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Curie A, Lion-François L, Valayannopoulos V, Perreton N, Gavanon M, Touil N, Brun-Laurisse A, Gheurbi F, Buchy M, Halep H, Cheillan D, Mercier C, Brassier A, Desnous B, Kassai B, De Lonlay P, Des Portes V. Clinical Characteristics, Developmental Trajectory, and Caregiver Burden of Patients With Creatine Transporter Deficiency ( SLC6A8). Neurology 2024; 102:e209243. [PMID: 38531017 DOI: 10.1212/wnl.0000000000209243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 01/19/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Creatine transporter deficiency (CTD) is a rare X-linked genetic disorder characterized by intellectual disability (ID). We evaluated the clinical characteristics and trajectory of patients with CTD and the impact of the disease on caregivers to identify relevant endpoints for future therapeutic trials. METHODS As part of a French National Research Program, patients with CTD were included based on (1) a pathogenic SLC6A8 variant and (2) ID and/or autism spectrum disorder. Families and patients were referred by the physician who ordered the genetic analysis through Reference Centers of ID from rare causes and inherited metabolic diseases. After we informed the patients and their parents/guardians about the study, all of them gave written consent and were included. A control group of age-matched and sex-matched patients with Fragile X syndrome was also included. Physical examination, neuropsychological assessments, and caregiver impact were assessed. All data were analyzed using R software. RESULTS Thirty-one patients (27 male, 4 female) were included (25/31 aged 18 years or younger). Most of the patients (71%) had symptoms at <24 months of age. The mean age at diagnosis was 6.5 years. Epilepsy occurred in 45% (mean age at onset: 8 years). Early-onset behavioral disorder occurred in 82%. Developmental trajectory was consistently delayed (fine and gross motor skills, language, and communication/sociability). Half of the patients with CTD had axial hypotonia during the first year of life. All patients were able to walk without help, but 7/31 had ataxia and only 14/31 could walk tandem gait. Most of them had abnormal fine motor skills (27/31), and most of them had language impairment (30/31), but 12/23 male patients (52.2%) completed the Peabody Picture Vocabulary Test. Approximately half (14/31) had slender build. Most of them needed nursing care (20/31), generally 1-4 h/d. Adaptive assessment (Vineland) confirmed that male patients with CTD had moderate-to-severe ID. Most caregivers (79%) were at risk of burnout, as shown by Caregiver Burden Inventory (CBI) > 36 (significantly higher than for patients with Fragile X syndrome) with a high burden of time dependence. DISCUSSION In addition to clinical endpoints, such as the assessment of epilepsy and the developmental trajectory of the patient, the Vineland scale, PPVT5, and CBI are of particular interest as outcome measures for future trials. TRIAL REGISTRATION INFORMATION ANSM Registration Number 2010-A00327-32.
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Affiliation(s)
- Aurore Curie
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Laurence Lion-François
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Vassili Valayannopoulos
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Nathalie Perreton
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Marie Gavanon
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Nathalie Touil
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Amandine Brun-Laurisse
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Fahra Gheurbi
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Marion Buchy
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Hulya Halep
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - David Cheillan
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Catherine Mercier
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Anaïs Brassier
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Béatrice Desnous
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Behrouz Kassai
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Pascale De Lonlay
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
| | - Vincent Des Portes
- From the Child Neurology Department and Reference Centre of Rare Disease with Intellectual Disability (A.C., L.L.-F., M.G., A.B.-L., F.G., M.B., V.D.P.), Hospices Civils de Lyon, Lyon University Hospital; Lyon Neuroscience Research Centre (A.C., M.G., A.B.-L., F.G., M.B., V.D.P.), CNRS UMR5292, INSERM U1028; Lyon University (A.C., V.D.P.); Reference Centre for Inherited Metabolic Diseases (V.V., A.B., P.D.L.), Imagine Institute, Necker Enfants-Malades Hospital, Paris University Hospital, University of Paris Descartes; Clinical Investigation Center 1407/INSERM-Hospices Civils de Lyon (N.P., N.T., H.H., B.K.), Bron; Inborn Errors of Metabolism Unit (D.C.), Biochemistry and Molecular Biology Department; Department of Biostatistics (C.M.), Lyon University Hospital; and Reference Centre for Inherited Metabolic Diseases (B.D.), Department of Child Neurology, Marseille University Hospital, France
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Curie A, Oberlander TF, Jensen KB. Placebo effects in children with autism spectrum disorder. Dev Med Child Neurol 2023; 65:1316-1320. [PMID: 36917698 DOI: 10.1111/dmcn.15574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 03/16/2023]
Abstract
Placebo responses are frequently observed in research studies and clinical contexts, yet there is limited knowledge about the placebo effect among children with neurodevelopmental disorders. Here, we review the placebo effect in autism spectrum disorder (ASD). Placebo responses are widely evident in ASD clinical trials and could partly operate via so-called placebo-by-proxy, whereby caregivers or clinicians indirectly shape patient outcomes. Understanding the role of placebo effects in ASD may help discern genuine treatment effects from contextual factors in clinical trials. The much less studied nocebo effect, or negative placebo, might contribute to the experience of side effects in ASD treatments but empirical data is missing. Better knowledge about placebo and nocebo mechanisms may contribute to the development of more effective research designs, such as three-armed designs that account for natural history, and improved treatments for ASD symptoms. At a clinical level, deeper knowledge about placebo and nocebo effects may optimize the delivery of care for individuals with ASD in the future. WHAT THIS PAPER ADDS: Placebo responses are evident in autism spectrum disorder (ASD) clinical trials. Placebo responses in ASD are likely dependent on a placebo-by-proxy mechanism.
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Affiliation(s)
- Aurore Curie
- Reference Center for Intellectual Disability from Rare Causes, Department of Child Neurology, Woman Mother and Child Hospital, Hospices Civils de Lyon, Bron, France
| | - Tim F Oberlander
- Department of Pediatrics and School of Population and Public Health, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Karin B Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Aran A, Harel M, Ovadia A, Shalgy S, Cayam-Rand D. Mediators of Placebo Response to Cannabinoid Treatment in Children with Autism Spectrum Disorder. J Clin Med 2023; 12:jcm12093098. [PMID: 37176538 PMCID: PMC10179251 DOI: 10.3390/jcm12093098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
The placebo response has a substantial impact on treatment outcome. However, data regarding mediators of the placebo response in children with autism spectrum disorder (ASD) are sparse. This retrospective study investigated possible mediators of the placebo response among participants of a placebo-controlled trial of cannabinoid treatment for behavioral problems in children with ASD (CBA trial, age 5-21 years). We used a specifically designed questionnaire to explore possible mediators of the placebo response in 88 participants of the CBA trial who received a placebo and had valid outcome scores. The parents of 67 participants completed the questionnaire. The placebo response was positively associated with the child's comprehension of the treatment purpose (p = 0.037). There was also a trend for participants who had a relative aggravation of symptoms before treatment onset to improve following placebo treatment (p = 0.053). No other domains, including parental expectations, previous positive experience with similar treatments (behavioral conditioning), parental locus of control, quality of the patient-physician relationships, and adherence to study medications were associated with placebo-response. This finding suggests that efforts to explain the treatment purpose to children with disabilities may enhance treatment efficacy in clinical practice and decrease differences in the placebo response between study arms. Contrary to our hypothesis, parental expectations regarding cannabinoid treatment were not associated with the placebo response.
