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Devinsky O, Hyland K, Loftus R, Nortvedt C, Nabbout R. Placebo response in patients with Dravet syndrome: Post-hoc analysis of two clinical trials. Epilepsy Behav 2024; 156:109805. [PMID: 38677101 DOI: 10.1016/j.yebeh.2024.109805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Dravet syndrome is a rare, early childhood-onset epileptic and developmental encephalopathy. Responses to placebo in clinical trials for epilepsy therapies range widely, but factors influencing placebo response remain poorly understood. This study explored placebo response and its effects on safety, efficacy, and quality of life outcomes in patients with Dravet syndrome. METHODS We performed exploratory post-hoc analyses of pooled data from placebo-treated patients from the GWPCARE 1B and GWPCARE 2 randomized controlled phase III trials, comparing cannabidiol and matched placebo in 2-18 year old Dravet syndrome patients. All patients had ≥4 convulsive seizures during a baseline period of 4 weeks. RESULTS 124 Dravet syndrome-treated patients were included in the analysis (2-5 years: n = 35; 6-12 years: n = 52; 13-18 years: n = 37). Convulsive seizures were experienced by all placebo group patients at all timepoints, with decreased median convulsive seizure frequency during the treatment period versus baseline; the number of convulsive seizure-free days was similar to baseline. Convulsive seizure frequency had a nominally significant positive correlation with age and a nominally significant negative correlation with body mass index. Most placebo-treated patients experienced a treatment-emergent adverse event; however, most resolved quickly, and serious adverse events were infrequent. Placebo treatment had very little effect on reported Caregiver Global Impression of Change outcomes versus baseline. INTERPRETATION Placebo had little impact on convulsive seizure-free days and Caregiver Global Impression of Change versus baseline, suggesting that these metrics may help differentiate placebo and active treatment effects in future studies. However, future research should further assess placebo responses to confirm these results.
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Affiliation(s)
- Orrin Devinsky
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | | | | | | | - Rima Nabbout
- Department of Pediatric Neurology, Necker Enfants Malades Hospital, APHP, Reference Centre for Rare Epilepsies and Member of the ERN EpiCARE, Imagine Institute UMR1163, Université Paris Cité, Paris, France
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Amminger GP, Rice S, Davey CG, Quinn AL, Hermens DF, Zmicerevska N, Nichles A, Hickie I, Incerti L, Weller A, Joseph S, Hilton Z, Pugh C, Rayner M, Reid N, Ratheesh A, Yung AR, Yuen HP, Mackinnon A, Hetrick S, Parker A, Street R, Berger M, Berk M, McGorry PD, Lin A. The Addition of Fish Oil to Cognitive Behavioral Case Management for Youth Depression: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Clinical Trial. Biol Psychiatry 2024; 95:426-433. [PMID: 37355004 DOI: 10.1016/j.biopsych.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Clinical trials suggest that long-chain omega-3 polyunsaturated fatty acids (n-3 PUFAs) (fish oil) may reduce depressive symptoms in adults with major depressive disorder. Therefore, n-3 PUFAs may be a potential treatment for depression in youth. METHODS Participants were 15- to-25 year-old individuals with major depressive disorder who sought care in one of three government-funded mental health services for young people in metropolitan Melbourne, Perth, or Sydney, Australia. Participants were randomly assigned in a double-blind, parallel-arm design to receive either fish oil (840 mg of eicosapentaenoic acid and 560 mg of docosahexaenoic acid) or placebo capsules as adjunct to cognitive behavioral case management. All participants were offered 50-minute cognitive behavioral case management sessions every 2 weeks delivered by qualified therapists (treatment as usual) at the study sites during the intervention period. The primary outcome was change in the interviewer-rated Quick Inventory of Depressive Symptomatology, Adolescent Version, score at 12 weeks. Erythrocyte n-3 PUFA levels were assessed pre-post intervention. RESULTS A total of 233 young people were randomized to the treatment arms: 115 participants to the n-3 PUFA group and 118 to the placebo group. Mean change from baseline in the Quick Inventory of Depressive Symptomatology score was -5.8 in the n-3 PUFA group and -5.6 in the placebo group (mean difference, 0.2; 95% CI, -1.1 to 1.5; p = .75). Erythrocyte PUFA levels were not associated with depression severity at any time point. The incidence and severity of adverse events were similar in the two groups. CONCLUSIONS This placebo-controlled trial and biomarker analysis found no evidence to support the use of fish oil for treatment in young people with major depressive disorder.
