, this study examined patient dropout prior to treatment and compared these "nonstarters" with treatment starters and in-treatment dropouts. Patients (N = 200) with chronic PTSD were randomized to "choice" (prolonged exposure [PE] or sertraline) or "no choice" (re-randomized to PE or sertraline) and received up to 10 weeks of treatment. Overall dropout rate was 33.0% (n = 66). A substantial minority were nonstarters (n = 19; 28.8%). Relative to patients who began treatment, nonstarters reported less severe PTSD symptomatology (p = .03, d = 0.57) and were less likely to have received their preferred treatment (p < .001). These differences remained even when comparing nonstarters to patients that began treatment but eventually dropped out. Differences in beliefs (i.e., perceived credibility) toward one treatment versus the other were also linked to pretreatment dropout. Reasons underlying dropout likely differ during various treatment stages. Better understanding risk factors for types of dropout may inform strategies to boost engagement and retention, ultimately improving patient outcomes.
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Kline AC, Feeny NC, Zoellner LA. Race and cultural factors in an RCT of prolonged exposure and sertraline for PTSD. Behav Res Ther 2020; 132:103690. [PMID: 32650231 PMCID: PMC7398839 DOI: 10.1016/j.brat.2020.103690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 03/27/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022]
Abstract
The efficacy of treatments for posttraumatic stress disorder (PTSD) among African Americans is less clear given underrepresentation in clinical research. Additionally, intervention research examining race has typically not considered within-group heterogeneity, such as acculturation, ethnic identity, and cultural attitudes. In a randomized controlled trial, African American (n = 43) and Caucasian (n = 130) individuals received prolonged exposure (PE) or sertraline for PTSD, comparing: treatment response, retention, and treatment beliefs and preferences. Indirect effects of cultural variables were also examined. African Americans reported stronger ethnic identity (d = 0.71), less positive attitudes toward other groups (d = 0.36), and less acculturation (d = 0.51) than Caucasians. Noninferiority analyses indicated clinically equivalent PTSD outcomes for African Americans and Caucasians in both treatments. Groups showed comparable improvements in depression and functioning, and similar treatment preferences and beliefs. African Americans attended fewer sessions in PE (d = 0.87) and sertraline (d = 0.53) than Caucasians. Indirect effects analyses indicated positive cultural attitudes toward other ethnoracial groups were consistently associated with better treatment outcome and retention. Despite no differential effectiveness, findings may highlight the need to target retention among African Americans. Within-group cultural aspects of race may be an informative complement to basic, categorical conceptualizations.
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Affiliation(s)
- Alexander C Kline
- PTSD Treatment and Research Program, Case Western Reserve University, Department of Psychological Sciences, 11220 Bellflower Road, Cleveland, OH, 44106-7123, USA.
| | - Norah C Feeny
- PTSD Treatment and Research Program, Case Western Reserve University, Department of Psychological Sciences, 11220 Bellflower Road, Cleveland, OH, 44106-7123, USA
| | - Lori A Zoellner
- Center for Anxiety and Traumatic Stress, University of Washington, Department of Psychology, Guthrie Hall, Box 351525, Seattle, WA, 98195-1525, USA
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Torous J, Lipschitz J, Ng M, Firth J. Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis. J Affect Disord 2020; 263:413-419. [PMID: 31969272 DOI: 10.1016/j.jad.2019.11.167] [Citation(s) in RCA: 254] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/13/2019] [Accepted: 11/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Low engagement and attrition from app interventions is an increasingly recognized challenge for interpreting and translating the findings from digital health research. Focusing on randomized controlled trials (RCTs) of smartphone apps for depressive symptoms, we aimed to establish overall dropout rates, and how this differed between different types of apps. METHODS A systematic review of RCTs of apps targeting depressive symptoms in adults was conducted in May 2019. Random-effects meta-analysis were applied to calculate the pooled dropout rates in intervention and control conditions. Trim-and-fill analyses were used to adjust estimates after accounting for publication bias. RESULTS The systematic search retrieved 2,326 results. 18 independent studies were eligible for inclusion, using data from 3,336 participants randomized to either smartphone interventions for depression (n = 1,786) or control conditions (n = 1,550). The pooled dropout rate was 26.2%. This increased to 47.8% when adjusting for publication bias. Study retention rates did not differ between depression vs. placebo apps, clinically-diagnosed vs. self-reported depression, paid vs. unpaid assessments, CBT vs. non-CBT apps, or mindfulness vs. non-mindfulness app studies. Dropout rates were higher in studies with large samples, but lower in studies offering human feedback and in-app mood monitoring. DISCUSSION High dropout rates present a threat to the validity of RCTs of mental health apps. Strategies to improve retention may include providing human feedback, and enabling in-app mood monitoring. However, it critical to consider bias when interpreting results of apps for depressive symptoms, especially given the strong indication of publication bias, and the higher attrition in larger studies.