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Affiliation(s)
- Adi Aran
- Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Moria Harel
- Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Aminadav Ovadia
- Psychology Department, Yezreel Valley College, Yezreel Valley 1930600, Israel
| | - Shulamit Shalgy
- Psychology Department, Yezreel Valley College, Yezreel Valley 1930600, Israel
| | - Dalit Cayam-Rand
- Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
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Abstract
The fragile X-related disorders are an important group of hereditary disorders that are caused by expanded CGG repeats in the 5' untranslated region of the FMR1 gene or by mutations in the coding sequence of this gene. Two categories of pathological CGG repeats are associated with these disorders, full mutation alleles and shorter premutation alleles. Individuals with full mutation alleles develop fragile X syndrome, which causes autism and intellectual disability, whereas those with premutation alleles, which have shorter CGG expansions, can develop fragile X-associated tremor/ataxia syndrome, a progressive neurodegenerative disease. Thus, fragile X-related disorders can manifest as neurodegenerative or neurodevelopmental disorders, depending on the size of the repeat expansion. Here, we review mouse models of fragile X-related disorders and discuss how they have informed our understanding of neurodegenerative and neurodevelopmental disorders. We also assess the translational value of these models for developing rational targeted therapies for intellectual disability and autism disorders.
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Affiliation(s)
- Rob Willemsen
- Department of Clinical Genetics, Erasmus University Medical Center, 3015 CN Rotterdam, the Netherlands. Department of Medical Genetics, University of Antwerp, 2000 Antwerp, Belgium
| | - R Frank Kooy
- Department of Clinical Genetics, Erasmus University Medical Center, 3015 CN Rotterdam, the Netherlands. Department of Medical Genetics, University of Antwerp, 2000 Antwerp, Belgium
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Johnson D, Clark C, Hagerman R. Targeted Treatments for Fragile X Syndrome. ADVANCES IN NEUROBIOLOGY 2023; 30:225-253. [PMID: 36928853 DOI: 10.1007/978-3-031-21054-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
The histories of targeted treatment trials in fragile X syndrome (FXS) are reviewed in animal studies and human trials. Advances in understanding the neurobiology of FXS have identified a number of pathways that are dysregulated in the absence of FMRP and are therefore pathways that can be targeted with new medication. The utilization of quantitative outcome measures to assess efficacy in multiple studies has improved the quality of more recent trials. Current treatment trials including the use of cannabidiol (CBD) topically and metformin orally have positive preliminary data, and both of these medications are available clinically. The use of the phosphodiesterase inhibitor (PDE4D), BPN1440, which raised the level of cAMP that is low in FXS has very promising results for improving cognition in adult males who underwent a controlled trial. There are many more targeted treatments that will undergo trials in FXS, so the future looks bright for new treatments.
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Affiliation(s)
- Devon Johnson
- MIND Institute, University of California Davis Health, Sacramento, CA, USA
| | - Courtney Clark
- MIND Institute, University of California Davis Health, Sacramento, CA, USA
| | - Randi Hagerman
- MIND Institute, University of California Davis Health, Sacramento, CA, USA
- Department of Pediatrics, University of California Davis Health, Sacramento, CA, USA
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Ahmadzad-Asl M, Davoudi F, Mohamadi S, Hadi F, Nejadghaderi SA, Mirbehbahani SH, Jabbarinejad R, Saneh S, Arshadi M, Naserbakht M, Sinyor M, Kabir A, Shamshiri A. Systematic review and meta-analysis of the placebo effect in panic disorder: Implications for research and clinical practice. Aust N Z J Psychiatry 2022; 56:1130-1141. [PMID: 34996304 DOI: 10.1177/00048674211068793] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This review aimed to measure the degree of placebo response in panic disorder. DATA SOURCES We searched major databases up to 31 January 2021, for randomized pharmacotherapy trials published in English. STUDY SELECTION A total of 43 studies met inclusion criteria to be in the analysis (with 174 separate outcome measurements). DATA EXTRACTION Changes in outcome measures from baseline in the placebo group were used to estimate modified Cohen's d effect size. RESULTS A total of 43 trials (2392 subjects, 174 outcomes using 27 rating scales) were included in the meta-analysis. Overall placebo effect size was 0.57 (95% confidence interval = [0.50, 0.64]), heterogeneity (I2: 96.3%). Higher placebo effect size was observed among clinician-rated scales compared to patient reports (0.75 vs 0.35) and among general symptom and anxiety scales compared to panic symptoms and depression scales (0.92 and 0.64 vs 0.56 and 0.54, respectively). There was an upward trend in effect size over the publication period (r = 0.02, p = 0.002) that was only significant among clinician-rated scales (r = 0.02, p = 0.011). There was no significant publication bias, Egger's test (p = 0.08). CONCLUSION We observed a substantial placebo effect size in panic disorder. This effect was more prominent for some aspects of panic disorder psychopathology than for others and was correlated with the source of the assessment and publication year. This finding has implications both for research design, to address the heterogeneity and diversity in placebo responses, and for clinical practice to ensure optimal quality of care. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO, CRD42019125979.
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Affiliation(s)
- Masoud Ahmadzad-Asl
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Farnoush Davoudi
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Safoura Mohamadi
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Hadi
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Roxana Jabbarinejad
- Cognitive Neuroscience Laboratory, Brain Injury Research, Think+Speak Lab, Shirley Ryan Ability Lab, Northwestern University, Chicago, IL, USA
| | - Sadaf Saneh
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Arshadi
- Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Morteza Naserbakht
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mark Sinyor
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Ali Kabir
- Education Development Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Shamshiri
- Department of Epidemiology, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
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7
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Matthiesen ST, Rosenkjær S, Pontén M, Jensen KB, Gottrup H, Vase L. Does Certainty of Genuine Treatment Increase the Drug Response in Alzheimer's Disease Patients: A Meta-Analysis and Critical Discussion. J Alzheimers Dis 2021; 84:1821-1832. [PMID: 34744076 DOI: 10.3233/jad-210108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Non-specific treatment effects, such as expectations, contribute to the effectiveness of pharmacological treatments across diseases. However, the contribution of expectancy, i.e., certainty of receiving treatment, in patients with Alzheimer's disease (AD) is unknown. OBJECTIVE The aim is to investigate whether certainty of receiving a genuine treatment influences the response to active treatment in AD patients. METHODS The efficacy of active treatments in open-label trials, where patients are certain of receiving treatment (100%certainty), was compared to the same active treatments in randomized controlled trials (RCT), where patients are uncertain of receiving treatment or placebo (50%certainty). RESULTS In the seven open-label trials, there was no significant difference between post- and pre-treatment scores (difference in means = 0.14, 95%CI [-0.51; 0.81], p = 0.66). In the eight RCT trials, there was a significant difference between post- and pre-treatment (difference in means = -0.91, 95%CI [-1.43; -0.41], p < 0.001). There was a statistically significant difference between open-label and RCT trials (difference = 1.06, 95%CI [0.23; 1.90], p = 0.001). CONCLUSION Patients with AD did not benefit from certainty of receiving genuine treatment. This could be due to the nature/progression of the disease, but it could also be related to an order effect in the practice of running AD trials, where RCTs are conducted prior to open label. These findings have implications for the understanding of non-specific treatment effects in AD patients as well as for the design of clinical trials that test pharmacological treatments in AD.
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Affiliation(s)
- Susan Tomczak Matthiesen
- Division for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Sophie Rosenkjær
- Division for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
| | - Moa Pontén
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Karin B Jensen
- Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Hanne Gottrup
- Department of Clinical Medicine, Department of Neurology, Aarhus University Hospital, Denmark
| | - Lene Vase
- Division for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Denmark
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8
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Arandia IR, Di Paolo EA. Placebo From an Enactive Perspective. Front Psychol 2021; 12:660118. [PMID: 34149551 PMCID: PMC8206487 DOI: 10.3389/fpsyg.2021.660118] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/28/2021] [Indexed: 12/12/2022] Open
Abstract
Due to their complexity and variability, placebo effects remain controversial. We suggest this is also due to a set of problematic assumptions (dualism, reductionism, individualism, passivity). We critically assess current explanations and empirical evidence and propose an alternative theoretical framework—the enactive approach to life and mind—based on recent developments in embodied cognitive science. We review core enactive concepts such as autonomy, agency, and sense-making. Following these ideas, we propose a move from binary distinctions (e.g., conscious vs. non-conscious) to the more workable categories of reflective and pre-reflective activity. We introduce an ontology of individuation, following the work of Gilbert Simondon, that allow us to see placebo interventions not as originating causal chains, but as modulators and triggers in the regulation of tensions between ongoing embodied and interpersonal processes. We describe these interrelated processes involving looping effects through three intertwined dimensions of embodiment: organic, sensorimotor, and intersubjective. Finally, we defend the need to investigate therapeutic interactions in terms of participatory sense-making, going beyond the identification of individual social traits (e.g., empathy, trust) that contribute to placebo effects. We discuss resonances and differences between the enactive proposal, popular explanations such as expectations and conditioning, and other approaches based on meaning responses and phenomenological/ecological ideas.
