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Fountoulakis KN, Tsapakis EM. Neither serotonin disorder is at the core of depression nor dopamine at the core of schizophrenia; still these are biologically based mental disorders. Mol Psychiatry 2024:10.1038/s41380-024-02458-z. [PMID: 38374355 DOI: 10.1038/s41380-024-02458-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/13/2023] [Accepted: 01/24/2024] [Indexed: 02/21/2024]
Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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2
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Fugger G, Bartova L, Fabbri C, Fanelli G, Dold M, Swoboda MMM, Kautzky A, Zohar J, Souery D, Mendlewicz J, Montgomery S, Rujescu D, Serretti A, Kasper S. The sociodemographic and clinical profile of patients with major depressive disorder receiving SSRIs as first-line antidepressant treatment in European countries. Eur Arch Psychiatry Clin Neurosci 2022; 272:715-727. [PMID: 34989830 PMCID: PMC9095529 DOI: 10.1007/s00406-021-01368-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/29/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Due to favorable antidepressant (AD) efficacy and tolerability, selective-serotonin reuptake inhibitors (SSRIs) are consistently recommended as substances of first choice for the treatment of major depressive disorder (MDD) in international guidelines. However, little is known about the real-world clinical correlates of patients primarily prescribed SSRIs in contrast to those receiving alternative first-line ADs. METHODS These secondary analyses are based on a naturalistic, multinational cross-sectional study conducted by the European Group for the Study of Resistant Depression at ten research sites. We compared the socio-demographic and clinical characteristics of 1410 patients with primary MDD, who were either prescribed SSRIs or alternative substances as first-line AD treatment, using chi-squared tests, analyses of covariance, and logistic regression analyses. RESULTS SSRIs were prescribed in 52.1% of MDD patients who showed lower odds for unemployment, current severity of depressive symptoms, melancholic features, suicidality, as well as current inpatient treatment compared to patients receiving alternative first-line ADs. Furthermore, patients prescribed SSRIs less likely received add-on therapies including AD combination and augmentation with antipsychotics, and exhibited a trend towards higher response rates. CONCLUSION A more favorable socio-demographic and clinical profile associated with SSRIs in contrast to alternative first-line ADs may have guided European psychiatrists' treatment choice for SSRIs, rather than any relevant pharmacological differences in mechanisms of action of the investigated ADs. Our results must be cautiously interpreted in light of predictable biases resulting from the open treatment selection, the possible allocation of less severely ill patients to SSRIs as well as the cross-sectional study design that does not allow to ascertain any causal conclusions.
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Affiliation(s)
- Gernot Fugger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria ,Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Lucie Bartova
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria ,Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Chiara Fabbri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy ,Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Giuseppe Fanelli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy ,Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Markus Dold
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | | | - Alexander Kautzky
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Joseph Zohar
- Psychiatric Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Daniel Souery
- School of Medicine, Free University of Brussels, Brussels, Belgium ,Psy Pluriel-European Centre of Psychological Medicine, Brussels, Belgium
| | | | - Stuart Montgomery
- Imperial College School of Medicine, University of London, London, UK
| | - Dan Rujescu
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria. .,Center for Brain Research, Medical University of Vienna, Spitalgasse 4, 1090, Vienna, Austria.
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Appleton KM, Voyias PD, Sallis HM, Dawson S, Ness AR, Churchill R, Perry R. Omega-3 fatty acids for depression in adults. Cochrane Database Syst Rev 2021; 11:CD004692. [PMID: 34817851 PMCID: PMC8612309 DOI: 10.1002/14651858.cd004692.pub5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One potential treatment for MDD is n-3 polyunsaturated fatty acids (n-3PUFAs), also known as omega-3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n-3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta-analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest different effects of n-3PUFAs, depending on the severity of depressive symptoms, where no effects of n-3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. Hence it is important to establish their effectiveness in treating MDD. This review updates and incorporates an earlier review with the same research objective (Appleton 2015). OBJECTIVES To assess the effects of n-3 polyunsaturated fatty acids (also known as omega-3 fatty acids) versus a comparator (e.g. placebo, antidepressant treatment, standard care, no treatment, wait-list control) for major depressive disorder (MDD) in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO together with trial registries and grey literature sources (to 9 January 2021). We checked reference lists and contacted authors of included studies for additional information when necessary. SELECTION CRITERIA We included studies in the review if they: used a randomised controlled trial design; provided n-3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and non-completion of studies. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. We assessed the certainty of the evidence using GRADE criteria. MAIN RESULTS The review includes 35 relevant studies: 34 studies involving a total of 1924 participants investigated the impact of n-3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n-3PUFA supplementation compared to antidepressant treatment. For the placebo comparison, n-3PUFA supplementation resulted in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) (random-effects model) -0.40 (95% confidence interval (CI) -0.64 to -0.16; 33 studies, 1848 participants; very low-certainty evidence), but this effect is unlikely to be clinically meaningful. An SMD of 0.40 represents a difference between groups in scores on the HDRS (17-item) of approximately 2.5 points (95% CI 1.0 to 4.0), where the minimal clinically important change score on this scale is 3.0 points. The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between studies. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well-conducted trials also suggest that this effect estimate may be biased towards a positive finding for n-3PUFAs. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.27, 95% CI 0.99 to 1.64; 24 studies, 1503 participants; very low-certainty evidence), the confidence intervals include a small decrease to a modest increase in adverse events with n-3PUFAs. There was no evidence for a difference between n-3PUFA and placebo groups in remission rates (OR 1.13, 95% CI 0.74 to 1.72; 8 studies, 609 participants, low-certainty evidence), response rates (OR 1.20, 95% CI 0.80 to 1.79; 17 studies, 794 participants; low-certainty evidence), quality of life (SMD -0.38 (95% CI -0.82 to 0.06), 12 studies, 476 participants, very low-certainty evidence), or trial non-completion (OR 0.92, 95% CI 0.70 to 1.22; 29 studies, 1777 participants, very low-certainty evidence). The evidence on which these results are based was also very limited, highly heterogeneous, and potentially biased. Only one study, involving 40 participants, was available for the antidepressant comparison. This study found no differences between treatment with n-3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) -0.70, 95% CI -5.88 to 4.48), rates of response to treatment (OR 1.23, 95% CI 0.35 to 4.31), or trial non-completion (OR 1.00, 95% CI 0.21 to 4.71). Confidence intervals are however very wide in all analyses, and do not rule out important beneficial or detrimental effects of n-3PUFAs compared to antidepressants. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. AUTHORS' CONCLUSIONS At present, we do not have sufficient high-certainty evidence to determine the effects of n-3PUFAs as a treatment for MDD. Our primary analyses may suggest a small-to-modest, non-clinically beneficial effect of n-3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the certainty of the evidence on which this result is based to be low to very low. Our data may also suggest similar rates of adverse events and trial non-completion in n-3PUFA and placebo groups, but again our estimates are very imprecise. Effects of n-3PUFAs compared to antidepressants are very imprecise and uncertain. More complete evidence is required for both the potential positive and negative effects of n-3PUFAs for MDD.
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Affiliation(s)
| | - Philip D Voyias
- North Bristol NHS Trust, Bristol, UK
- University of Bristol, Bristol, UK
| | - Hannah M Sallis
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit (IEU) at the University of Bristol, Bristol, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Cochrane Common Mental Disorders, University of York, York, UK
| | - Andrew R Ness
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Rachel Perry
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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Zimmerman M, Balling C, Chelminski I, Dalrymple K. Have Treatment Studies of Depression Become Even Less Generalizable? Applying the Inclusion and Exclusion Criteria in Placebo-Controlled Antidepressant Efficacy Trials Published over 20 Years to a Clinical Sample. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 88:165-170. [PMID: 31096246 DOI: 10.1159/000499917] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Antidepressants are amongst the most frequently prescribed medications. More than a decade ago, our clinical research group applied a prototypic set of inclusion/exclusion criteria used in an antidepressant efficacy trial (AET) to patients presenting for treatment in our outpatient practice and found that most patients would not qualify for the trial. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we apply the psychiatric inclusion/exclusion criteria used in 158 placebo-controlled studies to a large sample of depressed patients who presented for outpatient treatment to determine the range and extent of the representativeness of samples treated in AETs and whether this has changed over time. METHOD We applied the inclusion and exclusion criteria used in 158 AETs to 1,271 patients presenting to an outpatient practice who received a principal diagnosis of major depressive disorder. The patients underwent a thorough diagnostic evaluation. RESULTS Across all 158 studies, the percentage of patients that would have been excluded ranged from 44.4 to 99.8% (mean = 86.1%). The percentage of patients that would have been excluded was significantly higher in the studies published in 2010 through 2014 compared to the studies published from 1995 to 2009 (91.4 vs. 83.8%, t(156) = 3.74, p < 0.001). CONCLUSIONS Only a minority of depressed patients seen in clinical practice are likely to be eligible for most AETs. The generalizability of AETs has decreased over time. It is unclear how generalizable the results of AETs are to patients treated in real-world clinical practice.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, Rhode Island, USA,
| | - Caroline Balling
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Iwona Chelminski
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kristy Dalrymple
- Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, Rhode Island, USA
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Holper L. Combining threshold analysis and GRADE to assess sensitivity to bias in antidepressant treatment recommendations adjusted for depression severity. Res Synth Methods 2019; 11:275-286. [PMID: 31873975 DOI: 10.1002/jrsm.1393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 01/07/2023]
Abstract
Threshold analysis has recently been proposed to be used in combination with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in order to assess the sensitivity to plausible bias of treatment recommendations derived from Bayesian network meta-analysis (NMA). Here, it was aimed to apply the combination of threshold analysis and GRADE to judge quantitative and qualitative information on risk of bias in antidepressant treatment recommendations. The analysis was based on the data set provided by Cipriani et al. (The Lancet 2018) comparing 21 antidepressants in adult major depressive disorder (MDD). Primary outcomes were efficacy (response rate) and acceptability (dropout rate) adjusted for the covariate depression severity. The combined approach suggested sensitivity to plausible bias to be largest for antidepressant recommendations top ranked by Cipriani et al., that is, amitriptyline, duloxetine, paroxetine, and venlafaxine in terms of efficacy and agomelatine, escitalopram, paroxetine, and venlafaxine in terms of acceptability. Covariate ranges within which recommendations were most sensitive to plausible bias were very severe depression in terms of efficacy (smallest threshold, ie, the largest sensitivity, around 39 Hamilton Depression Rating Scale [HDRS]) and moderate depression in terms of acceptability (smallest thresholds around 16 and 35 HDRS). This indicates that treatment recommendations within these ranges may likely change if plausible bias adjustments take place. The present findings may support decision makers in judging the sensitivity to plausible bias of current antidepressant treatment recommendations to accurately guide treatment decisions in MDD depending on depression severity.