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Affiliation(s)
- G Paul Amminger
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia.
| | - Simon Rice
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher G Davey
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Amelia L Quinn
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel F Hermens
- Thompson Institute, University of the Sunshine Coast, Birtinya, Queensland, Australia
| | - Natalia Zmicerevska
- Youth Mental Health Team, Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Alissa Nichles
- Youth Mental Health Team, Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Ian Hickie
- Youth Mental Health Team, Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Lisa Incerti
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Amber Weller
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Sarah Joseph
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Zarah Hilton
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Charlotte Pugh
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Madeline Rayner
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Nate Reid
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Aswin Ratheesh
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Alison R Yung
- Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Victoria, Australia
| | - Hok Pan Yuen
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Mackinnon
- Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Sarah Hetrick
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Alexandra Parker
- Institute for Health and Sport, Victoria University, Melbourne, Victoria, Australia
| | - Rebekah Street
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Maximus Berger
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Michael Berk
- Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Victoria, Australia
| | - Patrick D McGorry
- Orygen, Melbourne, Victoria, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Ashleigh Lin
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
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Singh MK, Gorelik AJ, Stave C, Gotlib IH. Genetics, epigenetics, and neurobiology of childhood-onset depression: an umbrella review. Mol Psychiatry 2023:10.1038/s41380-023-02347-x. [PMID: 38102485 DOI: 10.1038/s41380-023-02347-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023]
Abstract
Depression is a serious and persistent psychiatric disorder that commonly first manifests during childhood. Depression that starts in childhood is increasing in frequency, likely due both to evolutionary trends and to increased recognition of the disorder. In this umbrella review, we systematically searched the extant literature for genetic, epigenetic, and neurobiological factors that contribute to a childhood onset of depression. We searched PubMed, EMBASE, OVID/PsychInfo, and Google Scholar with the following inclusion criteria: (1) systematic review or meta-analysis from a peer-reviewed journal; (2) inclusion of a measure assessing early age of onset of depression; and (3) assessment of neurobiological, genetic, environmental, and epigenetic predictors of early onset depression. Findings from 89 systematic reviews of moderate to high quality suggest that childhood-onset depressive disorders have neurobiological, genetic, environmental, and epigenetic roots consistent with a diathesis-stress theory of depression. This review identified key putative markers that may be targeted for personalized clinical decision-making and provide important insights concerning candidate mechanisms that might underpin the early onset of depression.
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Saito T, Takahashi H, Tsujii N, Sasaki T, Yamaguchi Y, Takatsu M, Sato M. Efficacy of Preventing Relapse Evaluated by a Multicenter Randomized Double-Blind Placebo-Controlled Withdrawal Study of Escitalopram in Japanese Adolescents with Major Depressive Disorder. J Child Adolesc Psychopharmacol 2023; 33:418-427. [PMID: 38055198 PMCID: PMC10733774 DOI: 10.1089/cap.2023.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Objective: To evaluate the efficacy and safety of escitalopram (ESC) in a 48-week relapse prevention study in Japanese adolescents with major depressive disorder (MDD). Methods: This was a 48-week multicenter randomized double-blind placebo-controlled parallel-group study of patients aged 12-17 years with MDD. Patients received ESC for 12 weeks as an open-label treatment period (open-label period). Patients who achieved criteria for remission or response in the open-label period received either ESC or placebo for 36 weeks as a double-blind treatment period (double-blind period). The primary endpoint was the time to relapse during the double-blind period. Safety was evaluated in terms of type, incidence, and severity of adverse events. Results: Of the 128 patients who entered the open-label period, 80 patients entered the double-blind period, all of whom were in the primary analysis population. The primary endpoint, time to relapse, was marginally less than statistically significant between the ESC and placebo groups (p = 0.051, log-rank test). In the Cox proportional hazards model, the estimated hazard ratio [two-sided 95% confidence interval] for relapse in the placebo group versus the ESC group was 2.96 [0.94, 9.30]. There were statistically significant differences between the ESC and placebo groups in several secondary endpoints (change in Children's Depression Rating Scale-Revised, change in Clinical Global Impressions-Severity Scale, etc.). No notable safety/tolerability issues were observed in this study compared with the results of studies in Japanese adults with MDD. Conclusions: Superiority of ESC over placebo for relapse prevention in Japanese adolescents aged 12-17 years with MDD could not be verified with time to relapse evaluated by log-rank test. However, secondary endpoint results and a post hoc analysis of time to relapse suggest that ESC may be effective in preventing MDD relapse. No notable safety/tolerability issues were observed compared with the results of studies in Japanese adults with MDD. Study Registry Number: jRCT2080224520.