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Affiliation(s)
- Iñigo R Arandia
- IAS-Research Center for Life, Mind and Society, University of the Basque Country, Leioa, Spain.,ISAAC Lab, Aragón Institute of Engineering Research, University of Zaragoza, Zaragoza, Spain
| | - Ezequiel A Di Paolo
- IAS-Research Center for Life, Mind and Society, University of the Basque Country, Leioa, Spain.,Ikerbasque-Basque Foundation for Science, Bilbao, Spain.,Center for Computational Neuroscience and Robotics, University of Sussex, Brighton, United Kingdom
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9
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Yang WC, Chen YF, Yang CC, Wu PF, Chan HM, Chen JLY, Chen GY, Cheng JCH, Kuo SH, Hsu FM. Hippocampal avoidance whole-brain radiotherapy without memantine in preserving neurocognitive function for brain metastases: a phase II blinded randomized trial. Neuro Oncol 2021; 23:478-486. [PMID: 32789503 DOI: 10.1093/neuonc/noaa193] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hippocampal avoidance whole-brain radiotherapy (HA-WBRT) shows potential for neurocognitive preservation. This study aimed to evaluate whether HA-WBRT or conformal WBRT (C-WBRT) is better for preserving neurocognitive function. METHODS This single-blinded randomized phase II trial enrolled patients with brain metastases and randomly assigned them to receive HA-WBRT or C-WBRT. Primary endpoint is decline of the Hopkins Verbal Learning Test-Revised (HVLT-R) delayed recall at 4 months after treatment. Neurocognitive function tests were analyzed with a mixed effect model. Brain progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS From March 2015 to December 2018, seventy patients were randomized to yield a total cohort of 65 evaluable patients (33 in the HA-WBRT arm and 32 in the C-WBRT arm) with a median follow-up of 12.4 months. No differences in baseline neurocognitive function existed between the 2 arms. The mean change of HVLT-R delayed recall at 4 months was -8.8% in the HA-WBRT arm and +3.8% in the C-WBRT arm (P = 0.31). At 6 months, patients receiving HA-WBRT showed favorable perpetuation of HVLT-R total recall (mean difference = 2.60, P = 0.079) and significantly better preservation of the HVLT-R recognition-discrimination index (mean difference = 1.78, P = 0.019) and memory score (mean difference = 4.38, P = 0.020) compared with patients undergoing C-WBRT. There were no differences in Trail Making Test Part A or Part B or the Controlled Oral Word Association test between the 2 arms at any time point. There were no differences in brain PFS or OS between arms as well. CONCLUSION Patients receiving HA-WBRT without memantine showed better preservation in memory at 6-month follow-up, but not in verbal fluency or executive function.
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Affiliation(s)
- Wen-Chi Yang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Chengchi University, Taipei, Taiwan.,Cancer Research Center, National Chengchi University, Taipei, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medical Imaging, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Chi-Cheng Yang
- Department of Psychology, National Chengchi University, Taipei, Taiwan.,Holistic Mental Health Center, Taipei City Hospital, Taipei, Taiwan
| | - Pei-Fang Wu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsing-Min Chan
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jenny Ling-Yu Chen
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Guann-Yiing Chen
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medical Imaging, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Jason Chia-Hsien Cheng
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Chengchi University, Taipei, Taiwan.,Cancer Research Center, National Chengchi University, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Chengchi University, Taipei, Taiwan.,Cancer Research Center, National Chengchi University, Taipei, Taiwan
| | - Feng-Ming Hsu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Chengchi University, Taipei, Taiwan.,Cancer Research Center, National Chengchi University, Taipei, Taiwan
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10
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Luu S, Province H, Berry-Kravis E, Hagerman R, Hessl D, Vaidya D, Lozano R, Rosselot H, Erickson C, Kaufmann WE, Budimirovic DB. Response to Placebo in Fragile X Syndrome Clinical Trials: An Initial Analysis. Brain Sci 2020; 10:E629. [PMID: 32932789 PMCID: PMC7563217 DOI: 10.3390/brainsci10090629] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 12/16/2022] Open
Abstract
Fragile X syndrome (FXS) is the leading cause of inherited intellectual disability and autism spectrum disorder. Individuals with FXS often present with a wide range of cognitive deficits and problem behaviors. Educational, behavioral and pharmacological interventions are used to manage these and other complex issues affecting individuals with FXS. Despite the success of preclinical models and early-phase drug clinical studies in FXS, large-scale randomized-controlled trials have failed to meet primary endpoints. Currently, no targeted or disease-modifying treatments for FXS have received regulatory approval. Here, we examined the placebo response in FXS clinical trials conducted between 2006 and 2018. Specifically, we performed a meta-analysis of placebo-treated groups in eight double-blind, randomized controlled trials. Placebo groups demonstrated significant improvements on caregiver-rated efficacy endpoints, which were greater in adolescents and adults than in children. Among the latter measures, the Visual Analog Scale scores displayed the greatest improvements, whereas the positive effects on the Vineland-II Adaptive Behavior Composite and the Aberrant Behavior Checklist-Community/fragile X version were statistically significant in both children and adolescents/adults. Although the Clinical Global Impression scale Improvement appears to have exhibited a substantial placebo effect in multiple clinical trials in FXS, limited data availability for meta-analysis, prevented us from drawing conclusions. No placebo-related improvements were observed in performance-rated measures. These findings raise substantial concerns about placebo effects in outcome measures commonly used in the randomized-controlled trials in FXS and suggest several potential improvements in the study design and implementation of such trials. Considering the small number of trials available for this study, larger and more detailed follow up meta-analyses are needed. Meanwhile, efforts to improve the measurement properties of endpoints and rater training in drug trials in FXS should be prioritized.
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Affiliation(s)
- Skylar Luu
- Albany Medical Center, Albany Medical College, 43 New Scotland Ave, Albany, NY 12208, USA;
| | - Haley Province
- Feinberg School of Medicine, Northwestern University, 420 E. Superior St, Chicago, IL 60611, USA;
| | - Elizabeth Berry-Kravis
- Departments of Pediatrics, Neurological Sciences, Biochemistry, Rush University Medical Center, 1725 West Harrison, Suite 718, Chicago, IL 60612, USA;
| | - Randi Hagerman
- MIND Institute and the Department of Pediatrics, University of California Davis Medical Center, 2825 50th Street, Sacramento, CA 95817, USA;
| | - David Hessl
- MIND Institute and the Department of Psychiatry and Behavioral Sciences, University of California Davis Medical Center, 2825 50th Street, Sacramento, CA 95817, USA;
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Reymundo Lozano
- Departments of Genetics and Genomic Sciences, Pediatrics and Psychiatry, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA;
| | | | - Craig Erickson
- Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 4002, Cincinnati, OH 45229, USA;
| | - Walter E. Kaufmann
- Boston Children’s Hospital and Department of Human Genetics, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322, USA
| | - Dejan B. Budimirovic
- Kennedy Krieger Institute/The Johns Hopkins Medical Institutions, Department of Psychiatry & Behavioral Sciences-Child Psychiatry, the Johns Hopkins University School of Medicine, 1741 Ashland Ave, Rm 241, Baltimore, MD 21205, USA
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11
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Hall KT, Vase L, Tobias DK, Dashti HT, Vollert J, Kaptchuk TJ, Cook NR. Historical Controls in Randomized Clinical Trials: Opportunities and Challenges. Clin Pharmacol Ther 2020; 109:343-351. [PMID: 32602555 DOI: 10.1002/cpt.1970] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
Abstract
Randomized control trials (RCTs) with placebo are the gold standard for determining efficacy of novel pharmaceutical treatments. Since their inception, over 75 years ago, researchers have amassed a large body of underutilized data on outcomes in the placebo control arms of these trials. Although rare disease indications have used these historical placebo data as synthetic controls to reduce burden on patients and accelerate drug discovery, broad use of historical controls is in its infancy. Large-scale historical placebo data could be leveraged to benefit both drug developers and patients if warehoused and made more available to guide trial design and analysis. Here, we examine challenges in utilizing historical controls related to heterogeneity in trial design, outcome ascertainment, patient characteristics, and unmeasured pharmacogenomic effects. We then discuss the advantages and disadvantages of current approaches and propose a path forward to broader use of historical controls in RCTs.