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Affiliation(s)
- L Holper
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
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Hieronymus F, Lisinski A, Nilsson S, Eriksson E. Influence of baseline severity on the effects of SSRIs in depression: an item-based, patient-level post-hoc analysis. Lancet Psychiatry 2019; 6:745-752. [PMID: 31303567 DOI: 10.1016/s2215-0366(19)30216-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/18/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Reports claiming that antidepressants are effective only in patients with severe depression have affected treatment guidelines but these reports usually use a disputed measure of improvement, a decrease in the sum-score of the 17-item Hamilton Depression Rating Scale (HDRS-17), and are based on group-level rather than patient-level data. METHOD In this item-based, patient-level, post-hoc analysis, we pooled data from all completed, acute-phase, placebo-controlled, industry-sponsored, HDRS-based trials of the SSRIs citalopram, paroxetine, or sertraline in adult major depression. Patient-level data were pooled and subjected to item-based post-hoc analyses to assess the effect of baseline severity of depression on the response to treatment as assessed with HDRS-17 sum score, the depressed mood item of the HDRS, a six-item HDRS subscale (HDRS-6), and the remaining 11 HDRS items not included in this subscale (non-HDRS-6). Patients were defined as having non-severe depression if they had a baseline HDRS-17 sum score of 18 points or less and as having severe depression if they had a score of 27 points or more. FINDINGS Our study population consisted of 8262 patients from 28 placebo-controlled SSRI trials. Participants were treated with either citalopram (n=744), paroxetine (n=2981), sertraline (n=1202), fluoxetine (active-control group; n=754), or placebo (n=2581). 654 patients were defined as having non-severe depression and 1377 as having severe depression. Patients with non-severe and severe depression did not differ with respect to SSRI-induced decrease in depressed mood and other HDRS symptoms belonging to the HDRS-6 subscale. However, after exclusion of patients with rare extreme baseline values, a positive association was seen between severity and efficacy when using HDRS-17 sum score as the effect parameter. This result was largely due to a more pronounced response to treatment with respect to non-HDRS-6 items in patients with severe depression than in those with non-severe depression. This outcome could be explained by non-HDRS-6 items, more so than HDRS-6 items, being more severe and prevalent at baseline in severe than in non-severe cases; hence, less room was left for improvement in these areas in patients with non-severe depression. INTERPRETATION The use of an outcome measure that includes symptoms that rate low at baseline in patients with non-severe depression might result in the interpretation that SSRIs are ineffective in these patients. With respect to alleviation of HDRS-6 items, SSRIs appear to be as effective in patients with non-severe depression as in those with severe depression. FUNDING Swedish Medical Research Council, AFA Insurance, Swedish Brain Foundation, Sahlgrenska University Hospital (Avtal om Läkarutbildning och Forskning), Bertil Hållsten's Foundation, and Söderberg's Foundation.
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Affiliation(s)
- Fredrik Hieronymus
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alexander Lisinski
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Staffan Nilsson
- Institute of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden; Department of Pathology and Genetics, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elias Eriksson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Strawn JR, Mills JA, Croarkin PE. Switching Selective Serotonin Reuptake Inhibitors in Adolescents with Selective Serotonin Reuptake Inhibitor-Resistant Major Depressive Disorder: Balancing Tolerability and Efficacy. J Child Adolesc Psychopharmacol 2019; 29:250-255. [PMID: 30810350 PMCID: PMC6534091 DOI: 10.1089/cap.2018.0145] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: To guide clinicians in selecting the "next line" selective serotonin reuptake inhibitor (SSRI) for adolescents with treatment-resistant major depressive disorder, we sought to compare response rates among SSRIs in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study and to jointly model tolerability and efficacy for the specific SSRI comparisons. Methods: Efficacy and tolerability data for paroxetine, citalopram, and fluoxetine were extracted from the TORDIA study. Using a joint bivariate normal likelihood for response and tolerability (based on the maximum implied variance from the 95% credible intervals previously reported for the three SSRIs), a Monte Carlo pseudorandom sample (100,000 draws) was obtained, from which credible intervals, means, posterior tail probabilities, etc. were determined. Joint null hypotheses of no difference in efficacy and tolerability were then evaluated with regard to superiority of each SSRI over the others. Results: No significant differences in response were observed for citalopram compared with fluoxetine (p = 0.247) or for fluoxetine compared with paroxetine (p = 0.110), although citalopram trended toward being superior to paroxetine (mean difference: 0.2, p = 0.055). For efficacy-tolerability models, citalopram and fluoxetine were superior to paroxetine (p = 0.029 and p = 0.022, respectively) but did not differ between each other (p = 0.146). Conclusions: Joint efficacy-tolerability models suggest that citalopram and fluoxetine were statistically significantly superior to paroxetine while citalopram trended toward superiority over paroxetine in the efficacy model. These findings provide a more granular and practical evidence base for clinicians faced with treatment sequencing decisions in adolescents with SSRI-resistant depression.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Address correspondence to: Jeffrey R. Strawn, MD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Box 670559, Cincinnati, OH 45267-0559
| | - Jeffrey A. Mills
- Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio
| | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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Estimating patient-specific treatment advantages in the 'Treatment for Adolescents with Depression Study'. J Psychiatr Res 2019; 112:61-70. [PMID: 30856378 DOI: 10.1016/j.jpsychires.2019.02.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 01/12/2019] [Accepted: 02/25/2019] [Indexed: 11/23/2022]
Abstract
The 'Treatment for Adolescents with Depression Study' (TADS, ClinicalTrials.gov, identifier: NCT00006286) was a cornerstone, randomized controlled trial evaluating the effectiveness of standard treatment options for major depression in adolescents. Whereas previous TADS analyses examined primarily effect modifications of treatment-placebo differences by various patient characteristics, less is known about the modification of inter-treatment differences, and hence, patient characteristics that might guide treatment selection. We sought to fill this gap by estimating patient-specific inter-treatment differences as a function of patients' baseline characteristics. We did so by applying the 'model-based random forest', a recently-introduced machine learning-based method for evaluating effect heterogeneity that allows for the estimation of patient-specific treatment effects as a function of arbitrary baseline characteristics. Treatment conditions were cognitive-behavioural therapy (CBT) alone, fluoxetine (FLX) alone, and the combination of CBT and fluoxetine (COMB). All inter-treatment differences (CBT vs. FLX; CBT vs. COMB; FLX vs. COMB) were evaluated across 23 potential effect modifiers extracted from previous studies. Overall, FLX was superior to CBT, while COMB was superior to both CBT and FLX. Evidence for effect heterogeneity was found for the CBT-FLX difference and the FLX-COMB difference, but not for the CBT-COMB difference. Baseline depression severity modified the CBT-FLX difference; whereas baseline depression severity, patients' treatment expectations, and childhood trauma modified the FLX-COMB difference. All modifications were quantitative rather than qualitative, however, meaning that the differences varied only in magnitude, but not direction. These findings imply that combining CBT with fluoxetine may be superior to either therapy used alone across a broad range of patients.
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Abstract
Severity is an important consideration in treatment decision-making for depression. Two controversies in the treatment of depression are related to the issue of severity. First, are antidepressants only effective for severely depressed patients? Second, should the severity of depression be used as the basis for recommending medication or psychotherapy as first-line treatment? More specifically, should patients with severe depression preferentially be treated with medication? A related question is whether psychotherapy is beneficial for severely depressed patients. Some controversial articles sparked coverage in the popular press related to these questions and stimulated subsequent research on the impact of depression severity on treatment efficacy. The results of three recent large pooled analyses of patient level data indicate that the efficacy of antidepressants is not limited to the narrow band of patients who score highest on symptom severity scales. A meta-analysis of 132 controlled psychotherapy studies of more than 10,000 patients found that greater mean baseline symptom severity did not predict poorer response. A pooled analysis of individual patient data from 16 studies comparing antidepressants and cognitive behavior therapy found that severity was not associated with differential treatment outcome. These results are discussed in the context of recommendations in official treatment guidelines.
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10
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The right to choose treatment-without-treatment: respecting civil rights or an unprecedented manifestation of 'reverse stigma'? Acta Neuropsychiatr 2019; 31:56-58. [PMID: 30311596 DOI: 10.1017/neu.2018.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Recently the Norwegian Health Minister ordered the creation of medication-free treatment wards as a result of the lobbying by patients' groups and activists. The idea behind this is that patients should have the right to choose their treatment, but for the first time, with this arrangement, the user/patient does not choose between treatment options; he literally determines by himself what efficacious treatment is. In our opinion this is another step towards a 'reverse stigma' which denies patients the right to be considered as such and eventually kicks them out of the health care system, deprives them of the right for proper treatment and care and instead puts them at the jurisdiction of the much cheaper and ineffective social services.