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Affiliation(s)
- Takuya Saito
- Department of Child and Adolescent Psychiatry, Hokkaido University Hospital, Sapporo, Japan
| | - Hidetoshi Takahashi
- Kochi Medical School Department of Child and Adolescent Psychiatry, Kochi University, Kochi, Japan
| | - Noa Tsujii
- Department of Child Mental Health and Development, Toyama University Hospital, Toyama, Japan
| | - Tsuyoshi Sasaki
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
| | | | | | - Masaki Sato
- Mochida Pharmaceutical Co., LTD., Shinjuku-ku, Japan
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Okubo R, Matsui K, Narukawa M. Factors Related to Placebo Response in Randomized, Double-Blind Clinical Trials of Antidepressants in Children and Adolescents: A Meta-regression Analysis. Clin Drug Investig 2023:10.1007/s40261-023-01273-8. [PMID: 37222973 DOI: 10.1007/s40261-023-01273-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Many randomized clinical trials (RCTs) for antidepressants in children and adolescents have failed to demonstrate efficacy due to a high placebo response. The aim of this study was to identify the potential factors affecting placebo response using meta-regression analysis of RCTs for antidepressants in children and adolescents using the Children's Depressive Rating Scale-Revised (CDRS-R) as the outcome. METHODS PubMed and ClinicalTrials.gov were searched for randomized, double-blind, placebo-controlled trials of antidepressants for the acute treatment of major depressive disorder in children and adolescents. The outcome used in the present study was the mean change of the CDRS-R total score from baseline to the last assessment for the primary efficacy in the placebo arm. Potential factors related to the placebo response, such as study design, operational, and patient factors, were explored using meta-regression. RESULTS The analyses included 23 trials. On multivariable meta-regression, setting up a placebo lead-in period was significantly associated with a smaller placebo response in the CDRS-R. CONCLUSION Setting up a placebo lead-in period should be considered in future clinical trials of antidepressants in adolescents and children.
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Affiliation(s)
- Risa Okubo
- Department of Clinical Medicine (Pharmaceutical Medicine), Graduate School of Pharmaceutical Sciences, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan.
| | - Kazuhiro Matsui
- Department of Clinical Medicine (Pharmaceutical Medicine), Graduate School of Pharmaceutical Sciences, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
| | - Mamoru Narukawa
- Department of Clinical Medicine (Pharmaceutical Medicine), Graduate School of Pharmaceutical Sciences, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Motta LS, Gosmann NP, Costa MDA, Jaeger MDB, Frozi J, Grevet LT, Spanemberg L, Manfro GG, Cuijpers P, Pine DS, Salum G. Placebo response in trials with patients with anxiety, obsessive-compulsive and stress disorders across the lifespan: a three-level meta-analysis. BMJ Ment Health 2023; 26:e300630. [PMID: 37142305 PMCID: PMC10163479 DOI: 10.1136/bmjment-2022-300630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/07/2023] [Indexed: 05/06/2023]
Abstract
QUESTION Randomised controlled trials assessing treatments for anxiety, obsessive-compulsive and stress-related disorders often present high placebo response rates in placebo groups. Understanding the placebo response is essential in accurately estimating the benefits of pharmacological agents; nevertheless, no studies have evaluated the placebo response across these disorders using a lifespan approach. STUDY SELECTION AND ANALYSIS We searched MEDLINE, PsycINFO, Embase, Cochrane, websites of regulatory agencies and international registers from inception to 9 September 2022. The primary outcome was the aggregate measure of internalising symptoms of participants in the placebo arms of randomised controlled trials designed to assess the efficacy of selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) in individuals diagnosed with anxiety, obsessive-compulsive or stress-related disorders. The secondary outcomes were placebo response and remission rates. Data were analysed through a three-level meta-analysis. FINDINGS We analysed 366 outcome measures from 135 studies (n=12 583). We found a large overall placebo response (standardised mean difference (SMD)=-1.11, 95% CI -1.22 to -1.00). The average response and remission rates in placebo groups were 37% and 24%, respectively. Larger placebo response was associated with a diagnosis of generalised anxiety disorder and post-traumatic stress disorder, when compared with panic, social anxiety and obsessive-compulsive disorder (SMD range, 0.40-0.49), and with absence of a placebo lead-in period (SMD=0.44, 95% CI 0.10 to 0.78). No significant differences were found in placebo response across age groups. We found substantial heterogeneity and moderate risk of bias. CONCLUSIONS Placebo response is substantial in SSRI and SNRI trials for anxiety, obsessive-compulsive and stress-related disorders. Clinicians and researchers should accurately interpret the benefits of pharmacological agents in contrast to placebo response. PROSPERO REGISTRATION NUMBER CRD42017069090.