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Affiliation(s)
- Kathryn T Hall
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lene Vase
- Department of Psychology and Behavioral Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Deirdre K Tobias
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hesam T Dashti
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Neurophysiology, Centre for Biomedicine and Medical Technology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-University, Heidelberg, Germany
| | - Ted J Kaptchuk
- Harvard Medical School, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nancy R Cook
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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12
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Khullar V, Rahnama'i MS, Veit-Rubin N, Cardozo L, Wein AJ. Can we harness the placebo effect to improve care in lower urinary tract dysfunction? ICI-RS 2019. Neurourol Urodyn 2020; 39 Suppl 3:S80-S87. [PMID: 32311166 DOI: 10.1002/nau.24351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 11/09/2022]
Abstract
The proposal "Can we harness the placebo effect to improve care in lower urinary tract dysfunction?" was discussed at the International Consultation on Incontinence-Research Society (ICI-RS) 2019 meeting. The placebo effect can change the treatment outcome whether the treatment is an active treatment or placebo. The total active treatment outcome is a combination of the placebo and the active treatment effect which is seen in placebo-controlled trials. The placebo effect plays an important role in the treatment of lower urinary tract dysfunction in overactive bladder, bladder pain syndrome, and stress urinary incontinence. In clinical practice, a number of factors can be employed to use the placebo effect to maximize its effect on patients receiving an active treatment, such as having the same environment for review such as the same appointment time, same room, and same clinician. Clinicians should also be aware of the nocebo effect which is increased with an overemphasis on side effects or negative outcomes.
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Affiliation(s)
- Vik Khullar
- Urogynaecology Department, St Mary's Hospital, Imperial College London, London, UK
| | - Mohammad S Rahnama'i
- Department of Urology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Nikolaus Veit-Rubin
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Linda Cardozo
- Department of Urogynaecology, Kings College Hospital, London, UK
| | - Alan J Wein
- Department of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Neuenschwander R, Weik E, Tipper CM, Jensen K, Oberlander TF. Conditioned Placebo- and Nocebo-Like Effects in Adolescents: The Role of Conscious Awareness, Sensory Discrimination, and Executive Function. Front Psychiatry 2020; 11:586455. [PMID: 33329131 PMCID: PMC7710613 DOI: 10.3389/fpsyt.2020.586455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/23/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Conditioning is a key mechanism of placebo and nocebo effects in adults. Little is known about the underlying mechanisms of placebo and nocebo effects in youth and how they might be influenced by conscious awareness and cognitive abilities. In this study, the role of conditioning on thermal perception in youth was investigated. Methods: Differences in thermal ratings were assessed in response to consciously and non-consciously perceived cues that were conditioned to either low or high heat. Furthermore, we tested whether executive function mediates the effect of conditioning on thermal perception. Thirty-five high-school students (14-17 years) completed an executive function task and underwent a sensory perception paradigm. In a conditioning phase, two distinct neutral faces (conditioned cues) were coupled to either a low or a high temperature stimulus delivered to participants' forearms. In a testing phase, the conditioned cues, and novel faces (non-conditioned control cues), were paired with identical moderate thermal stimuli. In this testing phase, for half of the participants cues were presented consciously (supraliminally) and for the other half non-consciously (subliminally). Results: We found a significant main effect of cue type on thermal ratings (p = 0.003) in spite of identical heat being administered following all cues. Post-hoc analyses indicated that the nocebo-like effect (conditioned high cue compared to control) was significant (p = 0.027); the placebo-like effect (conditioned low cue compared to control) was non-significant. No difference between cues presented supra- vs. subliminally and no significant interaction effects were found. The association between sensory discrimination and the magnitude of the nocebo-like effect was mediated by executive function. Conclusions: To our best knowledge, this is the first study establishing a relationship between thermal perception, nocebo effects, and executive function in youth. Our results may have important implications for understanding cognitive/ learning processes involved in nocebo effects.
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Affiliation(s)
- Regula Neuenschwander
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada.,Institute of Psychology, University of Bern, Bern, Switzerland
| | - Ella Weik
- Department of Psychiatry, BC Mental Health and Substance Use Services Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Christine M Tipper
- Department of Psychiatry, BC Mental Health and Substance Use Services Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Karin Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Tim F Oberlander
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
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14
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Czerniak E, Oberlander TF, Weimer K, Kossowsky J, Enck P. "Placebo by Proxy" and "Nocebo by Proxy" in Children: A Review of Parents' Role in Treatment Outcomes. Front Psychiatry 2020; 11:169. [PMID: 32218746 PMCID: PMC7078585 DOI: 10.3389/fpsyt.2020.00169] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 02/21/2020] [Indexed: 12/12/2022] Open
Abstract
The "placebo (effect) by proxy" (PbP) concept, introduced by Grelotti and Kaptchuk (1), describes a positive effect of a patient's treatment on persons in their surrounding such as family members or healthcare providers, who feel better because the patient is being treated. The PbP effect is a complex dynamic phenomenon which attempts to explain a change in treatment outcome arising from an interaction between a patient and an effect from proxies such as parents, caregivers, physicians or even the media. By extension the effect of the proxy can also have a negative or adverse effect whereby a proxy feels worse when a patient is treated, giving rise to the possibility of a "nocebo (effect) by proxy" (NbP), and by extension can influence a patient's treatment response. While this has yet to be systematically investigated, such an effect could occur when a proxy observes that a treatment is ineffective or is perceived as causing adverse effects leading the patient to experience side effects. In this narrative review, we take these definitions one step further to include the impact of PbP/NbP as they transform to affect the treatment outcome for the patient or child being treated, not just the people surrounding the individual being treated. Following a systematic search of literature on the subject using the Journal of Interdisciplinary Placebo Studies (JIPS) database (https://jips.online) and PubMed (NCBI) resulted in very few relevant studies, especially in children. The effect of PbP per se has been studied in parents and their children for temper tantrums, acupuncture for postoperative symptoms, as well as for neuroprotection in very preterm-born infants. This paper will review the PbP/NbP concepts, show evidence for its presence in children's treatment outcome and introduce clinical implications. We will also offer suggestions for future research to further our understanding of the role of the proxy in promoting or distracting from treatment benefit in children. Increasing an appreciation of the PbP and NbP phenomena and the role of the proxy in children's treatment should improve research study design and ultimately harness them to improve clinical child healthcare.