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Affiliation(s)
- John Torous
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Jessica Lipschitz
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michelle Ng
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Joseph Firth
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; NICM Health Research Institute, Western Sydney University, Westmead, Australia.
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Abstract
The purpose of this study was to assess the acceptability and efficacy of all types of pharmacotherapeutic agents in reducing the symptoms of posttraumatic stress disorder (PTSD). In this systematic meta-analysis, the dropout and response rates of various pharmacotherapy and placebo treatments reported by randomized clinical trials were compared. A total of 34 reports that described the acceptability and efficacy of PTSD pharmacotherapies were retrieved and analyzed. Of them, 30 trials examined the dropout rate as an index of acceptability and revealed the superiority of the PTSD pharmacotherapy to placebos (odds ratio, 0.75; 95% confidence interval, 0.66-0.86; n = 4313). The response rate was determined in 20 trials as an index of efficacy, showing that the PTSD pharmacotherapies were superior to the placebos (odds ratio, 1.47; 95% confidence interval, 1.34-1.62; n = 2166). Pharmacotherapy is an important component of the care of patients with PTSD.
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Hussain JA, White IR, Langan D, Johnson MJ, Currow DC, Torgerson DJ, Bland M. Missing data in randomized controlled trials testing palliative interventions pose a significant risk of bias and loss of power: a systematic review and meta-analyses. J Clin Epidemiol 2015; 74:57-65. [PMID: 26718729 PMCID: PMC4910872 DOI: 10.1016/j.jclinepi.2015.12.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/12/2015] [Accepted: 12/16/2015] [Indexed: 11/27/2022]
Abstract
Objectives To assess the risk posed by missing data (MD) to the power and validity of trials evaluating palliative interventions. Study Design and Setting A systematic review of MD in published randomized controlled trials (RCTs) of palliative interventions in participants with life-limiting illnesses was conducted, and random-effects meta-analyses and metaregression were performed. CENTRAL, MEDLINE, and EMBASE (2009–2014) were searched with no language restrictions. Results One hundred and eight RCTs representing 15,560 patients were included. The weighted estimate for MD at the primary endpoint was 23.1% (95% confidence interval [CI] 19.3, 27.4). Larger MD proportions were associated with increasing numbers of questions/tests requested (odds ratio [OR], 1.19; 95% CI 1.05, 1.35) and with longer study duration (OR, 1.09; 95% CI 1.02, 1.17). Meta-analysis found evidence of differential rates of MD between trial arms, which varied in direction (OR, 1.04; 95% CI 0.90, 1.20; I2 35.9, P = 0.001). Despite randomization, MD in the intervention arms (vs. control) were more likely to be attributed to disease progression unrelated to the intervention (OR, 1.31; 95% CI 1.02, 1.69). This was not the case for MD due to death (OR, 0.92; 95% CI 0.78, 1.08). Conclusion The overall proportion and differential rates and reasons for MD reduce the power and potentially introduce bias to palliative care trials.
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Affiliation(s)
- Jamilla A Hussain
- Hull York Medical School, University of York, Heslington, York YO10 5DD, UK.