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11
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Kim S, Cho HR, Zhang X. Initial severity-dependent longitudinal model with application to a randomized controlled trial of women with depression. Stat Med 2018; 38:1678-1689. [PMID: 30586677 DOI: 10.1002/sim.8072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/22/2018] [Accepted: 11/27/2018] [Indexed: 12/26/2022]
Abstract
The assessment of initial severity of a disease is arguably one of the most important factors in identifying appropriate therapies. In this paper, we propose an initial severity-dependent longitudinal model to account for the influence of the initial severity of a disease on the posttreatment severity and the efficacy of medical treatments. The proposed model has the flexibility of nonparametric modeling, as it allows coefficients to vary with the initial severity of the disease. It also provides attractive and practical patient-specific interpretation of initial severity-dependent coefficients. As a result, the proposed model enables patient-specific modeling and treatment recommendations consistent with the assessment of the patient's initial severity, and thus, it can be used as a decision support tool for clinicians. A new empirical likelihood approach is employed for efficient estimation and statistical inference about the initial severity-dependent coefficients. In contrast to the literature on marginal regression models, the proposed estimation procedure allows nuisance parameters associated with the working correlation matrix and the error variances to vary smoothly with the initial severity. The effectiveness of the proposed procedure is demonstrated via simulation studies. We further apply the proposed method by analyzing a data set arising from a randomized controlled trial of women with depression and discover an interesting phenomenon; antidepressant medication intervention is effective for patients with moderate or severe depression, whereas psychotherapy intervention using manual-guided cognitive behavior therapy is effective for patients with a severe case of depression.
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Affiliation(s)
- Seonjin Kim
- Department of Statistics, Miami University, Oxford, Ohio
| | | | - Xianyang Zhang
- Department of Statistics, Texas A&M University, College Station, Texas
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12
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Tuchina OD, Agibalova TV, Shustov DI, Shustova SA, Buzik ОG, Petrosyan YE. [The practical use of placebo effect in psychotherapeutic treatment of patients with substance use disorders: therapeutic and ethic consequences]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 116:61-68. [PMID: 28300816 DOI: 10.17116/jnevro201611611261-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article discusses therapeutic potential of placebo and nocebo effects in treatment of substance use disorders. The authors review the background of the issue, describe neurobiological and psychological mechanisms of placebo effects and demonstrate their impact on psychotherapy of patients with substance use disorders. Attention is drawn to the clinical and ethical issues of practical use of placebo effects including that in terms of placebo-therapy, indirect suggestion psychotherapy, motivational interventions and cognitive-behavioral psychotherapy, psychotherapy with the use of disulfiram, psychopharmacotherapy with opioid antagonists. The authors conclude that the ethical use of placebo-effects in treatment of substance use disorders may improve its overall efficiency.
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Affiliation(s)
- O D Tuchina
- Peoples' Friendship University of Russia, Moscow, Russia
| | - T V Agibalova
- Peoples' Friendship University of Russia, Moscow, Russia; Serbsky Federal Medical Research Center for Psychiatry and Narcology, Ministry of Health of the Russian Federation, Moscow, Russia
| | - D I Shustov
- Academician Pavlov Ryazan State Medical University, Ryazan, Russia
| | - S A Shustova
- Academician Pavlov Ryazan State Medical University, Ryazan, Russia
| | - О G Buzik
- Peoples' Friendship University of Russia, Moscow, Russia
| | - Yu E Petrosyan
- Peoples' Friendship University of Russia, Moscow, Russia
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Kelley ME, Dunlop B, Nemeroff CB, Lori A, Carrillo-Roa T, Binder EB, Kutner MH, Rivera VA, Craighead WE, Mayberg HS. Response rate profiles for major depressive disorder: Characterizing early response and longitudinal nonresponse. Depress Anxiety 2018; 35:992-1000. [PMID: 30260539 PMCID: PMC6662579 DOI: 10.1002/da.22832] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/23/2018] [Accepted: 07/11/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Definition of response is critical when seeking to establish valid predictors of treatment success. However, response at the end of study or endpoint only provides one view of the overall clinical picture that is relevant in testing for predictors. The current study employed a classification technique designed to group subjects based on their rate of change over time, while simultaneously addressing the issue of controlling for baseline severity. METHODS A set of latent class trajectory analyses, incorporating baseline level of symptoms, were performed on a sample of 344 depressed patients from a clinical trial evaluating the efficacy of cognitive behavior therapy and two antidepressant medications (escitalopram and duloxetine) in patients with major depressive disorder. RESULTS Although very few demographic and illness-related features were associated with response rate profiles, the aggregated effect of candidate genetic variants previously identified in large pharmacogenetic studies and meta-analyses showed a significant association with early remission as well as nonresponse. These same genetic scores showed a less compelling relationship with endpoint response categories. In addition, consistent nonresponse throughout the study treatment period was shown to occur in different subjects than endpoint nonresponse, which was verified by follow-up augmentation treatment outcomes. CONCLUSIONS When defining groups based on the rate of change, controlling for baseline depression severity may help to identify the clinically relevant distinctions of early response on one end and consistent nonresponse on the other.
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Affiliation(s)
- Mary E. Kelley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - BoadieW. Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Charles B. Nemeroff
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Adriana Lori
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Tania Carrillo-Roa
- Department of Translational Research in Psychiatry, Max-Planck Institute of Psychiatry, Munich, Germany
| | - Elisabeth B. Binder
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia,Department of Translational Research in Psychiatry, Max-Planck Institute of Psychiatry, Munich, Germany
| | - Michael H. Kutner
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Vivianne Aponte Rivera
- Departmentof Psychiatry and Behavioral Sciences, Tulane University, NewOrleans, Louisiana
| | - W. Edward Craighead
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia,Department of Psychology, Emory University, Atlanta, Georgia
| | - Helen S. Mayberg
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Eriksson E, Hieronymus F. The alleged lack of efficacy of antidepressants in non-severe depression: a myth debunked. Acta Psychiatr Scand 2018; 137:447-449. [PMID: 29878350 DOI: 10.1111/acps.12902] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E Eriksson
- Department of Pharmacology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - F Hieronymus
- Department of Pharmacology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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15
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Strawn JR, Mills JA, Cornwall GJ, Mossman SA, Varney ST, Keeshin BR, Croarkin PE. Buspirone in Children and Adolescents with Anxiety: A Review and Bayesian Analysis of Abandoned Randomized Controlled Trials. J Child Adolesc Psychopharmacol 2018; 28:2-9. [PMID: 28846022 PMCID: PMC5771537 DOI: 10.1089/cap.2017.0060] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES An increasing number of abandoned clinical trials have forestalled efforts to advance the evidence base for the treatment of mood and anxiety disorders in children and adolescents. With this in mind, we sought to present and validate a Bayesian approach for the reanalysis of summary data in abandoned clinical trials and to review and re-evaluate available pharmacokinetic, tolerability, and efficacy data from two large, randomized controlled trials of buspirone in pediatric patients with generalized anxiety disorder (GAD). METHODS Prospective, randomized, parallel-group controlled trials of buspirone in pediatric patients with GAD as well as associated pharmacokinetic studies were identified and data were extracted. In addition to descriptive statistics, marginal posterior densities for each variable of interest were determined and a Monte Carlo pseudosample was generated with random draws obtained from the Student's t-distribution to assess, with inferential statistics, differences in variables of interest. RESULTS Buspirone was evaluated in one flexibly dosed (N = 227) and one fixed-dose (N = 341) trial in children and adolescents aged 6-17 years with a primary diagnosis of GAD. With regard to improvement in the sum of the Columbia Schedule for Affective Disorders and Schizophrenia GAD items, buspirone did not separate from placebo in the fixed-dose trial at low (95% CI: -0.78 to 2.39, p = 0.32) or high dose (95% CI: -0.87 to 1.87, p = 0.47) nor did it separate from placebo in the flexibly dosed study (95% CI: -0.3 to 1.9, p = 0.15). Drop out as a result of a treatment-emergent adverse event was significantly greater in buspirone-treated patients compared to placebo (p = 0.011). Side effects were consistent with the known profile of buspirone with lightheadedness occurring more frequently in buspirone-treated patients (p < 0.001). CONCLUSIONS Buspirone is well tolerated in pediatric patients with GAD, although two randomized controlled trials were underpowered to detect small effect sizes (Cohen's d < 0.15). Finally, Bayesian approaches may facilitate re-examination of data from abandoned clinical trials.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio
- Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey A. Mills
- Department of Economics, Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio
| | - Gary J. Cornwall
- Department of Economics, Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio
| | - Sarah A. Mossman
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Sara T. Varney
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | | | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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Ekkekakis P, Hartman ME, Ladwig MA. Mass media representations of the evidence as a possible deterrent to recommending exercise for the treatment of depression: Lessons five years after the extraordinary case of TREAD-UK. J Sports Sci 2018; 36:1860-1871. [PMID: 29350586 DOI: 10.1080/02640414.2018.1423856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Exercise or physical activity are recommended options within stepped-care treatment models for depression. However, few physicians present these options to patients, in part because of the impression that the supporting evidence is weak or inconsistent. We speculate that the coocurrence of "counter-messaging" and deficient critical appraisal may lead to such impressions. We focus on TREAD-UK (ISRCTN16900744), the largest trial to investigate "whether physical activity can be an effective treatment for depression within primary care". In media statements, researchers declared that exercise was ineffective in lowering depression. We examined (a) the results of the trial, critiques, and rejoinders, (b) the impact on internet searches, and (c) whether TREAD-UK was critically appraised, as reflected in citing articles. We show that the results of TREAD-UK were misrepresented. The media campaign resulted in a fourfold increase in relevant internet searches. Of articles characterising the results, 57% adopted the interpretation that exercise failed to lower depression, whereas only 17% were critiques. We identify similarities to media portrayals of the OPERA (ISRCTN43769277), DEMO (NCT00103415), and DEMO-II trials (NCT00695552). We note a disconcerting trend of media campaigns that misrepresent the effects of exercise on depression and call for increased scrutiny in peer reviewing both pre- and post-publication.