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Affiliation(s)
- Efrat Czerniak
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Tim F Oberlander
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Katja Weimer
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Ulm, Germany
| | - Joe Kossowsky
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States.,Department of Clinical Psychology & Psychotherapy, University of Basel, Basel, Switzerland
| | - Paul Enck
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Hospital Tübingen, Tübingen, Germany
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15
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Lee SE, Duran-Martinez M, Khantsis S, Bianchi DW, Guedj F. Challenges and Opportunities for Translation of Therapies to Improve Cognition in Down Syndrome. Trends Mol Med 2019; 26:150-169. [PMID: 31706840 DOI: 10.1016/j.molmed.2019.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 02/07/2023]
Abstract
While preclinical studies have reported improvement of behavioral deficits in the Ts65Dn mouse model of Down syndrome (DS), translation to human clinical trials to improve cognition in individuals with DS has had a poor success record. Timing of the intervention, choice of animal models, strategy for drug selection, and lack of translational endpoints between animals and humans contributed to prior failures of human clinical trials. Here, we focus on in vitro cell models from humans with DS to identify the molecular mechanisms underlying the brain phenotype associated with DS. We emphasize the importance of using these cell models to screen for therapeutic molecules, followed by validating them in the most suitable animal models prior to initiating human clinical trials.
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Affiliation(s)
- Sarah E Lee
- Medical Genetics Branch (Prenatal Genomic and Therapy Section), National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Monica Duran-Martinez
- Medical Genetics Branch (Prenatal Genomic and Therapy Section), National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sabina Khantsis
- Medical Genetics Branch (Prenatal Genomic and Therapy Section), National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Diana W Bianchi
- Medical Genetics Branch (Prenatal Genomic and Therapy Section), National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA; Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda 20892, MD, USA
| | - Faycal Guedj
- Medical Genetics Branch (Prenatal Genomic and Therapy Section), National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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Hagerman R, Tuchman R. Turning the tide on targeted treatments for neurodevelopmental disorders. Neurology 2019; 92:741-742. [DOI: 10.1212/wnl.0000000000007301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Hessl D, Schweitzer JB, Nguyen DV, McLennan YA, Johnston C, Shickman R, Chen Y. Cognitive training for children and adolescents with fragile X syndrome: a randomized controlled trial of Cogmed. J Neurodev Disord 2019; 11:4. [PMID: 30982467 PMCID: PMC6463634 DOI: 10.1186/s11689-019-9264-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with fragile X syndrome (FXS) typically demonstrate profound executive function (EF) deficits that interfere with learning, socialization, and emotion regulation. We completed the first large, non-pharmacological controlled trial for FXS, designed to evaluate the efficacy of Cogmed, a computer/tablet-based working memory (WM) training program. METHODS The study was a randomized, blinded, parallel two-arm controlled trial in 100 children and adolescents with FXS (63 male, 37 female; 15.28 ± 3.36 yrs.). Participants were randomized equally to adaptive (difficulty level adjusted to performance) or non-adaptive (control) Cogmed training. Participants were assessed at home using objective measures of WM (primary outcome) and EF at baseline, following 20-25 caregiver-supported sessions over 5-6 weeks, and at follow-up 3 months after cessation of training. Parents and teachers provided ratings of WM, attention, and EF. RESULTS The WM composite and selective domains of EF (distractibility, cognitive flexibility), as well as parent- and teacher-reported attention and EF, significantly improved across the full study sample, with many changes maintained at follow-up. However, comparisons of improvement between adaptive and non-adaptive control conditions did not differ, showing that progressively challenging the WM system by expanding span length did not provide added benefit overall. CONCLUSIONS Further experimental comparisons are needed before Cogmed working memory training can be considered empirically validated for children with FXS, forming the basis of treatment recommendation. However, given that prior studies show no significant changes on these measures in FXS without treatment, that improvements were maintained for 3 months, and that blinded teachers reported improvements in the classroom, the modest benefits seen in both adaptive and non-adaptive groups overall are unlikely to be attributable to placebo or practice effects alone. Future analyses examining inter-individual differences (e.g., baseline capacity, training efficiency, co-morbidity, training environment, characteristics of training aide) may help to link this intervention to outcomes and potential transfer effects. TRIAL REGISTRATION US National Institutes of Health (ClinicalTrials.gov), NCT02747394 .
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Affiliation(s)
- David Hessl
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
- Translational Psychophysiology and Assessment Laboratory (T-PAL), MIND Institute, UC Davis Medical Center, 2825 50th Street, Sacramento, CA 95817 USA
| | - Julie B. Schweitzer
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
| | - Danh V. Nguyen
- Department of Medicine, University of California Irvine, 333 City Blvd. West, Orange, CA 92868 USA
| | - Yingratana A. McLennan
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Pediatrics, University of California Davis School of Medicine, 2516 Stockton Blvd, Sacramento, CA 95817 USA
| | - Cindy Johnston
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
| | - Ryan Shickman
- MIND Institute, University of California Davis Medical Center, 2825 50th St, Sacramento, CA 95817 USA
- Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, 2230 Stockton Blvd, Sacramento, CA 95817 USA
| | - Yanjun Chen
- Institute for Clinical and Translational Science, Irvine, CA 92697 USA
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18
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Coton J, Le HH, Veuillet V, Janiaud P, Cucherat M, Kassai-Koupai B, Gueyffier F, Reix P. Do patients with cystic fibrosis participating in clinical trials demonstrate placebo response? A meta-analysis. J Cyst Fibros 2019; 18:461-467. [PMID: 30772244 DOI: 10.1016/j.jcf.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients' and families' expectation that a cure for cystic fibrosis (CF) will be found is high. In other debilitating conditions, high expectation has been shown to drive a strong placebo response (PR). Therefore, our goal was to evaluate PR on objective continuous outcomes (FEV1, BMI) and the CF Questionnaire Revised-Respiratory Domain (CFQR-RD) monitored during randomised clinical trials (RCTs) for CF. METHODS We conducted a meta-analysis after a systematic review of the literature carried out to identify RCTs with FEV1, CFQR-RD and BMI as outcome measures. The standardised mean difference (SMD) was calculated to estimate the PR. A meta-regression analysis was conducted to assess other contributing factors on PR such as study design, trial duration, patient age and disease severity. RESULTS Out of 289 RCTs found in the search, we identified 61 articles (published from 1987 to 2017) with respectively 59, 17 and 9 reporting FEV1, CFQR-RD and BMI at the start and at the end of the RCTs. No significant PR was found on FEV1 or CFQR-RD. However, a small but significant PR was found on BMI SMD, 0.09 (95% CI (0.01; 0.17); p = 0.03). CONCLUSION The PR seems higher when measuring BMI. However, it is not clear whether this improvement can be explained by a PR alone.
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Affiliation(s)
- Julie Coton
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; Centre de ressources et de compétences de la mucoviscidose, Hospices Civils de Lyon, Lyon, France
| | - Ha-Hai Le
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France
| | - Victor Veuillet
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France
| | - Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
| | - Michel Cucherat
- Department of Clinical Pharmacology, Université Claude Bernard Lyon 1, Lyon, France
| | - Behrouz Kassai-Koupai
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; EPICIME-Clinical Investigation Center, INSERM CIC1407/UMR5558, Bron, France
| | - François Gueyffier
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; EPICIME-Clinical Investigation Center, INSERM CIC1407/UMR5558, Bron, France
| | - Philippe Reix
- UMR 5558 CNRS, Equipe EMET, Université Claude Bernard Lyon 1, Lyon, France; Centre de ressources et de compétences de la mucoviscidose, Hospices Civils de Lyon, Lyon, France.
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19
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Best Practices in Fragile X Syndrome Treatment Development. Brain Sci 2018; 8:brainsci8120224. [PMID: 30558274 PMCID: PMC6315698 DOI: 10.3390/brainsci8120224] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 01/14/2023] Open
Abstract
Preclinical studies using animal models of fragile X syndrome have yielded several agents that rescue a wide variety of phenotypes. However, translation of these treatments to humans with the disorder has not yet been successful, shedding light on a variety of limitations with both animal models and human trial design. As members of the Clinical Trials Committee of the National Fragile X Foundation, we have discussed a variety of recommendations at the level of preclinical development, transition from preclinical to human projects, family involvement, and multi-site trial planning. Our recommendations are made with the vision that effective new treatment will lie at the intersection of innovation, rigorous and reproducible research, and stakeholder involvement.