| | - Ian R White
- MRC Biostatistics Unit, Cambridge Institute for Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Dean Langan
- Centre for Reviews and Dissemination, University of York, Heslington, York YO10 5DD, UK
| | | | - David C Currow
- Hull York Medical School, University of York, Heslington, York YO10 5DD, UK; Palliative and Supportive Services, Flinders University, 216 Daws Road, Daw Park, South Australia 5041, Australia
| | | | - Martin Bland
- Health Sciences Department, University of York, Heslington, York YO10 5DD, UK
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Cosmesis and Body Image in Patients Undergoing Single-port Versus Conventional Laparoscopic Cholecystectomy. Ann Surg 2015; 262:728-34; discussion 734-5. [DOI: 10.1097/sla.0000000000001474] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Crutzen R, Viechtbauer W, Spigt M, Kotz D. Differential attrition in health behaviour change trials: a systematic review and meta-analysis. Psychol Health 2015; 30:122-34. [PMID: 25109224 DOI: 10.1080/08870446.2014.953526] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Attrition is a common problem in health behaviour change (HBC) trials. When the degree of attrition differs between treatment conditions, then this is called differential attrition and is regarded as a major threat to internal validity. The primary research question of this study was: how often and to what degree does differential attrition occur in HBC trials? DESIGN A systematic review and meta-analysis of a random selection of HBC trials (k = 60). We meta-analysed the relative attrition rates using a random-effects model and examined the relationship between the relative attrition rates and the potential moderators: the amount of human contact in delivery and the intensity of the intervention/control condition, the type of control condition, and the follow-up intensity and duration. MAIN OUTCOME MEASURES Relative attrition rates. RESULTS The average attrition rate was 18% (SD = .15; M = .15) in the intervention and 17% (SD = .13; M = .13) in the control conditions. The estimated average relative attrition rate was 1.10 (95% CI: 1.01-1.20, p = .02), suggesting an overall higher attrition rate of 10% in the intervention conditions. This relative attrition rate was not related to any of the potential moderators. CONCLUSION There is indication of a slightly higher amount of attrition on average in the intervention conditions of HBC trials.
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Affiliation(s)
- Rik Crutzen
- a CAPHRI School for Public Health and Primary Care , Maastricht University , Maastricht , The Netherlands
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Haga SB, Mills R, Bosworth H. Striking a balance in communicating pharmacogenetic test results: promoting comprehension and minimizing adverse psychological and behavioral response. PATIENT EDUCATION AND COUNSELING 2014; 97:10-5. [PMID: 24985359 PMCID: PMC4162835 DOI: 10.1016/j.pec.2014.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/29/2014] [Accepted: 06/15/2014] [Indexed: 05/07/2023]
Abstract
OBJECTIVE Pharmacogenetic (PGx) testing can provide information about a patient's likelihood to respond to a medication or experience an adverse event, and be used to inform medication selection and/or dosing. Promoting patient comprehension of PGx test results will be important to improving engagement and understanding of treatment decisions. METHODS The discussion in this paper is based on our experiences and the literature on communication of genetic test results for disease risk and broad risk communication strategies. RESULTS Clinical laboratory reports often describe PGx test results using standard terminology such as 'poor metabolizer' or 'ultra-rapid metabolizer.' While this type of terminology may promote patient recall with its simple, yet descriptive nature, it may be difficult for some patients to comprehend and/or cause adverse psychological or behavioral responses. CONCLUSION The language used to communicate results and their significance to patients will be important to consider in order to minimize confusion and potential psychological consequences such as increased anxiety that can adversely impact medication-taking behaviors. PRACTICE IMPLICATIONS Due to patients' unfamiliarity with PGx testing and the potential for confusion, adverse psychological effects, and decreased medication adherence, health providers need to be cognizant of the language used in discussing PGx test results with patients.
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Affiliation(s)
- Susanne B Haga
- Institute for Genome Sciences & Policy and Sanford School of Public Policy, Duke University, Durham, USA.
| | - Rachel Mills
- Institute for Genome Sciences & Policy, Duke University, Durham, USA
| | - Hayden Bosworth
- Departments of Medicine, Psychiatry, and Nursing, Duke University, Center for Health Services Research in Primary Care, Durham VAMC, Durham, USA
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Rodrigues H, Figueira I, Lopes A, Gonçalves R, Mendlowicz MV, Coutinho ESF, Ventura P. Does D-cycloserine enhance exposure therapy for anxiety disorders in humans? A meta-analysis. PLoS One 2014; 9:e93519. [PMID: 24991926 PMCID: PMC4081005 DOI: 10.1371/journal.pone.0093519] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 03/07/2014] [Indexed: 11/21/2022] Open
Abstract
The treatment of anxiety is on the edge of a new era of combinations of pharmacologic and psychosocial interventions. A new wave of translational research has focused on the use of pharmacological agents as psychotherapy adjuvants using neurobiological insights into the mechanism of the action of certain psychological treatments such as exposure therapy. Recently, d-cycloserine (DCS) an antibiotic used to treat tuberculosis has been applied to enhance exposure-based treatment for anxiety and has proved to be a promising, but as yet unproven intervention. The present study aimed to evaluate the efficacy of DCS in the enhancement of exposure therapy in anxiety disorders. A systematic review/meta-analysis was conducted. Electronic searches were conducted in the databases ISI-Web of Science, Pubmed and PsycINFO. We included only randomized, double-blind, placebo-controlled trials with humans, focusing on the role of DCS in enhancing the action of exposure therapy for anxiety disorders. We identified 328 references, 13 studies were included in our final sample: 4 on obsessive-compulsive disorder, 2 on panic disorder, 2 on social anxiety disorder, 2 on posttraumatic stress disorder, one on acrophobia, and 2 on snake phobia. The results of the present meta-analysis show that DCS enhances exposure therapy in the treatment of anxiety disorders (Cohen d = −0.34; CI: −0.54 to −0.14), facilitating the specific process of extinction of fear. DCS seems to be effective when administered at a time close to the exposure therapy, at low doses and a limited number of times. DCS emerges as a potential new therapeutic approach for patients with refractory anxiety disorders that are unresponsive to the conventional treatments available. When administered correctly, DCS is a promising strategy for augmentation of CBT and could reduce health care costs, drop-out rates and bring faster relief to patients.