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Affiliation(s)
| | - Mark E Hartman
- a Department of Kinesiology , Iowa State University, Ames, IA, USA
| | - Matthew A Ladwig
- a Department of Kinesiology , Iowa State University, Ames, IA, USA
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Weiller E, Weiss C, Watling CP, Edge C, Hobart M, Eriksson H, Fava M. Functioning outcomes with adjunctive treatments for major depressive disorder: a systematic review of randomized placebo-controlled studies. Neuropsychiatr Dis Treat 2018; 14:103-115. [PMID: 29343962 PMCID: PMC5751804 DOI: 10.2147/ndt.s146840] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Patients with major depressive disorder (MDD) with inadequate response to antidepressant treatment (ADT) may suffer a prolonged loss of functioning. This review aimed to determine if self-rated functional measures are informative in randomized placebo-controlled studies of adjunctive therapy in patients with MDD and inadequate response to ADT. METHODS This was a systematic literature review of articles in any language from the MEDLINE database published between January 1990 and March 2017. Eligible studies met the following criteria: patients with MDD; inadequate response to at least one ADT; adjunctive therapy (pharmacological or otherwise) to ADT; placebo control group; randomized controlled trial or a post hoc analysis of a randomized controlled trial; reported a self-rated functioning scale. Study characteristics and functioning efficacy data were extracted. RESULTS A total of 2,090 discrete records were screened, 293 full-text articles were assessed for eligibility, and 26 studies were included. All studies were acute (6-12 weeks) except for one 52-week study. The only self-rated functioning scale used in the included studies was the Sheehan Disability Scale (SDS). Of the 13 adjunctive agents identified, aripiprazole, brexpiprazole, edivoxetine, and risperidone improved functioning versus placebo (p<0.05), as measured by the SDS total or mean score. On the SDS "work/studies" item, only aripiprazole had a statistically significant benefit, in one study out of four. Thus, where a benefit was observed on the SDS total or mean, this was generally driven by improvement on the "social life" and "family life" items. A limitation of the review is that it only considered published literature from one database. CONCLUSION The SDS, a self-rated functional measure, is informative in acute randomized placebo-controlled studies of adjunctive therapy in patients with MDD and inadequate response to ADT. However, the item that measures work performance may be less relevant to this population than the items that measure social and family life.
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Affiliation(s)
| | - Catherine Weiss
- Otsuka Pharmaceutical Development & Commercialization Inc., Princeton, NJ, USA
| | | | | | - Mary Hobart
- Otsuka Pharmaceutical Development & Commercialization Inc., Princeton, NJ, USA
| | | | - Maurizio Fava
- Division of Clinical Research of the MGH Research Institute.,Department of Psychiatry.,Clinical Trials Network & Institute (CTNI), Massachusetts General Hospital, Boston, MA, USA
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18
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Whitworth JW, Craft LL, Dunsiger SI, Ciccolo JT. Direct and indirect effects of exercise on posttraumatic stress disorder symptoms: A longitudinal study. Gen Hosp Psychiatry 2017; 49:56-62. [PMID: 29122149 DOI: 10.1016/j.genhosppsych.2017.06.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/21/2017] [Accepted: 06/25/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Emerging evidence suggests that exercise may have beneficial effects on posttraumatic stress disorder (PTSD), and that this relationship may be indirectly affected by sleep, pain, and alcohol/substance use. The present study examined the longitudinal direct and indirect effects of exercise on PTSD symptoms. METHOD A national sample of 182 individuals, screening positive for PTSD, completed online assessments of PTSD symptoms, exercise behavior, psychological distress, sleep quality, and alcohol/substance use at baseline and three-month follow-up. RESULTS There were direct effects of strenuous intensity exercise on avoidance/numbing (b=-2.18, SE=1.12, p=0.05) and hyperarousal symptoms (b=-1.87, SE=0.82, p=0.03); and direct effects of total exercise on avoidance/numbing symptoms (b=-1.76, SE=0.94, p=0.05). Strenuous intensity exercise was indirectly associated with total PTSD symptoms (ab=-2.53, 95% CI: -5.72 to -0.38), avoidance/numbing (ab=-0.99, 95% CI: -2.43 to -0.05), and hyperarousal symptoms (ab=-0.78, 95% CI: -1.88 to -0.07) through sleep, while total exercise was indirectly associated with total PTSD symptoms through alcohol use (ab=0.32, 95% CI: 0.18-1.42). CONCLUSION Findings suggest that exercise has a complex, longitudinal, and beneficial association with PTSD symptoms. Future studies should continue to examine this relationship and any direct and indirect effects exercise may have on PTSD and its related conditions.
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Affiliation(s)
- James W Whitworth
- Department of Biobehavioral Sciences, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027, USA
| | - Lynette L Craft
- American College of Sports Medicine, 401 W. Michigan Street, Indianapolis, IN 46202, USA
| | - Shira I Dunsiger
- Centers for Behavioral and Preventive Medicine, Department of Behavioral and Social Sciences, Brown University and The Miriam Hospital, 167 Point Street, Providence, RI 02903, USA
| | - Joseph T Ciccolo
- Department of Biobehavioral Sciences, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027, USA.
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19
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Ekkekakis P, Murri MB. Exercise as antidepressant treatment: Time for the transition from trials to clinic? Gen Hosp Psychiatry 2017; 49:A1-A5. [PMID: 29173370 DOI: 10.1016/j.genhosppsych.2017.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 04/21/2017] [Indexed: 01/01/2023]
Affiliation(s)
| | - Martino Belvederi Murri
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, L.go Rosanna Benzi 10, Genoa, Italy
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20
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Ekkekakis P, Murri MB. Exercise as antidepressant treatment: Time for the transition from trials to clinic? Gen Hosp Psychiatry 2017; 49:1. [PMID: 29122144 DOI: 10.1016/j.genhosppsych.2017.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 04/21/2017] [Indexed: 01/24/2023]
Abstract
The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
| | - Martino Belvederi Murri
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, L.go Rosanna Benzi, 10, Genoa, Italy
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21
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Shoval G, Stubbs B, Balicer RD, Feldman B, Hoshen M, Zalsman G, Sagy R, Hochman E, Weizman A, Krivoy A. Low adherence to antidepressants is associated with increased mortality in Parkinson disease patients. Parkinsonism Relat Disord 2017; 43:92-96. [PMID: 28797565 DOI: 10.1016/j.parkreldis.2017.07.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/14/2017] [Accepted: 07/31/2017] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate the relationship between adherence to antidepressants (AD) and all-cause mortality in a population-based cohort of patients with Parkinson's Disease (PD). METHODS From a database of more than 4 million people, 8553 patients with PD who purchased an AD at least once between the years 2008-2011 were retrospectively followed for all-cause mortality over 4-years. Adherence was measured as a ratio between dispensed and prescribed durations and was modeled as: non-adherence (<20%, n = 1566), poor (20%-50%, n = 1184), moderate (50%-80%, n = 1584), and good (>80%, n = 4219) adherence. Multivariable survival analyses adjusted for demographic and clinical variables including physical comorbidities known to influence mortality were conducted, however there was no adjustment for other psychiatric disorders and medications. RESULTS Unadjusted mortality rates were 20.4%, 25.1%, 23.4% and 25.6% in those classified as non-adherent, poor, moderate and good adherence respectively (χ2 = 18.45, p < 0.0001). The non-adherent and poor adherence groups had significantly increased adjusted mortality hazard ratios (HR) of 1.43 (CI: 1.26-1.62) and 1.26 (CI: 1.1-1.44) respectively compared to the good adherence group. Using the same model, the adjusted HR for death among males was 1.49 [95% CI: 1.36-1.62] compared to females. People with PD and Charslon's Comorbidity Index score of 3-4 (HR 1.3, P < 0.001) and 5+ (HR 1.78, P < 0.001) were more likely to die than those with 0-2 comorbidities. CONCLUSIONS Our findings suggest that poor adherence to AD is associated with increased all-cause mortality in people with PD. Given the high prevalence of depression and AD effectiveness, efforts to promote adherence should be prioritized in clinical practice.
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Affiliation(s)
- Gal Shoval
- Clalit Research Institute, Chief Physician Office, Clalit Health Services, Tel Aviv, Israel; Geha Mental Health Center, Petah Tiqva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom; Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London Box SE5 8AF, United Kingdom
| | - Ran D Balicer
- Clalit Research Institute, Chief Physician Office, Clalit Health Services, Tel Aviv, Israel; Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Becca Feldman
- Clalit Research Institute, Chief Physician Office, Clalit Health Services, Tel Aviv, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Chief Physician Office, Clalit Health Services, Tel Aviv, Israel
| | - Gil Zalsman
- Geha Mental Health Center, Petah Tiqva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, NY, USA
| | - Roi Sagy
- Clalit Research Institute, Chief Physician Office, Clalit Health Services, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldar Hochman
- Geha Mental Health Center, Petah Tiqva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Weizman
- Geha Mental Health Center, Petah Tiqva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Krivoy
- Clalit Research Institute, Chief Physician Office, Clalit Health Services, Tel Aviv, Israel; Geha Mental Health Center, Petah Tiqva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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22
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Fountoulakis KN. Changing response rates in clinical trials of depression: how did the introduction of DSM-III and DSM-III-R influence the outcome? EVIDENCE-BASED MENTAL HEALTH 2017; 20:64. [PMID: 28246121 PMCID: PMC10688527 DOI: 10.1136/eb-2016-102606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/07/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Efficacy of Desvenlafaxine Compared With Placebo in Major Depressive Disorder Patients by Age Group and Severity of Depression at Baseline. J Clin Psychopharmacol 2017; 37:182-192. [PMID: 28146000 DOI: 10.1097/jcp.0000000000000674] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE This post hoc meta-analysis evaluated the efficacy and safety of desvenlafaxine 50 and 100 mg versus placebo across age groups and severity of depression at baseline in patients with major depressive disorder. METHODS Data from placebo and desvenlafaxine 50-mg and 100-mg dose arms were pooled from 9 short-term, placebo-controlled, major depressive disorder studies (N = 4279). Effects of age (18-40 years, >40 to <55 years, 55-<65 years, and ≥65 years) and baseline depression severity (mild, 17-item Hamilton Rating Scale for Depression total score [HAM-D17] ≤18; moderate, HAM-D17 >18 to <25; severe, HAM-D17 ≥25) on desvenlafaxine efficacy were assessed using analysis of covariance for continuous end points and logistic regression for categorical end points. FINDINGS Desvenlafaxine-treated (50 or 100 mg/d) patients had significantly (P < 0.05, 2-sided) greater improvement in most measures of depression and function compared with placebo for patients 18 to 40 years, older than 40 to younger than 55 years, and 55 to younger than 65 years, with no significant evidence of an effect of age. Desvenlafaxine significantly improved most measures of depression and function in moderately and severely depressed patients. There was a significant baseline severity by treatment interaction for HAM-D17 total score only (P = 0.027), with a larger treatment effect for the severely depressed group. IMPLICATIONS Desvenlafaxine significantly improved depressive symptoms in patients younger than 65 years and in patients with moderate or severe baseline depression. Sample sizes were not adequate to assess desvenlafaxine efficacy in patients 65 years or older or with mild baseline depression.