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20
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Mavoglurant in Fragile X Syndrome: Results of two open-label, extension trials in adults and adolescents. Sci Rep 2018; 8:16970. [PMID: 30451888 PMCID: PMC6242849 DOI: 10.1038/s41598-018-34978-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/22/2018] [Indexed: 02/06/2023] Open
Abstract
Fragile X syndrome (FXS) is the most common monogenic cause of inherited intellectual and developmental disabilities. Mavoglurant, a selective metabotropic glutamate receptor subtype-5 antagonist, has shown positive neuronal and behavioral effects in preclinical studies, but failed to demonstrate any behavioral benefits in two 12-week, randomized, placebo-controlled, double-blind, phase IIb studies in adults and adolescents with FXS. Here we report the long-term safety (primary endpoint) and efficacy (secondary endpoint) results of the open-label extensions. Adolescent (n = 119, aged 12–19 years) and adult (n = 148, aged 18–45 years) participants received up to 100 mg bid mavoglurant for up to 34 months. Both extension studies were terminated prematurely due to lack of proven efficacy in the core studies. Mavoglurant was well tolerated with no new safety signal. Five percent of adults and 16.9 percent of adolescents discontinued treatment due to adverse events. Gradual and consistent behavioral improvements as measured by the ABC-CFX scale were observed, which were numerically superior to those seen in the placebo arm of the core studies. These two extension studies confirm the long-term safety of mavoglurant in FXS, but further investigations are required to determine whether and under which conditions the significant preclinical results obtained with mGluR5 inhibition can translate to humans.
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21
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Modi ME, Sahin M. The Way Forward for Mechanism-Based Therapeutics in Genetically Defined Neurodevelopmental Disorders. Clin Pharmacol Ther 2018; 104:603-606. [PMID: 30101418 DOI: 10.1002/cpt.1181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Rare genetically defined neurodevelopmental disorders with increased risk of autism have recently become an entry point for autism-related drug discovery. Through exploration of downstream effects of the pathological mutations, specific mechanistic pathways have been identified as dysregulated. The identification of shared mechanisms across forms of autism opens the door for the development of novel "mechanism-based therapeutics." However, confidence in the therapeutic mechanism does not diminish the need for well-designed clinical trials.
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Affiliation(s)
- Meera E Modi
- Translational Neuroscience Center, F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mustafa Sahin
- Translational Neuroscience Center, F.M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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22
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Polich G, Iaccarino MA, Kaptchuk TJ, Morales-Quezada L, Zafonte R. Placebo Effects in Traumatic Brain Injury. J Neurotrauma 2018; 35:1205-1212. [PMID: 29343158 PMCID: PMC6016098 DOI: 10.1089/neu.2017.5506] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In recent years, several randomized controlled trials evaluating pharmaceutical treatments for traumatic brain injury (TBI) have failed to demonstrate efficacy over placebo, with both active and placebo arms improving at comparable rates. These findings could be viewed in opposing ways, suggesting on the one hand failure of the tested outcome, but on the other, representing evidence of robust placebo effects in TBI. In this article, we examine several of the primary psychological processes driving placebo effects (verbal suggestion, cognitive re-framing, interpersonal interactions, conditioning, therapeutic alliance, anxiety reduction) as well as placebo neurobiology (top-down cortical regulation, reward system activation, dopaminergic and serotonergic neurotransmission). We then extrapolate from the literature to explore whether something inherent in TBI makes it particularly responsive to placebos. Viewed as such here, placebos may indeed represent a powerful and effective treatment for a variety of post-TBI complaints.
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Affiliation(s)
- Ginger Polich
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Mary Alexis Iaccarino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
- Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, Massachusetts
| | - Ted J. Kaptchuk
- Program in Placebo Studies and Therapeutic Encounter, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Leon Morales-Quezada
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
- Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, Massachusetts
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23
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Jensen KB. What Is Minimally Required to Elicit Placebo Effects? INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 138:181-199. [PMID: 29681325 DOI: 10.1016/bs.irn.2018.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Placebo effects have often been attributed to cognitive processes described as "learning" and/or "expectancy," yet the role of conscious awareness is unclear. Furthermore, little is known about the placebo effects in patients with limited cognitive abilities, such as intellectual disability. Here, recent data on placebo mechanisms in patients with impaired cognitive function will be discussed, as well as experimental studies investigating how implicit cognitive processes may shape placebo effects. Together these studies comment on the minimum requirements in order to elicit placebo effects, both from the view of conscious awareness and from the perspective of Intelligence Quotient and basic brain function. Together with recent conceptualizations of placebo effects in terms of predictive coding, there is evidence to suggest that placebo effects are fundamental responses of the brain that have developed to promote survival.
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24
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Drug development for neurodevelopmental disorders: lessons learned from fragile X syndrome. Nat Rev Drug Discov 2017; 17:280-299. [PMID: 29217836 DOI: 10.1038/nrd.2017.221] [Citation(s) in RCA: 212] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Neurodevelopmental disorders such as fragile X syndrome (FXS) result in lifelong cognitive and behavioural deficits and represent a major public health burden. FXS is the most frequent monogenic form of intellectual disability and autism, and the underlying pathophysiology linked to its causal gene, FMR1, has been the focus of intense research. Key alterations in synaptic function thought to underlie this neurodevelopmental disorder have been characterized and rescued in animal models of FXS using genetic and pharmacological approaches. These robust preclinical findings have led to the implementation of the most comprehensive drug development programme undertaken thus far for a genetically defined neurodevelopmental disorder, including phase IIb trials of metabotropic glutamate receptor 5 (mGluR5) antagonists and a phase III trial of a GABAB receptor agonist. However, none of the trials has been able to unambiguously demonstrate efficacy, and they have also highlighted the extent of the knowledge gaps in drug development for FXS and other neurodevelopmental disorders. In this Review, we examine potential issues in the previous studies and future directions for preclinical and clinical trials. FXS is at the forefront of efforts to develop drugs for neurodevelopmental disorders, and lessons learned in the process will also be important for such disorders.
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Abstract
Fragile X syndrome (FXS) is the leading inherited form of intellectual disability and autism spectrum disorder, and patients can present with severe behavioural alterations, including hyperactivity, impulsivity and anxiety, in addition to poor language development and seizures. FXS is a trinucleotide repeat disorder, in which >200 repeats of the CGG motif in FMR1 leads to silencing of the gene and the consequent loss of its product, fragile X mental retardation 1 protein (FMRP). FMRP has a central role in gene expression and regulates the translation of potentially hundreds of mRNAs, many of which are involved in the development and maintenance of neuronal synaptic connections. Indeed, disturbances in neuroplasticity is a key finding in FXS animal models, and an imbalance in inhibitory and excitatory neuronal circuits is believed to underlie many of the clinical manifestations of this disorder. Our knowledge of the proteins that are regulated by FMRP is rapidly growing, and this has led to the identification of multiple targets for therapeutic intervention, some of which have already moved into clinical trials or clinical practice.
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26
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Keeling LA, Spiridigliozzi GA, Hart SJ, Baker JA, Jones HN, Kishnani PS. Challenges in measuring the effects of pharmacological interventions on cognitive and adaptive functioning in individuals with Down syndrome: A systematic review. Am J Med Genet A 2017; 173:3058-3066. [PMID: 28857390 DOI: 10.1002/ajmg.a.38416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 07/24/2017] [Accepted: 07/29/2017] [Indexed: 12/16/2022]
Abstract
We systematically reviewed the measures used in pharmaceutical trials in children/adults with Down syndrome without dementia. Our purpose was to identify developmentally appropriate outcome measures capable of detecting changes in cognitive and adaptive functioning in this population. Eleven studies were included and used diverse outcome measures across the domains of language, memory, attention, behavior, and executive/adaptive functioning. Our results highlight the challenges in selecting measures capable of capturing improvements in pharmaceutical trials in individuals with DS. We offer suggestions to enhance future research, including: conducting studies with larger samples of participants with a range of developmental abilities; modifying existing/developing novel outcome measures; incorporating advances from related areas and DS observational studies; and considering alternative analytic techniques to characterize treatment effects.