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Affiliation(s)
- Luis Souza Motta
- Section of Negative Affect and Social Processes, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Natan Pereira Gosmann
- Section of Negative Affect and Social Processes, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Postgraduate Program in Psychiatry and Behavioral Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anxiety Disorders Outpatient Program, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marianna de Abreu Costa
- Anxiety Disorders Outpatient Program, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marianna de Barros Jaeger
- Anxiety Disorders Outpatient Program, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Júlia Frozi
- Section of Negative Affect and Social Processes, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura Tietzmann Grevet
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Lucas Spanemberg
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gisele Gus Manfro
- Postgraduate Program in Psychiatry and Behavioral Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anxiety Disorders Outpatient Program, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Daniel Samuel Pine
- Emotion and Development Branch, Section on Development and Affective Neuroscience, National Institute of Mental Health, Bethesda, Maryland, USA
| | - Giovanni Salum
- Section of Negative Affect and Social Processes, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Postgraduate Program in Psychiatry and Behavioral Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- National Institute of Developmental Psychiatry for Children and Adolescents (INCT-CNPq), São Paulo, Brazil
- Child Mind Institute, New York, New York, USA
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Jacob S, Anagnostou E, Hollander E, Jou R, McNamara N, Sikich L, Tobe R, Murphy D, McCracken J, Ashford E, Chatham C, Clinch S, Smith J, Sanders K, Murtagh L, Noeldeke J, Veenstra-VanderWeele J. Large multicenter randomized trials in autism: key insights gained from the balovaptan clinical development program. Mol Autism 2022; 13:25. [PMID: 35690870 PMCID: PMC9188723 DOI: 10.1186/s13229-022-00505-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/31/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Autism spectrum disorder (ASD) is a common and heterogeneous neurodevelopmental condition that is characterized by the core symptoms of social communication difficulties and restricted and repetitive behaviors. At present, there is an unmet medical need for therapies to ameliorate these core symptoms in order to improve quality of life of autistic individuals. However, several challenges are currently faced by the ASD community relating to the development of pharmacotherapies, namely in the conduct of clinical trials. Balovaptan is a V1a receptor antagonist that has been investigated to improve social communication difficulties in individuals with ASD. In this viewpoint, we draw upon our recent first-hand experiences of the balovaptan clinical development program to describe current challenges of ASD trials. DISCUSSION POINTS The balovaptan trials were conducted in a wide age range of individuals with ASD with the added complexities associated with international trials. When summarizing all three randomized trials of balovaptan, a placebo response was observed across several outcome measures. Placebo response was predicted by greater baseline symptom severity, online recruitment of participants, and less experienced or non-academic trial sites. We also highlight challenges relating to selection of outcome measures in ASD, the impact of baseline characteristics, and the role of expectation bias in influencing trial results. CONCLUSION Taken together, the balovaptan clinical development program has advanced our understanding of the key challenges facing ASD treatment research. The insights gained can be used to inform and improve the design of future clinical trials with the collective aim of developing efficacious therapies to support individuals with ASD.
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Affiliation(s)
- Suma Jacob
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA.