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Oren-Yagoda R, Björgvinsson T, Aderka IM. The relationship between positive affect and negative affect during treatment for major depressive disorder. Psychother Res 2017; 28:958-968. [PMID: 28277040 DOI: 10.1080/10503307.2017.1292066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The present study examined the relationship between positive affect (PA) and negative affect (NA) along the course of combined cognitive behavior therapy and pharmacological treatment for major depressive disorder (MDD). METHOD Participants were 165 individuals who sought treatment for MDD in a partial hospital setting. Participants' PA, NA, and depressive symptoms were measured at pre- and post-treatment and PA and NA were measured at up to 10 additional measurements along the course of treatment. RESULTS Results indicated that PA at pre-treatment predicted depressive symptoms at post-treatment above and beyond NA and the PA*NA interaction. However, an analysis of patterns of change during treatment using lower level mediational modeling in a multilevel framework indicated that NA predicted subsequent PA to a greater extent than vice versa. CONCLUSION Though many treatments for MDD predominantly focus on reducing NA, our findings suggest that PA may be an important predictor of outcome in treatment for MDD, and that the inclusion of interventions to increase the experience of PA may help improve the efficacy of treatment.
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Affiliation(s)
- Roni Oren-Yagoda
- a Department of Psychology, Faculty of Social Sciences , University of Haifa , Haifa , Israel
| | | | - Idan M Aderka
- a Department of Psychology, Faculty of Social Sciences , University of Haifa , Haifa , Israel
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25
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Thase M, Asami Y, Wajsbrot D, Dorries K, Boucher M, Pappadopulos E. A meta-analysis of the efficacy of venlafaxine extended release 75-225 mg/day for the treatment of major depressive disorder. Curr Med Res Opin 2017; 33:317-326. [PMID: 27794623 DOI: 10.1080/03007995.2016.1255185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the short-term efficacy of venlafaxine extended release (ER) 75-225 mg/day compared with placebo for treating major depressive disorder (MDD) and to examine associations between baseline characteristics and efficacy outcomes in MDD patients treated with venlafaxine ER 75-225 mg/day. RESEARCH DESIGN AND METHODS This meta-analysis included published and unpublished short-term, double-blind, placebo-controlled, Wyeth/Pfizer sponsored studies of venlafaxine ER at doses up to 225 mg/day in adults with MDD. CLINICAL TRIAL REGISTRATION All trials were conducted before trial registration became mandatory. MAIN OUTCOME MEASURES Change from baseline in the 17-item Hamilton Rating Scale for Depression (HAM-D17) total score was analyzed over time using a mixed-effects model for repeated measures with terms for study, treatment group, visit, interaction between treatment group and visit, and baseline score as a covariate. Associations between baseline demographic and clinical characteristics and the probability of HAM-D17 response and remission at week 8 were evaluated using logistic regression models, with terms for study, treatment group, and baseline characteristics in the models. Safety and tolerability was assessed based on adverse events (AEs) and discontinuations due to AEs. RESULTS The full analysis set included 1087 patients from five studies that fulfilled selection criteria. Statistically significant separation between venlafaxine ER and placebo groups for HAM-D17 total score was seen at week 2 and all subsequent assessments (p-values <.0001). There was no significant interaction between treatment and baseline HAM-D17 total score. Probability of HAM-D17 remission at week 8 decreased with increasing baseline HAM-D17 total score (p = .0012; OR: 0.94); however, baseline HAM-D17 total score did not predict response. Discontinuations due to AEs were reported for 9.4% of venlafaxine-ER-treated patients compared with 3.6% of placebo-treated patients. Key limitations: Five studies met the criteria for inclusion. Several differences in design between included studies limited the analysis: one study did not include a week 3 assessment (the week 3 time point was therefore dropped from the analysis), one study had two venlafaxine ER dose arms, which were combined into one group for the meta-analysis, and mixed- and flexible-dose studies were pooled. CONCLUSIONS Venlafaxine ER 75-225 mg/day effectively reduced symptoms of depression in patients with MDD overall and in patients with either lower (≤23) or higher (>23) HAM-D17 total score at baseline.
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Affiliation(s)
- Michael Thase
- a Perelman School of Medicine , University of Pennsylvania , Philadelphia , USA
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Fountoulakis KN. The misleading concept of initial severity in depression clinical trials: development and results from a mathematical model. Australas Psychiatry 2017; 25:18-20. [PMID: 27679636 DOI: 10.1177/1039856216671651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Recently, meta-analytic studies have suggested a positive relationship between initial severity and magnitude of treatment efficacy. The aim of the current study was to develop a mathematical model to test the assumption concerning the role of initial severity in treatment response. METHODS A number of experimental artificial datasets were developed on the basis of three different scenarios which reflect a pre-determined effect of initial severity. They were used to test for correlations at the patient level as well as at the meta-analysis level (trial level). RESULTS The results suggested that in all scenarios and analyses the correlations were so high that a ceiling effect was obvious. The testing concerned changes from baseline, but not differences between arms. CONCLUSIONS Overall the data suggest that the question concerning the role of initial severity cannot be answered. Any allegations on such a role are based on flawed methodology and do not take into consideration the true nature of data.
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Affiliation(s)
- Konstantinos N Fountoulakis
- Associate Professor of Psychiatry, School of Medicine, 3rd Department of Psychiatry, Aristotle University of Thessaloniki, Greece, and Chair, Research Methods in Psychiatry, World Psychiatric Association, Geneva, Switzerland
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Fountoulakis KN. DSM-III-R change in definition might have affected placebo response to antidepressants. Lancet Psychiatry 2017; 4:21-22. [PMID: 28012476 DOI: 10.1016/s2215-0366(16)30372-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 10/11/2016] [Accepted: 10/17/2016] [Indexed: 11/25/2022]
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Rabinowitz J, Werbeloff N, Mandel FS, Menard F, Marangell L, Kapur S. Initial depression severity and response to antidepressants v. placebo: patient-level data analysis from 34 randomised controlled trials. Br J Psychiatry 2016; 209:427-428. [PMID: 27198482 DOI: 10.1192/bjp.bp.115.173906] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 02/27/2016] [Indexed: 11/23/2022]
Abstract
Several often-cited meta-analyses have reported that the efficacy of antidepressant medications depends on the severity of depression. They found that drug-placebo differences increased as a function of initial severity, which was attributed to decreased responsiveness to placebo among patients with severe depression rather than to increased responsiveness to medication. We retested this using patient-level data and also undertaking a meta-analysis of trial-level data from 34 randomised placebo controlled trials (n = 10 737) from the NEWMEDS registry. Although our trial-level data support prevous findings, patient-level data did not show any significant effect of initial depression severity on drug v. placebo difference.
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Affiliation(s)
- Jonathan Rabinowitz
- Jonathan Rabinowitz, PhD, Nomi Werbeloff, PhD, School of Social Work, Ramat Gan, Bar Ilan University, Israel; Francine S. Mandel, PhD, Pfizer Development Operations, New York, USA; François Menard, MD, Lundbec Research Department, Paris, France; Lauren Marangell, MD, Department of Psychiatry, University of Texas Health Science Center, Houston, Texas, USA; Shitij Kapur, MD, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Nomi Werbeloff
- Jonathan Rabinowitz, PhD, Nomi Werbeloff, PhD, School of Social Work, Ramat Gan, Bar Ilan University, Israel; Francine S. Mandel, PhD, Pfizer Development Operations, New York, USA; François Menard, MD, Lundbec Research Department, Paris, France; Lauren Marangell, MD, Department of Psychiatry, University of Texas Health Science Center, Houston, Texas, USA; Shitij Kapur, MD, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Francine S Mandel
- Jonathan Rabinowitz, PhD, Nomi Werbeloff, PhD, School of Social Work, Ramat Gan, Bar Ilan University, Israel; Francine S. Mandel, PhD, Pfizer Development Operations, New York, USA; François Menard, MD, Lundbec Research Department, Paris, France; Lauren Marangell, MD, Department of Psychiatry, University of Texas Health Science Center, Houston, Texas, USA; Shitij Kapur, MD, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - François Menard
- Jonathan Rabinowitz, PhD, Nomi Werbeloff, PhD, School of Social Work, Ramat Gan, Bar Ilan University, Israel; Francine S. Mandel, PhD, Pfizer Development Operations, New York, USA; François Menard, MD, Lundbec Research Department, Paris, France; Lauren Marangell, MD, Department of Psychiatry, University of Texas Health Science Center, Houston, Texas, USA; Shitij Kapur, MD, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Lauren Marangell
- Jonathan Rabinowitz, PhD, Nomi Werbeloff, PhD, School of Social Work, Ramat Gan, Bar Ilan University, Israel; Francine S. Mandel, PhD, Pfizer Development Operations, New York, USA; François Menard, MD, Lundbec Research Department, Paris, France; Lauren Marangell, MD, Department of Psychiatry, University of Texas Health Science Center, Houston, Texas, USA; Shitij Kapur, MD, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Shitij Kapur
- Jonathan Rabinowitz, PhD, Nomi Werbeloff, PhD, School of Social Work, Ramat Gan, Bar Ilan University, Israel; Francine S. Mandel, PhD, Pfizer Development Operations, New York, USA; François Menard, MD, Lundbec Research Department, Paris, France; Lauren Marangell, MD, Department of Psychiatry, University of Texas Health Science Center, Houston, Texas, USA; Shitij Kapur, MD, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
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Hieronymus F, Emilsson JF, Nilsson S, Eriksson E. Consistent superiority of selective serotonin reuptake inhibitors over placebo in reducing depressed mood in patients with major depression. Mol Psychiatry 2016; 21:523-30. [PMID: 25917369 PMCID: PMC4804177 DOI: 10.1038/mp.2015.53] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/10/2015] [Accepted: 03/18/2015] [Indexed: 11/09/2022]
Abstract
The recent questioning of the antidepressant effect of selective serotonin reuptake inhibitors (SSRIs) is partly based on the observation that approximately half of company-sponsored trials have failed to reveal a significant difference between active drug and placebo. Most of these have applied the Hamilton depression rating scale to assess symptom severity, the sum score for its 17 items (HDRS-17-sum) serving as effect parameter. In this study, we examined whether the negative outcomes of many SSRI trials may be partly caused by the use of this frequently questioned measure of response. We undertook patient-level post-hoc analyses of 18 industry-sponsored placebo-controlled trials regarding paroxetine, citalopram, sertraline or fluoxetine, and including in total 6669 adults with major depression, the aim being to assess what the outcome would have been if the single item depressed mood (rated 0-4) had been used as a measure of efficacy. In total, 32 drug-placebo comparisons were reassessed. While 18 out of 32 comparisons (56%) failed to separate active drug from placebo at week 6 with respect to reduction in HDRS-17-sum, only 3 out of 32 comparisons (9%) were negative when depressed mood was used as an effect parameter (P<0.001). The observation that 29 out of 32 comparisons detected an antidepressant signal from the tested SSRI suggests the effect of these drugs to be more consistent across trials than previously assumed. Further, the frequent use of the HDRS-17-sum as an effect parameter may have distorted the current view on the usefulness of SSRIs and hampered the development of novel antidepressants.