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Affiliation(s)
- Lori A Keeling
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Gail A Spiridigliozzi
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Sarah J Hart
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Jane A Baker
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Harrison N Jones
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Priya S Kishnani
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
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'Emotiplay': a serious game for learning about emotions in children with autism: results of a cross-cultural evaluation. Eur Child Adolesc Psychiatry 2017; 26:979-992. [PMID: 28275895 DOI: 10.1007/s00787-017-0968-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 02/21/2017] [Indexed: 01/20/2023]
Abstract
Children with autism spectrum conditions (ASC) experience difficulties recognizing others' emotions and mental states. It has been shown that serious games (SG) can produce simplified versions of the socio-emotional world. The current study performed a cross-cultural evaluation (in the UK, Israel and Sweden) of Emotiplay's SG, a system aimed to teach emotion recognition (ER) to children with ASC in an entertaining, and intrinsically motivating way. Participants were 6-9 year olds with high functioning ASC who used the SG for 8-12 weeks. Measures included face, voice, body, and integrative ER tasks, as well as parent-reported level of autism symptoms, and adaptive socialization. In the UK, 15 children were tested before and after using the SG. In Israel (n = 38) and Sweden (n = 36), children were randomized into a SG or a waiting list control group. In the UK, results revealed that 8 weeks of SG use significantly improved participants' performance on ER body language and integrative tasks. Parents also reported their children improved their adaptive socialization. In Israel and Sweden, participants using the SG improved significantly more than controls on all ER measures. In addition, parents in the Israeli SG group reported their children showed reduced autism symptoms after using the SG. In conclusion, Emotiplay's SG is an effective and motivating psycho-educational intervention, cross-culturally teaching ER from faces, voices, body language, and their integration in context to children with high functioning ASC. Local evidence was found for more generalized gains to socialization and reduced autism symptoms.
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28
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Wartolowska KA, Gerry S, Feakins BG, Collins GS, Cook J, Judge A, Carr AJ. A meta-analysis of temporal changes of response in the placebo arm of surgical randomized controlled trials: an update. Trials 2017; 18:323. [PMID: 28701195 PMCID: PMC5508709 DOI: 10.1186/s13063-017-2070-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/27/2017] [Indexed: 12/04/2022] Open
Abstract
Background Temporal changes in the placebo arm of randomized controlled trials (RCTs) have not been thoroughly investigated, despite the fact that results of RCTs depend on the comparison between arms. Methods In this update of our earlier systematic review and meta-analysis, we set out to investigate the effect of assessment time and number of visits on the magnitude of change from baseline in the placebo arm of these trials. We used linear mixed-effects models to account for within-trial correlations. Results Across all 47 trials the magnitude of response in the placebo arm did not change with time (β = -0.0070, 95% CI -0.024, 0.010) or visit (β = -0.033, 95% CI -0.082, 0.017) and remained significantly different from baseline for at least 12 months or seven follow-up visits. Change in the placebo arm in trials with subjective outcomes was large (β0 = 0.68, 95% CI 0.53, 0.82) and relatively constant across time (β = -0.0042, 95% CI -0.024, 0.016) and visit (β = -0.029, 95% CI -0.089, 0.031), whereas in trials with objective outcomes the response was smaller (β0 = 0.28, 95% CI 0.11, 0.46) and diminished with time (β = -0.030, 95% CI -0.050, -0.010), but not with visit (β = -0.099, 95% CI -0.30, 0.11). For trials with assessed outcomes, there was no significant effect of time (β = -0.0071, 95% CI -0.026, 0.011) or visit (β = -0.032, 95% CI -0.33, 0.26); however, these results should be interpreted with caution due to the small number of studies, and high clinical heterogeneity between studies. In trials with pain as an outcome, the improvement was significant (β0 = 0.91, 95% CI 0.75, 1.07), but there was no effect of time (β = -0.013, 95% CI -0.06, 0.03) or visit (β = -0.045, 95% CI -0.16, 0.069), and pain ratings remained significantly different from baseline for 12 months or seven visits. Conclusions These results are consistent with our previous findings. In trials with subjective outcomes response in the placebo arm remains large and relatively constant for at least a year, which is interesting considering that this is an effect of a single application of an invasive procedure. The lack of effect of time and visit number on subjective outcomes raises further questions regarding whether the observed response is the result of placebo effect or the result of bias. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2070-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karolina A Wartolowska
- NIHR Oxford Musculoskeletal Biomedical Research Unit, Old Road, OX3 7LD, Oxford, UK. .,Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, OX3 7LD, Oxford, UK.
| | - Stephen Gerry
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, OX3 7LD, Oxford, UK.,Centre for Statistics in Medicine, University of Oxford, Windmill Road, OX3 7LD, Oxford, UK
| | - Benjamin G Feakins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, OX2 6GG, Oxford, UK
| | - Gary S Collins
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, OX3 7LD, Oxford, UK.,Centre for Statistics in Medicine, University of Oxford, Windmill Road, OX3 7LD, Oxford, UK
| | - Jonathan Cook
- NIHR Oxford Musculoskeletal Biomedical Research Unit, Old Road, OX3 7LD, Oxford, UK.,Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, OX3 7LD, Oxford, UK
| | - Andrew Judge
- NIHR Oxford Musculoskeletal Biomedical Research Unit, Old Road, OX3 7LD, Oxford, UK.,Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, OX3 7LD, Oxford, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, University Road, SO17 1BJ, Southampton, UK
| | - Andrew J Carr
- NIHR Oxford Musculoskeletal Biomedical Research Unit, Old Road, OX3 7LD, Oxford, UK.,Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Road, OX3 7LD, Oxford, UK
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29
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Burkart TL, Kraus A, Koller B, Natalucci G, Latal B, Fauchère JC, Bucher HU, Rüegger CM. Placebo by Proxy in Neonatal Randomized Controlled Trials: Does It Matter? CHILDREN-BASEL 2017; 4:children4060043. [PMID: 28556820 PMCID: PMC5483618 DOI: 10.3390/children4060043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/19/2017] [Accepted: 05/24/2017] [Indexed: 12/12/2022]
Abstract
Placebo effects emerging from the expectations of relatives, also known as placebo by proxy, have seldom been explored. The aim of this study was to investigate whether in a randomized controlled trial (RCT) there is a clinically relevant difference in long-term outcome between very preterm infants whose parents assume that verum (PAV) had been administered and very preterm infants whose parents assume that placebo (PAP) had been administered. The difference between the PAV and PAP infants with respect to the primary outcome–IQ at 5 years of age–was considered clinically irrelevant if the confidence interval (CI) for the mean difference resided within our pre-specified ±5-point equivalence margins. When adjusted for the effects of verum/placebo, socioeconomic status (SES), head circumference and sepsis, the CI was [−3.04, 5.67] points in favor of the PAV group. Consequently, our study did not show equivalence between the PAV and PAP groups, with respect to the pre-specified margins of equivalence. Therefore, our findings suggest that there is a small, but clinically irrelevant degree to which a preterm infant’s response to therapy is affected by its parents’ expectations, however, additional large-scale studies are needed to confirm this conjecture.
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Affiliation(s)
- Tiziana L Burkart
- Department of Neonatology, University Hospital Zürich, 8091 Zürich, Switzerland.
| | - Andrea Kraus
- Department of Mathematics and Statistics, Masaryk University, 611 37 Brno, Czech Republic.
| | - Brigitte Koller
- Department of Neonatology, University Hospital Zürich, 8091 Zürich, Switzerland.
| | - Giancarlo Natalucci
- Department of Neonatology, University Hospital Zürich, 8091 Zürich, Switzerland.