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Affiliation(s)
- Helga Rodrigues
- Institute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, Brazil
| | - Ivan Figueira
- Institute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, Brazil
| | - Alessandra Lopes
- Institute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, Brazil
| | - Raquel Gonçalves
- Institute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, Brazil
| | - Mauro Vitor Mendlowicz
- Department of Psychiatry and Mental Health, Universidade Federal Fluminense (MSM-UFF), Niteroi, Brazil
| | | | - Paula Ventura
- Institute of Psychology, Universidade Federal do Rio de Janeiro (IPUB-UFRJ), Rio de Janeiro, Brazil
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Kistin CJ. Transparent reporting of missing outcome data in clinical trials: applying the general principles of CONSORT 2010. ACTA ACUST UNITED AC 2014; 19:161-2. [DOI: 10.1136/eb-2014-101797] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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17
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Crutzen R, Viechtbauer W, Kotz D, Spigt M. No differential attrition was found in randomized controlled trials published in general medical journals: a meta-analysis. J Clin Epidemiol 2013; 66:948-54. [DOI: 10.1016/j.jclinepi.2013.03.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 02/27/2013] [Accepted: 03/12/2013] [Indexed: 10/26/2022]
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Little RJ, D'Agostino R, Cohen ML, Dickersin K, Emerson SS, Farrar JT, Frangakis C, Hogan JW, Molenberghs G, Murphy SA, Neaton JD, Rotnitzky A, Scharfstein D, Shih WJ, Siegel JP, Stern H. The prevention and treatment of missing data in clinical trials. N Engl J Med 2012; 367:1355-60. [PMID: 23034025 PMCID: PMC3771340 DOI: 10.1056/nejmsr1203730] [Citation(s) in RCA: 1018] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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19
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Non-adherence and non-response in the treatment of anxiety disorders. J Anxiety Disord 2012; 26:583-9. [PMID: 22440391 DOI: 10.1016/j.janxdis.2012.02.010] [Citation(s) in RCA: 198] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 02/04/2012] [Indexed: 11/24/2022]
Abstract
Among the best established treatments for anxiety disorders are cognitive-behavioral interventions and serotonin reuptake inhibitors. Although clinically useful, these therapies are far from universally efficacious; some patients are unable to complete treatment, and many treatment completers fail to achieve clinically significant improvement. A review of meta-analyses on the treatment of anxiety disorders reveals that about a fifth of patients drop out prematurely and a third of treatment completers are classified as non-responders. In this article we examine the predictors of, and potential solutions for, the problems of treatment non-adherence and non-response to cognitive-behavioral and serotonergic treatments of adult anxiety disorders. Despite decades of research, few reliable predictors have been identified, and no predictor has been consistently supported in the literature. However, there is suggestive evidence that risk of premature dropout is associated with low treatment motivation, side effects, and practical barriers to attending sessions. There is also suggestive evidence that poor response is associated with severe pretreatment psychopathology and comorbidity, as well as high expressed emotion in the patient's family environment. Methods for better estimating treatment prognosis are proposed and possible directions for improving treatment outcome are discussed.