| | - Evdokia Anagnostou
- Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Eric Hollander
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, New York, NY, USA
| | - Roger Jou
- Child Study Center, Yale School of Medicine, New Haven, CT, USA
| | - Nora McNamara
- Department of Psychiatry, University Hospitals, Cleveland, OH, USA
| | - Linmarie Sikich
- Department of Psychiatry and Behavioral Sciences, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Russell Tobe
- Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| | | | - James McCracken
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | | | | | - Janice Smith
- F. Hoffmann-La Roche Ltd, Welwyn Garden City, UK
| | - Kevin Sanders
- F. Hoffmann-La Roche Ltd, Genentech, South San Francisco, CA, USA
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Masi G. Controversies In The Pharmacotherapy Of Adolescent Depression. Curr Pharm Des 2022; 28:1975-1984. [PMID: 35619257 DOI: 10.2174/1381612828666220526150153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although fluoxetine and, in the USA, escitalopram are approved for depression in adolescence, substantial concern surrounds antidepressant use in youth. Major controversies regarding efficacy and safety (increased suicidality). INTRODUCTION The cathegory of depression is very broad and overinclusive, in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity, not fully controlled considered in Randomized Controlled Trials (RCTs), may account for the disappointing results on both efficacy and safety. METHOD Based on the available literature, we will address the following topics: a) controversies regarding the definition of depression as a unique homogeneous condition with a unique type of pharmacological treatment; b) controversies about the interpretation of data from Randomized Controlled Trials (RCTs) on the efficacy of pharmacological treatments in adolescent depression; c) the interpretation of data regarding the safety of antidepressant treatment in adolescent depression, particularly in terms of increased suicidal risk. RESULTS According to RCTs, antidepressants are minimally to moderately more effective than placebo, principally based on very high placebo responses, and only fluoxetine showed more evidence of efficacy. These differences in meta-analyses are sometimes statistically, but not clinically significant. Depression is a heterogeneous condition in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity may partly explain the low drug-placebo difference and the high placebo response (possibly related to a high level of natural recovery of the adolescent depression). In the National Institute of Mental Health (NIMH)-funded studies, including a lower number of study sites and more reliable enrollment procedures, lower placebo response rates and greater group differences between medication and placebo were found. Robust evidence supports an increased risk of emergent suicidality after starting antidepressants. A clear age effect on suicidal risk after antidepressants is supported by a comprehensive meta-analysis, showing that suicidal risk increased with decreasing age, being markedly greater in subjects aged between 18 and 25 years. However, the term suicidality is too broad, as it includes suicidal ideation, suicidal attempts, and completed suicide, with a hugely wide range of severity and pervasiveness. If emergent suicidality should be actively and carefully explored, empirical evidence, albeit weak, suggests that combined pharmacotherapy (antidepressant and/or lithium) associated with psychotherapy may be helpful in reducing pretreatment suicidal ideation and suicidal risk. DISCUSSION Moderate to severe depression should be treated with psychotherapy and/or fluoxetine, the best-supported medication, and treatment-resistant adolescents should always receive combined treatment with psychotherapy. Suicidal ideation, particularly with a plan, should be actively explored before starting an antidepressant, as a reason for the closest monitoring. Emergent suicidality after starting antidepressants, as well as antidepressant-related activation, should also be closely monitored and may lead to antidepressant discontinuation. Although no response to pharmacotherapy and psychotherapy may occur in up to 40% of depressed adolescents, possible predictors or mediators of poorer response in adolescents are uncertain, and only a few studies support possible treatment strategies. Finally, studies exploring the efficacy of antidepressants in specific depression subtypes, i.e., based on prevalent psychopathological dimensions (apathy, withdrawal, impulsivity), are warranted.
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Affiliation(s)
- Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
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10
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Feeney A, Hock RS, Fava M, Hernández Ortiz JM, Iovieno N, Papakostas GI. Antidepressants in children and adolescents with major depressive disorder and the influence of placebo response: A meta-analysis. J Affect Disord 2022; 305:55-64. [PMID: 35247482 DOI: 10.1016/j.jad.2022.02.074] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/29/2021] [Accepted: 02/27/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND There are few available antidepressants for pediatric Major Depressive Disorder (MDD). The objective of this systematic review and meta-analysis was to review industry-funded studies of antidepressants in children and adolescents with MDD, and to better understand the contribution of study design and placebo response to the findings of these studies. METHODS Randomized, double-blind, placebo-controlled clinical trials that compared antidepressant with placebo for the acute treatment of MDD in children and/or adolescents were selected. Estimates of the standardized mean difference (SMD) in change in Children's Depression Rating Scale-Revised scores were pooled, after examining for heterogeneity. A random-effects meta-analysis was completed. RESULTS Thirty-four antidepressant-placebo comparisons, involving 6161 subjects, were included. The SMD among all studies was 0.12 (CI 0.08, 0.17; p < 0.001), a very small effect size, lower than that seen in studies of adults with MDD. When the meta-analysis was limited to studies with a low mean placebo response, the SMD increased to 0.19 and further increased to 0.22 when studies with at least a 50% chance of receiving placebo were included. LIMITATIONS Many studies focused on older children and younger adolescents. Our findings may not reflect antidepressant efficacy in older adolescents. CONCLUSIONS The modest SMD identified in this analysis may reflect study design factors and the application of antidepressants developed for adults to pediatric patients. Given the urgent clinical need for more pediatric MDD treatments, the influence of placebo response and the need for drug development tailored to this population should be considered in pediatric MDD trial design.