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Affiliation(s)
- F Hieronymus
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - J F Emilsson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Nilsson
- Institute of Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - E Eriksson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, POB 432, Gothenburg SE 405 30, Sweden. E-mail:
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Appleton KM, Sallis HM, Perry R, Ness AR, Churchill R. ω-3 Fatty acids for major depressive disorder in adults: an abridged Cochrane review. BMJ Open 2016; 6:e010172. [PMID: 26936905 PMCID: PMC4785331 DOI: 10.1136/bmjopen-2015-010172] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/21/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the effects of n-3 polyunsaturated fatty acids (n-3PUFAs; also known as ω-3 fatty acids) compared with comparator for major depressive disorder (MDD) in adults. DESIGN Systematic review and meta-analyses. DATA SOURCES The Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Registers (CCDANCTR) and International Trial Registries searched to May 2015. CINAHL searched to September 2013. TRIAL SELECTION INCLUSION CRITERIA a randomised controlled trial (RCT); that provided n-3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and was conducted in adults with MDD. OUTCOMES Primary outcomes were depressive symptomology and adverse events. RESULTS 20 trials encompassing 26 relevant studies were found. For n-3PUFAs versus placebo, n-3PUFA supplementation resulted in a small-to-modest benefit for depressive symptomology: SMD=-0.32 (95% CI -0.52 to -0.12; 25 studies, 1373 participants, very low-quality evidence), but this effect is unlikely to be clinically meaningful, is very imprecise and, based on funnel plot inspection, sensitivity analyses and comparison with large well-conducted trials, is likely to be biased. Considerable evidence of heterogeneity between studies was also found, and was not explained by subgroup or sensitivity analyses. Numbers of individuals experiencing adverse events were similar in intervention and placebo groups (OR=1.24, 95% CI 0.95 to 1.62; 19 studies, 1207 participants; very low-quality evidence). For n-3PUFAs versus antidepressants, no differences were found between treatments in depressive symptomology (MD=-0.70 (95% CI -5.88 to 4.48); 1 study, 40 participants, very low-quality evidence). CONCLUSIONS At present, we do not have sufficient evidence to determine the effects of n-3PUFAs as a treatment for MDD. Further research in the form of adequately powered RCTs is needed.
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Affiliation(s)
- Katherine M Appleton
- Department of Psychology, Faculty of Science and Technology, Bournemouth University, Poole, UK
| | - Hannah M Sallis
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rachel Perry
- National Institute for Health Research (NIHR) Biomedical Research Unit in Nutrition, Diet and Lifestyle at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, UK
- School of Oral and Dental Sciences, University of Bristol, Bristol, UK
| | - Andrew R Ness
- National Institute for Health Research (NIHR) Biomedical Research Unit in Nutrition, Diet and Lifestyle at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, UK
- School of Oral and Dental Sciences, University of Bristol, Bristol, UK
| | - Rachel Churchill
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Möller-Leimkühler AM, Möller HJ, Maier W, Gaebel W, Falkai P. EPA guidance on improving the image of psychiatry. Eur Arch Psychiatry Clin Neurosci 2016; 266:139-54. [PMID: 26874959 DOI: 10.1007/s00406-016-0678-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
Abstract
This paper explores causes, explanations and consequences of the negative image of psychiatry and develops recommendations for improvement. It is primarily based on a WPA guidance paper on how to combat the stigmatization of psychiatry and psychiatrists and a Medline search on related publications since 2010. Furthermore, focussing on potential causes and explanations, the authors performed a selective literature search regarding additional image-related issues such as mental health literacy and diagnostic and treatment issues. Underestimation of psychiatry results from both unjustified prejudices of the general public, mass media and healthcare professionals and psychiatry's own unfavourable coping with external and internal concerns. Issues related to unjustified devaluation of psychiatry include overestimation of coercion, associative stigma, lack of public knowledge, need to simplify complex mental issues, problem of the continuum between normality and psychopathology, competition with medical and non-medical disciplines and psychopharmacological treatment. Issues related to psychiatry's own contribution to being underestimated include lack of a clear professional identity, lack of biomarkers supporting clinical diagnoses, limited consensus about best treatment options, lack of collaboration with other medical disciplines and low recruitment rates among medical students. Recommendations are proposed for creating and representing a positive self-concept with different components. The negative image of psychiatry is not only due to unfavourable communication with the media, but is basically a problem of self-conceptualization. Much can be improved. However, psychiatry will remain a profession with an exceptional position among the medical disciplines, which should be seen as its specific strength.
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Affiliation(s)
- A M Möller-Leimkühler
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Nussbaumstr. 7, 80336, Munich, Germany.
| | - H-J Möller
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Nussbaumstr. 7, 80336, Munich, Germany.
| | - W Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - W Gaebel
- Department of Psychiatry and Psychotherapy, Heinrich-Heine-University Düsseldorf, Bergische Landstraße 2, 40629, Düsseldorf, Germany
| | - P Falkai
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Nussbaumstr. 7, 80336, Munich, Germany
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Kirsch I. Der Placeboeffekt in der antidepressiven Behandlung. VERHALTENSTHERAPIE 2016. [DOI: 10.1159/000443542] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
BACKGROUND Major depressive disorder (MDD) is highly debilitating, difficult to treat, has a high rate of recurrence, and negatively impacts the individual and society as a whole. One emerging potential treatment for MDD is n-3 polyunsaturated fatty acids (n-3PUFAs), also known as omega-3 oils, naturally found in fatty fish, some other seafood, and some nuts and seeds. Various lines of evidence suggest a role for n-3PUFAs in MDD, but the evidence is far from conclusive. Reviews and meta-analyses clearly demonstrate heterogeneity between studies. Investigations of heterogeneity suggest differential effects of n-3PUFAs, depending on severity of depressive symptoms, where no effects of n-3PUFAs are found in studies of individuals with mild depressive symptomology, but possible benefit may be suggested in studies of individuals with more severe depressive symptomology. OBJECTIVES To assess the effects of n-3 polyunsaturated fatty acids (also known as omega-3 fatty acids) versus a comparator (e.g. placebo, anti-depressant treatment, standard care, no treatment, wait-list control) for major depressive disorder (MDD) in adults. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Registers (CCDANCTR) and International Trial Registries over all years to May 2015. We searched the database CINAHL over all years of records to September 2013. SELECTION CRITERIA We included studies in the review if they: were a randomised controlled trial; provided n-3PUFAs as an intervention; used a comparator; measured depressive symptomology as an outcome; and were conducted in adults with MDD. Primary outcomes were depressive symptomology (continuous data collected using a validated rating scale) and adverse events. Secondary outcomes were depressive symptomology (dichotomous data on remission and response), quality of life, and failure to complete studies. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We found 26 relevant studies: 25 studies involving a total of 1438 participants investigated the impact of n-3PUFA supplementation compared to placebo, and one study involving 40 participants investigated the impact of n-3PUFA supplementation compared to antidepressant treatment.For the placebo comparison, n-3PUFA supplementation results in a small to modest benefit for depressive symptomology, compared to placebo: standardised mean difference (SMD) -0.32 (95% confidence interval (CI) -0.12 to -0.52; 25 studies, 1373 participants, very low quality evidence), but this effect is unlikely to be clinically meaningful (an SMD of 0.32 represents a difference between groups in scores on the HDRS (17-item) of approximately 2.2 points (95% CI 0.8 to 3.6)). The confidence intervals include both a possible clinically important effect and a possible negligible effect, and there is considerable heterogeneity between the studies. Although the numbers of individuals experiencing adverse events were similar in intervention and placebo groups (odds ratio (OR) 1.24, 95% CI 0.95 to 1.62; 19 studies, 1207 participants; very low-quality evidence), the confidence intervals include a significant increase in adverse events with n-3PUFAs as well as a small possible decrease. Rates of remission and response, quality of life, and rates of failure to complete studies were also similar between groups, but confidence intervals are again wide.The evidence on which these results are based is very limited. All studies contributing to our analyses were of direct relevance to our research question, but we rated the quality of the evidence for all outcomes as low to very low. The number of studies and number of participants contributing to all analyses were low, and the majority of studies were small and judged to be at high risk of bias on several measures. Our analyses were also likely to be highly influenced by three large trials. Although we judge these trials to be at low risk of bias, they contribute 26.9% to 82% of data. Our effect size estimates are also imprecise. Funnel plot asymmetry and sensitivity analyses (using fixed-effect models, and only studies judged to be at low risk of selection bias, performance bias or attrition bias) also suggest a likely bias towards a positive finding for n-3PUFAs. There was substantial heterogeneity in analyses of our primary outcome of depressive symptomology. This heterogeneity was not explained by the presence or absence of comorbidities or by the presence or absence of adjunctive therapy.Only one study was available for the antidepressant comparison, involving 40 participants. This study found no differences between treatment with n-3PUFAs and treatment with antidepressants in depressive symptomology (mean difference (MD) -0.70 (95% CI -5.88 to 4.48)), rates of response to treatment or failure to complete. Adverse events were not reported in a manner suitable for analysis, and rates of depression remission and quality of life were not reported. AUTHORS' CONCLUSIONS At present, we do not have sufficient high quality evidence to determine the effects of n-3PUFAs as a treatment for MDD. Our primary analyses suggest a small-to-modest, non-clinically beneficial effect of n-3PUFAs on depressive symptomology compared to placebo; however the estimate is imprecise, and we judged the quality of the evidence on which this result is based to be low/very low. Sensitivity analyses, funnel plot inspection and comparison of our results with those of large well-conducted trials also suggest that this effect estimate is likely to be biased towards a positive finding for n-3PUFAs, and that the true effect is likely to be smaller. Our data, however, also suggest similar rates of adverse events and numbers failing to complete trials in n-3PUFA and placebo groups, but again our estimates are very imprecise. The one study that directly compares n-3PUFAs and antidepressants in our review finds comparable benefit. More evidence, and more complete evidence, are required, particularly regarding both the potential positive and negative effects of n-3PUFAs for MDD.