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Schneier FR, Neria Y, Pavlicova M, Hembree E, Suh EJ, Amsel L, Marshall MRD. Combined prolonged exposure therapy and paroxetine for PTSD related to the World Trade Center attack: a randomized controlled trial. Am J Psychiatry 2012; 169:80-8. [PMID: 21908494 PMCID: PMC3606709 DOI: 10.1176/appi.ajp.2011.11020321] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Selective serotonin reuptake inhibitors (SSRIs) are often recommended in combination with established cognitive-behavioral therapies (CBTs) for posttraumatic stress disorder (PTSD), but combined initial treatment of PTSD has not been studied under controlled conditions. There are also few studies of either SSRIs or CBT in treating PTSD related to terrorism. The authors compared prolonged exposure therapy (a CBT) plus paroxetine (an SSRI) with prolonged exposure plus placebo in the treatment of terrorism-related PTSD. METHOD Adult survivors of the World Trade Center attack of September 11, 2001, with PTSD were randomly assigned to 10 weeks of treatment with prolonged exposure (10 sessions) plus paroxetine (N=19) or prolonged exposure plus placebo (N=18). After week 10, patients discontinued prolonged exposure and were offered 12 additional weeks of continued randomized treatment. RESULTS Patients treated with prolonged exposure plus paroxetine experienced significantly greater improvement in PTSD symptoms (incidence rate ratio=0.50, 95% CI=0.30-0.85) and remission status (odds ratio=12.6, 95% CI=1.23-129) during 10 weeks of combined treatment than patients treated with prolonged exposure plus placebo. Response rate and quality of life were also significantly more improved with combined treatment. The subset of patients who continued randomized treatment for 12 additional weeks showed no group differences. CONCLUSIONS Initial treatment with paroxetine plus prolonged exposure was more efficacious than prolonged exposure plus placebo for PTSD related to the World Trade Center attack. Combined treatment medication and prolonged exposure therapy deserves further study in larger samples with diverse forms of PTSD and over longer follow-up periods.
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Steinemann DC, Raptis DA, Lurje G, Oberkofler CE, Wyss R, Zehnder A, Lesurtel M, Vonlanthen R, Clavien PA, Breitenstein S. Cosmesis and body image after single-port laparoscopic or conventional laparoscopic cholecystectomy: a multicenter double blinded randomised controlled trial (SPOCC-trial). BMC Surg 2011; 11:24. [PMID: 21910897 PMCID: PMC3189390 DOI: 10.1186/1471-2482-11-24] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 09/12/2011] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Emerging attempts have been made to reduce operative trauma and improve cosmetic results of laparoscopic cholecystectomy. There is a trend towards minimizing the number of incisions such as natural transluminal endoscopic surgery (NOTES) and single-port laparoscopic cholecystectomy (SPLC). Many retrospective case series propose excellent cosmesis and reduced pain in SPLC. As the latter has been confirmed in a randomized controlled trial, patient's satisfaction on cosmesis is still controversially debated. METHODS/DESIGN The SPOCC trial is a prospective, multi-center, double blinded, randomized controlled study comparing SPLC with 4-port conventional laparoscopic cholecystectomy (4PLC) in elective surgery. The hypothesis and primary objective is that patients undergoing SPLC will have a better outcome in cosmesis and body image 12 weeks after surgery. This primary endpoint is assessed using a validated 8-item multiple choice type questionnaire on cosmesis and body image. The secondary endpoint has three entities: the quality of life 12 weeks after surgery assessed by the validated Short-Form-36 Health Survey questionnaire, postoperative pain assessed by a visual analogue scale and the use of analgesics. Operative time, surgeon's experience with SPLC and 4PLC, use of additional ports, conversion to 4PLC or open cholecystectomy, length of stay, costs, time of work as well as intra- and postoperative complications are further aspects of the secondary endpoint. Patients are randomly assigned either to SPLC or to 4PLC. Patients as well as treating physicians, nurses and assessors are blinded until the 7th postoperative day. Sample size calculation performed by estimating a difference of cosmesis of 20% (alpha = 0.05 and beta = 0.90, drop out rate of 10%) resulted in a number of 55 randomized patients per arm. DISCUSSION The SPOCC-trial is a prospective, multi-center, double-blind, randomized controlled study to assess cosmesis and body image after SPLC. TRIAL REGISTRATION (clinicaltrial.gov): NCT 01278472.
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Affiliation(s)
- Daniel C Steinemann
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Georg Lurje
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Christian E Oberkofler
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Roland Wyss
- Department of Surgery, Cantonal Hospital Winterthur, 8401 Winterthur, Switzerland
| | - Adrian Zehnder
- Department of Surgery, Cantonal Hospital Winterthur, 8401 Winterthur, Switzerland
| | - Mickael Lesurtel
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - René Vonlanthen
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Stefan Breitenstein
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
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