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Affiliation(s)
- Anna Feeney
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| | - Rebecca S Hock
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Maurizio Fava
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Jesús M Hernández Ortiz
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Nadia Iovieno
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - George I Papakostas
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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11
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Saito T, Ishida M, Nishiyori A, Ochiai T, Katagiri H, Matsumoto H. Efficacy and Safety of Duloxetine in Children and Adolescents with Major Depressive Disorder in Japan: A Randomized Double-Blind Placebo-Controlled Clinical Trial Followed by an Open-Label Long-Term Extension Trial. J Child Adolesc Psychopharmacol 2022; 32:132-142. [PMID: 35319270 DOI: 10.1089/cap.2021.0104] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: The goal of this study was to evaluate the efficacy and safety of duloxetine in children and adolescents (9-17 years of age) with major depressive disorder (MDD) in Japan. Methods: This study consists of two clinical trials. First, a 6-week, randomized double-blind placebo-controlled clinical trial (RCT) was conducted. The primary endpoint of RCT was the change in Children's Depression Rating Scale-Revised (CDRS-R) total scores from baseline. Following RCT, an open-label long-term extension trial (OLE) was conducted to investigate the longer-term safety of duloxetine for ∼1 year. Results: In RCT, CDRS-R total score changes from baseline to 6 weeks after the start of administration (primary endpoint) were -21.03 in the duloxetine group (n = 74) and -22.42 in the placebo group (n = 74). No significant difference was observed in the primary endpoint between the groups (p = 0.5587). In addition, no significant difference was observed in secondary endpoints such as CDRS-R response rates. The proportion of patients with ≥1 treatment-emergent adverse event (TEAE) in RCT was significantly higher in the duloxetine group (78.7%) than in the placebo group (62.2%), and most were mild or moderate in severity. Changes in CDRS-R total scores during OLE, in consecutive patients from the duloxetine group in RCT (n = 63), or placebo group (n = 59) in RCT, and newly enrolled patients (n = 28), were -12.1, -11.3, and -17.8, respectively. The proportion of patients with ≥1 TEAE in OLE was 90.5%, 88.1%, and 89.3% in the respective groups, and most of them were mild or moderate in severity. Conclusions: Duloxetine did not show superiority to placebo in efficacy in children and adolescents with MDD in Japan. Overall reported TEAEs were consistent with the currently available duloxetine safety profile and no new safety finding was observed in the two clinical trials.
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Affiliation(s)
- Takuya Saito
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Mitsuhiro Ishida
- Project Management Department, Shionogi & Co., Ltd., Osaka, Japan
| | | | | | - Hideaki Katagiri
- Neuroscience and Pain Products, Bio-Medicines and Clinical Pharmacology Medical, Japan Drug Development and Medical Affairs, Eli Lilly Japan, Kobe, Japan
| | - Hideo Matsumoto
- Department of Psychiatry, Tokai University School of Medicine, Kanagawa, Japan
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12
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Park K, Tran NK, Momper JD, Green DJ, Burckart GJ. Pediatric and Adult Placebo Response Rates in Placebo-Controlled Clinical Trials Submitted to the US FDA 2012-2020. J Clin Pharmacol 2022; 62:970-982. [PMID: 35118684 DOI: 10.1002/jcph.2035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/30/2022] [Indexed: 11/10/2022]
Abstract
The use of placebo concurrent control (placebo-controlled) is the most rigorous method of evaluating the safety and efficacy of investigational treatments. However, the use of a placebo group in pediatric product development can be challenging due to ethical considerations and potential differences in placebo response rates between adults and children. This study reports the US Food and Drug Administration's experience with placebo response rates in the pediatric population. Products studied under the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act between 2012 and 2020 were screened. Study characteristics including study type, primary efficacy endpoint(s), placebo response rates for the primary efficacy endpoint(s) and studied age range were collected. A total of 71 drug products used a placebo-controlled trial. Of these, thirteen products had an identical study design and trial characteristics including the primary efficacy endpoints between pediatric and adult studies. Fifteen products were studied in trials with identical study design but only different primary efficacy endpoints in pediatric and adult populations. Ten products had combined adolescent and adult trials with separate pediatric trials in younger age groups. In each of these cases, the pediatric placebo response was greater, for some trials, and less, for other trials, than the adult placebo response. The pediatric placebo response can vary within an age group for a drug product. Future studies should examine the factors leading to a similarity or dissimilarity in placebo response between pediatric patients and adults. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kyunghun Park