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Affiliation(s)
- Katherine M Appleton
- Bournemouth UniversityDepartment of PsychologyPoole House, Fern BarrowPooleUKBH12 5BB
| | | | - Rachel Perry
- University Hospitals Bristol Education CentreNIHR Biomedical Research Unit in Nutrition, Diet and LifestyleUpper Maudlin StreetBristolUKBS2 8AE
| | - Andrew R Ness
- University Hospitals Bristol NHS Foundation Trust and the University of BristolNational Institute for Health Research (NIHR) Biomedical Research Unit in Nutrition, Diet and LifestyleUpper Maudlin StreetBristolUKBS2 8AE
| | - Rachel Churchill
- University of BristolCentre for Academic Mental Health, School of Social and Community MedicineBarley HouseOakfield GroveBristolUKBS8 2BN
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Locher C, Kossowsky J, Gaab J, Kirsch I, Bain P, Krummenacher P. Moderation of antidepressant and placebo outcomes by baseline severity in late-life depression: A systematic review and meta-analysis. J Affect Disord 2015; 181:50-60. [PMID: 25917293 DOI: 10.1016/j.jad.2015.03.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/31/2015] [Accepted: 03/31/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Baseline severity is a crucial moderator of trial outcomes in adult depression, with the advantage of antidepressants over placebo increasing as severity increases. However, this relationship has not been examined in late-life depression. METHODS PubMed, Embase, Web of Science, PsycINFO, and Cochrane were searched for studies published through September 2014. Randomized, acute phase, and double-blind studies comparing an antidepressant group with a placebo group in depressed elderly patients were included. RESULTS Nineteen studies met all inclusion criteria. Within-group effect sizes revealed significant improvement in antidepressant groups (g=1.35, p<.000), as well as in placebo groups (g=.96, p<.000). Change in depressive symptoms assessed by Hamilton Depression Rating Scale (HDRS) was moderated by baseline severity in antidepressant groups (Z=2.67, p=.008) and placebo groups (Z=4.46, p<.000). However, this would be expected as a result of regression toward the mean, and mean differences between groups did not increase (r=.19, p=.469) as a function of baseline severity. LIMITATIONS Limited to published data and information was only analyzed at the level of treatment groups. CONCLUSION Baseline severity was not associated with an antidepressant-placebo difference and placebo responses are large in the treatment of depressed elderly people. We propose a stepwise approach, i.e., to initially offer elderly depressed patients psychosocial interventions and only consider antidepressants if patients do not respond.
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Affiliation(s)
- Cosima Locher
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland.
| | - Joe Kossowsky
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, USA; Program in Placebo Studies and the Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Jens Gaab
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland
| | - Irving Kirsch
- Program in Placebo Studies and the Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Paul Bain
- Countway Library of Medicine, Harvard Medical School, Boston, USA
| | - Peter Krummenacher
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland; Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland
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Krivoy A, Balicer RD, Feldman B, Hoshen M, Zalsman G, Weizman A, Shoval G. Adherence to antidepressant therapy and mortality rates in ischaemic heart disease: cohort study. Br J Psychiatry 2015; 206:297-301. [PMID: 25657353 DOI: 10.1192/bjp.bp.114.155820] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 09/15/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND The use of antidepressant drugs in patients with ischaemic heart disease (IHD) has been debated owing to scarcity of data and conflicting results regarding the effect of these drugs on mortality. AIMS To evaluate the association between adherence to antidepressant therapy and all-cause mortality in a population-based cohort of patients with IHD. METHOD A total of 63 437 patients with IHD who purchased antidepressants at least once during the years 2008-2011 were retrospectively followed for all-cause mortality over 4 years. Adherence was measured as a ratio between claimed and prescribed durations of medication and modelled as non-adherence (<20%), poor (20-50%), moderate (50-80%) and good (>80%). We used multivariable survival analyses adjusted for demographic and clinical variables that may affect mortality. RESULTS The moderate and good adherence groups had significantly reduced adjusted mortality hazard ratios of 0.83 (95% CI 0.78-0.88) and 0.86 (95% CI 0.82-0.90) respectively, compared with the non-adherence group. CONCLUSIONS Adherence to antidepressant pharmacotherapy is associated with reduced all-cause mortality in a population-based large sample cohort of patients with IHD. Physicians and health policy decision-makers should step up their efforts to sustain and enhance these patients' adherence to their antidepressant regimen.
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Affiliation(s)
- Amir Krivoy
- Amir Krivoy, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Ran D. Balicer, MD, PhD, Clalit Research Institute, Tel Aviv, Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva; Becca Feldman, PhD, Moshe Hoshen, PhD, Clalit Research Institute, Tel Aviv, Israel; Gil Zalsman, MD, MHA, Geha Mental Health Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, USA; Abraham Weizman, MD, Geha Mental Health Center, Petah Tiqva, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Gal Shoval, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran D Balicer
- Amir Krivoy, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Ran D. Balicer, MD, PhD, Clalit Research Institute, Tel Aviv, Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva; Becca Feldman, PhD, Moshe Hoshen, PhD, Clalit Research Institute, Tel Aviv, Israel; Gil Zalsman, MD, MHA, Geha Mental Health Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, USA; Abraham Weizman, MD, Geha Mental Health Center, Petah Tiqva, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Gal Shoval, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Becca Feldman
- Amir Krivoy, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Ran D. Balicer, MD, PhD, Clalit Research Institute, Tel Aviv, Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva; Becca Feldman, PhD, Moshe Hoshen, PhD, Clalit Research Institute, Tel Aviv, Israel; Gil Zalsman, MD, MHA, Geha Mental Health Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, USA; Abraham Weizman, MD, Geha Mental Health Center, Petah Tiqva, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Gal Shoval, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Hoshen
- Amir Krivoy, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Ran D. Balicer, MD, PhD, Clalit Research Institute, Tel Aviv, Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva; Becca Feldman, PhD, Moshe Hoshen, PhD, Clalit Research Institute, Tel Aviv, Israel; Gil Zalsman, MD, MHA, Geha Mental Health Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, USA; Abraham Weizman, MD, Geha Mental Health Center, Petah Tiqva, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Gal Shoval, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Zalsman
- Amir Krivoy, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Ran D. Balicer, MD, PhD, Clalit Research Institute, Tel Aviv, Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva; Becca Feldman, PhD, Moshe Hoshen, PhD, Clalit Research Institute, Tel Aviv, Israel; Gil Zalsman, MD, MHA, Geha Mental Health Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, USA; Abraham Weizman, MD, Geha Mental Health Center, Petah Tiqva, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Gal Shoval, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Weizman
- Amir Krivoy, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Ran D. Balicer, MD, PhD, Clalit Research Institute, Tel Aviv, Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva; Becca Feldman, PhD, Moshe Hoshen, PhD, Clalit Research Institute, Tel Aviv, Israel; Gil Zalsman, MD, MHA, Geha Mental Health Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, USA; Abraham Weizman, MD, Geha Mental Health Center, Petah Tiqva, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Gal Shoval, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Shoval
- Amir Krivoy, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Ran D. Balicer, MD, PhD, Clalit Research Institute, Tel Aviv, Public Health Department, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva; Becca Feldman, PhD, Moshe Hoshen, PhD, Clalit Research Institute, Tel Aviv, Israel; Gil Zalsman, MD, MHA, Geha Mental Health Center, Petah Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, and Division of Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New York, USA; Abraham Weizman, MD, Geha Mental Health Center, Petah Tiqva, Felsenstein Medical Research Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; Gal Shoval, MD, Clalit Research Institute, Tel Aviv, Geha Mental Health Center, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jani BD, McLean G, Nicholl BI, Barry SJE, Sattar N, Mair FS, Cavanagh J. Risk assessment and predicting outcomes in patients with depressive symptoms: a review of potential role of peripheral blood based biomarkers. Front Hum Neurosci 2015; 9:18. [PMID: 25698954 PMCID: PMC4313702 DOI: 10.3389/fnhum.2015.00018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 01/09/2015] [Indexed: 11/13/2022] Open
Abstract
Depression is one of the major global health challenges and a leading contributor of health related disability and costs. Depression is a heterogeneous disorder and current methods for assessing its severity in clinical practice rely on symptom count, however this approach is unreliable and inconsistent. The clinical evaluation of depressive symptoms is particularly challenging in primary care, where the majority of patients with depression are managed, due to the presence of co-morbidities. Current methods for risk assessment of depression do not accurately predict treatment response or clinical outcomes. Several biological pathways have been implicated in the pathophysiology of depression; however, accurate and predictive biomarkers remain elusive. We conducted a systematic review of the published evidence supporting the use of peripheral biomarkers to predict outcomes in depression, using Medline and Embase. Peripheral biomarkers in depression were found to be statistically significant predictors of mental health outcomes such as treatment response, poor outcome and symptom remission; and physical health outcomes such as increased incidence of cardiovascular events and deaths, and all-cause mortality. However, the available evidence has multiple methodological limitations which must be overcome to make any real clinical progress. Despite extensive research on the relationship of depression with peripheral biomarkers, its translational application in practice remains uncertain. In future, peripheral biomarkers identified with novel techniques and combining multiple biomarkers may have a potential role in depression risk assessment but further research is needed in this area.