- Child Development Centre, University Children's Hospital, 8032 Zürich, Switzerland.
| | - Beatrice Latal
- Child Development Centre, University Children's Hospital, 8032 Zürich, Switzerland.
| | - Jean-Claude Fauchère
- Department of Neonatology, University Hospital Zürich, 8091 Zürich, Switzerland.
| | - Hans Ulrich Bucher
- Department of Neonatology, University Hospital Zürich, 8091 Zürich, Switzerland.
| | - Christoph M Rüegger
- Department of Neonatology, University Hospital Zürich, 8091 Zürich, Switzerland.
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Jensen KB, Kirsch I, Pontén M, Rosén A, Yang K, Gollub RL, des Portes V, Kaptchuk TJ, Curie A. Certainty of genuine treatment increases drug responses among intellectually disabled patients. Neurology 2017; 88:1912-1918. [PMID: 28424273 PMCID: PMC5444309 DOI: 10.1212/wnl.0000000000003934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 02/28/2017] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine the placebo component of treatment responses in patients with intellectual disability (ID). Methods: A statistical meta-analysis comparing bias-corrected effect sizes (Hedges g) of drug responses in open-label vs placebo-controlled clinical trials was performed, as these trial types represent different certainty of receiving genuine treatment (100% vs 50%). Studies in fragile X, Down, Prader-Willi, and Williams syndrome published before June 2015 were considered. Results: Seventeen open-label trials (n = 261, 65% male; mean age 23.6 years; mean trial duration 38 weeks) and 22 placebo-controlled trials (n = 721, 62% male; mean age 17.1 years; mean trial duration 35 weeks) were included. The overall effect size from pre to post treatment in open-label studies was g = 0.602 (p = 0.001). The effect of trial type was statistically significant (p = 0.001), and revealed higher effect sizes in studies with 100% likelihood of getting active drug, compared to both the drug and placebo arm of placebo-controlled trials. We thus provide evidence for genuine placebo effects, not explainable by natural history or regression toward the mean, among patients with ID. Conclusions: Our data suggest that clinical trials in patients with severe cognitive deficits are influenced by the certainty of receiving genuine medication, and open-label design should thus not be used to evaluate the effect of pharmacologic treatments in ID, as the results will be biased by an enhanced placebo component.
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Affiliation(s)
- Karin B Jensen
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France.
| | - Irving Kirsch
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Moa Pontén
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Annelie Rosén
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Kathy Yang
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Randy L Gollub
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Vincent des Portes
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Ted J Kaptchuk
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
| | - Aurore Curie
- From the Department of Clinical Neuroscience (K.B.J., M.P., A.R.), Karolinska Institute, Sweden; Program in Placebo Studies (I.K., T.J.K.), BIDMC, Harvard Medical School; Department of Psychiatry (K.Y., R.L.G.), Massachusetts General Hospital, Boston; Institut des Sciences Cognitives (V.d.P., A.C.), Bron; Université Claude Bernard Lyon 1 (V.d.P., A.C.); Centre de Référence Déficiences Intellectuelles de Causes Rares (V.d.P., A.C.), Hôpital Femmes Mères Enfants, Hospices Civils de Lyon; and EPICIME-CIC1407/INSERM (A.C.), Bron, France
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Chavarria V, Vian J, Pereira C, Data-Franco J, Fernandes BS, Berk M, Dodd S. The Placebo and Nocebo Phenomena: Their Clinical Management and Impact on Treatment Outcomes. Clin Ther 2017; 39:477-486. [PMID: 28237673 DOI: 10.1016/j.clinthera.2017.01.031] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/25/2017] [Accepted: 01/30/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE This overview focuses on placebo and nocebo effects in clinical trials and routine care. Our goal was to propose strategies to improve outcomes in clinical practice, maximizing placebo effects and reducing nocebo effects, as well as managing these phenomena in clinical trials. METHODS A narrative literature search of PubMed was conducted (January 1980-September 2016). Systematic reviews, randomized controlled trials, observational studies, and case series that had an emphasis on placebo or nocebo effects in clinical practice were included in the qualitative synthesis. Search terms included: placebo, nocebo, clinical, clinical trial, clinical setting, placebo effect, nocebo effect, adverse effects, and treatment outcomes. This search was augmented by a manual search of the references of the key articles and the related literature. FINDINGS Placebo and nocebo effects are psychobiological events imputable to the therapeutic context. Placebo is defined as an inert substance that provokes perceived benefits, whereas the term nocebo is used when an inert substance causes perceived harm. Their major mechanisms are expectancy and classical conditioning. Placebo is used in several fields of medicine, as a diagnostic tool or to reduce drug dosage. Placebo/nocebo effects are difficult to disentangle from the natural course of illness or the actual effects of a new drug in a clinical trial. There are known strategies to enhance clinical results by manipulating expectations and conditioning. IMPLICATIONS Placebo and nocebo effects occur frequently and are clinically significant but are underrecognized in clinical practice. Physicians should be able to recognize these phenomena and master tactics on how to manage these effects to enhance the quality of clinical practice.
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Affiliation(s)
- Victor Chavarria
- Institut de Neuropsiquiatria i Adiccions (INAD), Parc de salut Mar (PSM), Barcelona, Spain
| | - João Vian
- Psychiatry and Mental Health Department, Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Círia Pereira
- Psychiatry and Mental Health Department, Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - João Data-Franco
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal; Departamento de Psiquiatria e Saúde Mental, Hospital Beatriz Ângelo, Lisboa, Portugal
| | - Brisa S Fernandes
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia; Laboratory of Calcium Binding Proteins in the Central Nervous System, Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia; University Hospital Geelong, Barwon Health, Geelong, VIC Australia; Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia; Centre for Youth Mental Health, Parkville, VIC, Australia; Florey Institute, University of Melbourne, Parkville, VIC, Australia
| | - Seetal Dodd
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia; University Hospital Geelong, Barwon Health, Geelong, VIC Australia; Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia; Centre for Youth Mental Health, Parkville, VIC, Australia.
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32
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Is the perceived placebo effect comparable between adults and children? A meta-regression analysis. Pediatr Res 2017; 81:11-17. [PMID: 27648807 DOI: 10.1038/pr.2016.181] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/15/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND A potential larger perceived placebo effect in children compared with adults could influence the detection of the treatment effect and the extrapolation of the treatment benefit from adults to children. This study aims to explore this potential difference, using a meta-epidemiological approach. METHODS A systematic review of the literature was done to identify trials included in meta-analyses evaluating a drug intervention with separate data for adults and children. The standardized mean change and the proportion of responders (binary outcomes) were used to calculate the perceived placebo effect. A meta-regression analysis was conducted to test for the difference between adults and children of the perceived placebo effect. RESULTS For binary outcomes, the perceived placebo effect was significantly more favorable in children compared with adults (β = 0.13; P = 0.001). Parallel group trials (β = -1.83; P < 0.001), subjective outcomes (β = -0.76; P < 0.001), and the disease type significantly influenced the perceived placebo effect. CONCLUSION The perceived placebo effect is different between adults and children for binary outcomes. This difference seems to be influenced by the design, the disease, and outcomes. Calibration of new studies for children should consider cautiously the placebo effect in children.
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Alvares GA, Quintana DS, Whitehouse AJ. Beyond the hype and hope: Critical considerations for intranasal oxytocin research in autism spectrum disorder. Autism Res 2016; 10:25-41. [DOI: 10.1002/aur.1692] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 08/03/2016] [Accepted: 08/11/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Gail A. Alvares
- Telethon Kids Institute; The University of Western Australia; Perth Western Australia Australia
- Cooperative Research Centre for Living with Autism (Autism CRC); Long Pocket Brisbane, Queensland Australia
| | - Daniel S. Quintana
- NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction; Oslo University Hospital, University of Oslo; Oslo Norway
| | - Andrew J.O. Whitehouse
- Telethon Kids Institute; The University of Western Australia; Perth Western Australia Australia
- Cooperative Research Centre for Living with Autism (Autism CRC); Long Pocket Brisbane, Queensland Australia
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