- Office of Clinical Pharmacology, Office of Translational Sciences, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Ngan K Tran
- University of Southern California, School of Pharmacy, Los Angeles, CA, USA
| | - Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | - Dionna J Green
- Office of Pediatric Therapeutics, Office of the Commissioner, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Gilbert J Burckart
- Office of Clinical Pharmacology, Office of Translational Sciences, U.S. Food and Drug Administration, Silver Spring, MD, USA
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13
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Antel J, Tan S, Grabler M, Ludwig C, Lohkemper D, Brandenburg T, Barth N, Hinney A, Libuda L, Remy M, Milos G, Hebebrand J. Rapid amelioration of anorexia nervosa in a male adolescent during metreleptin treatment including recovery from hypogonadotropic hypogonadism. Eur Child Adolesc Psychiatry 2022; 31:1573-9. [PMID: 33966118 DOI: 10.1007/s00787-021-01778-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023]
Abstract
With this case report we support our medical hypothesis that metreleptin treatment ameliorates starvation related emotional, cognitive and behavioral symptomatology of anorexia nervosa (AN) and show for the first time strong effects in a male patient with AN. A 15.9 year old adolescent with severe AN of eight-month duration was treated off-label with metreleptin. Hyperactivity was assessed with accelerometry. Visual analogue scales (VAS), validated self- and clinician rating scales and lab results tracked changes from baseline to end of the 24-day dosing period and a five-month follow-up. Substantial improvements of mood and eating disorder related cognitions and hyperactivity set in after two days of treatment. During dosing, sub-physiological testosterone and TT3 levels normalized; clinically libido reemerged. Weight did not increase substantially during the dosing period. During follow-up target weight was attained; mood did not deteriorate; hyperactivity ceased. The results substantiate the strong effects seen in female cases and underscore the need for a double-blind placebo-controlled trial to confirm the observed strong, multiple and rapid onset beneficial effects of metreleptin in AN.
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14
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Chen H, Hu X, Gao J, Han H, Wang X, Xue C. Early Effects of Repetitive Transcranial Magnetic Stimulation Combined With Sertraline in Adolescents With First-Episode Major Depressive Disorder. Front Psychiatry 2022; 13:853961. [PMID: 35928782 PMCID: PMC9343750 DOI: 10.3389/fpsyt.2022.853961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Adolescence is a period of high incidence for depression. However, there is a limited treatment option for the adolescent depression. For treatment-resistant major depressive disorder, HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) appears therapeutically effective. The aim of the study is to explore the early effects of repetitive transcranial magnetic stimulation in combination with sertraline in adolescents with first-episode major depressive disorder. METHODS A total of 100 teenage patients with first-episode depression were randomly divided into the study groups. Both groups were treated with sertraline. In addition, the study group was treated with ten sessions of add-on rTMS. The control group was given sertraline only. The depressive symptom and cognitive function were assessed by the Hamilton depression rating scale 17 version (HAMD-17), Children's Depression Rating Scale-Revised (CDRS-R), Integrated visual and auditory continuous performance test (IVA-CPT), and THINC-it. RESULTS The number of early improvers after 2 weeks of treatment in the study group was statistically significant higher compared to the control group (95.83% vs 73.47%, χ2 = 9.277, P = 0.002). There was significant difference observed in responder rates (62.50% vs. 28.57%, χ2 = 11.262, P = 0.001) or in remission rates (31.25% vs. 6.12%, χ2 = 10.130, P = 0.001) between the two groups at 4 weeks. The score of HAMD-17 and CDRS-R in the study group were significantly lower than the control group (Fgroup = 12.91 vs 10.21, P < 0.05). Attention Quotient (listening, visual and full-scale) attention quotient of IVA-CPT in the study group were higher than those in the control group after treatment, and the differences were statistically significant(P < 0.05). The study group showed higher score in Spotter than the control group after treatment (P < 0.05). DISCUSSION This is the most extensive blinded, randomized clinical study to date examining the efficacy of 10-Hz add-on rTMS for first-onset adolescent depression. Our results support that add-on rTMS accelerates the efficacy of the antidepressants, improving the depressive symptoms and cold cognitive function in first-episode adolescent depression. CLINICAL TRIAL REGISTRATION [www.ClinicalTrials.gov], identifier [ChiCTR2100048534].