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Affiliation(s)
- Bhautesh D Jani
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow Glasgow, UK
| | - Gary McLean
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow Glasgow, UK
| | - Barbara I Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow Glasgow, UK
| | - Sarah J E Barry
- Robertson Centre for Biostatistics, Institute of Health and Well Being, College of Medical, Veterinary and Life Sciences, University of Glasgow Glasgow, UK
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow Glasgow, UK
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow Glasgow, UK
| | - Jonathan Cavanagh
- Mental Health and Wellbeing, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow Glasgow, UK
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Fountoulakis KN, McIntyre RS, Carvalho AF. From Randomized Controlled Trials of Antidepressant Drugs to the Meta-Analytic Synthesis of Evidence: Methodological Aspects Lead to Discrepant Findings. Curr Neuropharmacol 2015; 13:605-15. [PMID: 26467410 PMCID: PMC4761632 DOI: 10.2174/1570159x13666150630174343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/20/2015] [Accepted: 01/20/2015] [Indexed: 01/20/2023] Open
Abstract
During the last decade, several meta-analytic studies employing different methodological approaches have had inconsistent conclusions regarding antidepressant efficacy. Herein, we aim to comment on methodological aspects that may have contributed to disparate findings. We initially discuss methodological inconsistencies and limitations related to the conduct of individual antidepressant randomized controlled trials (RCTs), including differences in allocated samples, limitations of psychometric scales, possible explanations for the heightened placebo response rates in antidepressant RCTs across the past two decades as well as the reporting of conflicts of interest. In the second part of this article, we briefly describe the various meta-analyses techniques (e.g., simple random effects meta-analysis and network meta-analysis) and the application of these methods to synthesize evidence related to antidepressant efficacy. Recently published antidepressant metaanalyses often provide discrepant results and similar results often lead to different interpretations. Finally, we propose strategies to improve methodology considering real-world clinical scenarios.
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Affiliation(s)
| | | | - André F Carvalho
- 6, Odysseos str (1st Parodos Ampelonon str.), 55535 Pylaia Thessaloniki, Greece.
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Linde K, Kriston L, Rücker G, Jamil S, Schumann I, Meissner K, Sigterman K, Schneider A. Efficacy and acceptability of pharmacological treatments for depressive disorders in primary care: systematic review and network meta-analysis. Ann Fam Med 2015; 13:69-79. [PMID: 25583895 PMCID: PMC4291268 DOI: 10.1370/afm.1687] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 05/16/2014] [Accepted: 06/13/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate whether antidepressants are more effective than placebo in the primary care setting, and whether there are differences between substance classes regarding efficacy and acceptability. METHODS We conducted literature searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO up to December 2013. Randomized trials in depressed adults treated by primary care physicians were included in the review. We performed both conventional pairwise meta-analysis and network meta-analysis combining direct and indirect evidence. Main outcome measures were response and study discontinuation due to adverse effects. RESULTS A total of 66 studies with 15,161 patients met the inclusion criteria. In network meta-analysis, tricyclic and tetracyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), a serotonin-noradrenaline reuptake inhibitor (SNRI; venlafaxine), a low-dose serotonin antagonist and reuptake inhibitor (SARI; trazodone) and hypericum extracts were found to be significantly superior to placebo, with estimated odds ratios between 1.69 and 2.03. There were no statistically significant differences between these drug classes. Reversible inhibitors of monoaminoxidase A (rMAO-As) and hypericum extracts were associated with significantly fewer dropouts because of adverse effects compared with TCAs, SSRIs, the SNRI, a noradrenaline reuptake inhibitor (NRI), and noradrenergic and specific serotonergic antidepressant agents (NaSSAs). CONCLUSIONS Compared with other drugs, TCAs and SSRIs have the most solid evidence base for being effective in the primary care setting, but the effect size compared with placebo is relatively small. Further agents (hypericum, rMAO-As, SNRI, NRI, NaSSAs, SARI) showed some positive results, but limitations of the currently available evidence makes a clear recommendation on their place in clinical practice difficult.
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Affiliation(s)
- Klaus Linde
- Institute of General Practice, Technische Universität München, Munich, Germany
| | - Levente Kriston
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Freiburg, Germany
| | - Susanne Jamil
- Institute of General Practice, Technische Universität München, Munich, Germany
| | - Isabelle Schumann
- Institute of General Practice, Technische Universität München, Munich, Germany
| | - Karin Meissner
- Institute of General Practice, Technische Universität München, Munich, Germany Institute of Medical Psychology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Kirsten Sigterman
- Institute of General Practice, Technische Universität München, Munich, Germany
| | - Antonius Schneider
- Institute of General Practice, Technische Universität München, Munich, Germany
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Wang SM, Han C, Pae CU. Criticisms of drugs in early development for the treatment of depression: what can be improved? Expert Opin Investig Drugs 2014; 24:445-53. [DOI: 10.1517/13543784.2014.985784] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sheng-Min Wang
- 1The Catholic University of Korea College of Medicine, Department of Psychiatry, Seoul, Republic of Korea
- 2The Catholic University of Korea College of Medicine, Seoul St. Mary’s Hospital, International Health Care Center, Seoul, Republic of Korea
| | - Changsu Han
- 3Korea University, College of Medicine, Department of Psychiatry, Seoul, Republic of Korea
| | - Chi-Un Pae
- 1The Catholic University of Korea College of Medicine, Department of Psychiatry, Seoul, Republic of Korea
- 4Duke University Medical Center, Department of Psychiatry and Behavioural Sciences, Durham, NC, USA
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Mulsant BH, Blumberger DM, Ismail Z, Rabheru K, Rapoport MJ. A systematic approach to pharmacotherapy for geriatric major depression. Clin Geriatr Med 2014; 30:517-34. [PMID: 25037293 DOI: 10.1016/j.cger.2014.05.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The broadening use of antidepressants among older Americans has not been associated with a notable decrease in the burden of geriatric depression. This article, based on a selective review of the literature, explores several explanations for this paradox. The authors propose that the effectiveness of antidepressants depends in large part on the way they are used. Evidence supports that antidepressant pharmacotherapy leads to better outcomes when guided by a treatment algorithm as opposed to attempting to individualize treatment. Several published guidelines and pharmacotherapy algorithms developed for the treatment of geriatric depression are reviewed, and an updated algorithm proposed.
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Affiliation(s)
- Benoit H Mulsant
- Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J 1H4, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.
| | - Daniel M Blumberger
- Department of Psychiatry, Faculty of Medicine, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J 1H4, Canada
| | - Zahinoor Ismail
- Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J 1H4, Canada; Hotchkiss Brain Institute, Foothills Hospital, University of Calgary, 1403 29th Street Northwest, Calgary, Alberta T2N 2T9, Canada
| | - Kiran Rabheru
- Geriatric Psychiatry & ECT Program, Department of Psychiatry, The Ottawa Hospital, University of Ottawa, 75 Bruyere Street, Suite 137 Y, Ottawa, Ontario K1N 5C7, Canada
| | - Mark J Rapoport
- Department of Psychiatry, Faculty of Medicine, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada; Sunnybrook Health Sciences Centre, FG37-2075 Bayview Avenue, Toronto, Ontario M4C 5N6, Canada
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Fountoulakis KN, Möller HJ. Are antidepressants clinically useful? Conclusion of a decade of debate. World Psychiatry 2014; 13:201-2. [PMID: 24890076 PMCID: PMC4102296 DOI: 10.1002/wps.20112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Affiliation(s)
- Mazda Adli
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin and Fliedner Klinik Berlin, 10117 Berlin, Germany.
| | - Ulrich Hegerl
- Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
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43
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Doering BK, Rief W, Petrie KJ. Lessons to be learned from placebo arms in psychopharmacology trials. Handb Exp Pharmacol 2014; 225:273-290. [PMID: 25304537 DOI: 10.1007/978-3-662-44519-8_15] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Large placebo effects are typically reported in clinical drug trials and evidence suggests placebo effects have increased over time. The diminishing drug-placebo difference calls into question the effectiveness of pharmacological treatments and provides a challenge to prove the effectiveness of new medications. This chapter discusses explanations for the increasing placebo effect. It highlights the contribution of spontaneous remission to the improvement in placebo groups, but focuses particularly on the role of patient and clinician expectations. Certain characteristics of the trial design can influence the formation of patient expectations and, subsequently, true placebo responses. Side effects in clinical trials may also contribute inadvertently to placebo responses. Side effects after starting medication can inform participants about their allocation to an active treatment group. Thus, they may enhance expectations of improvement and contribute to nonspecific effects in clinical trials. It is argued that specific and nonspecific effects interact in drug groups of clinical trials. This interaction influences drug-placebo differences in clinical trials (i.e., trial sensitivity). Future research should aim to identify which patients will respond best to drugs and those who may be better treated with placebos.
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