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Affiliation(s)
- Haisi Chen
- Affiliated Mental Health Center and Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiwen Hu
- Affiliated Mental Health Center and Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingfang Gao
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China.,The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, China
| | - Huan Han
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaole Wang
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, China
| | - Chuang Xue
- Affiliated Mental Health Center and Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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15
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Sigrist C, Vöckel J, MacMaster FP, Farzan F, Croarkin PE, Galletly C, Kaess M, Bender S, Koenig J. Transcranial magnetic stimulation in the treatment of adolescent depression: a systematic review and meta-analysis of aggregated and individual-patient data from uncontrolled studies. Eur Child Adolesc Psychiatry 2022; 31:1501-25. [PMID: 35751003 DOI: 10.1007/s00787-022-02021-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/01/2022] [Indexed: 12/31/2022]
Abstract
Transcranial magnetic stimulation (TMS) is a non-invasive treatment for adolescent major depressive disorder (MDD). Existing evidence on the efficacy of TMS in adolescent MDD awaits quantitative synthesis. A systematic literature search was conducted, and data from eligible studies were synthesized using random-effects models. Treatment-covariate interactions were examined in exploratory analyses of individual-patient data (IPD). Systematic search of the literature yielded 1264 hits, of which 10 individual studies (2 randomized trials) were included for quantitative synthesis of mainly uncontrolled studies. Individual patient data (IPD) were available from five trials (all uncontrolled studies). Quantitative synthesis of aggregated data revealed a statistically significant negative overall standardized mean change (pooled SMCC = 2.04, 95% CI [1.46; 2.61], SE = 0.29, p < .001), as well as a significant overall treatment response rate (Transformed Proportion = 41.30%, 95% CI [31.03; 51.57], SE = 0.05; p < 0.001), considering data from baseline to post-treatment. Exploratory IPD analyses suggests TMS might be more effective in younger individuals and individuals with more severe depression, and efficacy might be enhanced with certain treatment modality settings, including higher number of TMS sessions, longer treatment durations, and unilateral and not bilateral stimulation. Existing studies exhibit methodological shortcomings, including small-study effects and lack of control group, blinding, and randomization-compromising the credibility of the present results. To date, two randomized controlled trials on TMS in adolescent depression have been published, and the only large-scale randomized trial suggests TMS is not more effective than sham stimulation. Future large-scale, randomized, and sham-controlled trials are warranted. Future trials should ensure appropriate selection of patients for TMS treatment and guide precision medicine approaches for stimulation protocols.
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16
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Crawford LS, Mills EP, Hanson T, Macey PM, Glarin R, Macefield VG, Keay KA, Henderson LA. Brainstem Mechanisms of Pain Modulation: A within-Subjects 7T fMRI Study of Placebo Analgesic and Nocebo Hyperalgesic Responses. J Neurosci 2021; 41:9794-806. [PMID: 34697093 DOI: 10.1523/JNEUROSCI.0806-21.2021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 11/21/2022] Open
Abstract
Pain perception can be powerfully influenced by an individual's expectations and beliefs. Although the cortical circuitry responsible for pain modulation has been thoroughly investigated, the brainstem pathways involved in the modulatory phenomena of placebo analgesia and nocebo hyperalgesia remain to be directly addressed. This study used ultra-high-field 7 tesla functional MRI (fMRI) to accurately resolve differences in brainstem circuitry present during the generation of placebo analgesia and nocebo hyperalgesia in healthy human participants (N = 25, 12 male). Over 2 successive days, through blinded application of altered thermal stimuli, participants were deceptively conditioned to believe that two inert creams labeled lidocaine (placebo) and capsaicin (nocebo) were acting to modulate their pain relative to a third Vaseline (control) cream. In a subsequent test phase, fMRI image sets were collected while participants were given identical noxious stimuli to all three cream sites. Pain intensity ratings were collected and placebo and nocebo responses determined. Brainstem-specific fMRI analysis revealed altered activity in key pain modulatory nuclei, including a disparate recruitment of the periaqueductal gray (PAG)-rostral ventromedial medulla (RVM) pathway when both greater placebo and nocebo effects were observed. Additionally, we found that placebo and nocebo responses differentially activated the parabrachial nucleus but overlapped in engagement of the substantia nigra and locus coeruleus. These data reveal that placebo and nocebo effects are generated through differential engagement of the PAG-RVM pathway, which in concert with other brainstem sites likely influences the experience of pain by modulating activity at the level of the dorsal horn.SIGNIFICANCE STATEMENT Understanding endogenous pain modulatory mechanisms would support development of effective clinical treatment strategies for both acute and chronic pain. Specific brainstem nuclei have long been known to play a central role in nociceptive modulation; however, because of the small size and complex organization of the nuclei, previous neuroimaging efforts have been limited in directly identifying how these subcortical networks interact during the development of antinociceptive and pro-nociceptive effects. We used ultra-high-field fMRI to resolve brainstem structures and measure signal change during placebo analgesia and nocebo hyperalgesia. We define overlapping and disparate brainstem circuitry responsible for altering pain perception. These findings extend our understanding of the detailed organization and function of discrete brainstem nuclei involved in pain processing and modulation.
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17
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Murphy SE, Capitão LP, Giles SLC, Cowen PJ, Stringaris A, Harmer CJ. The knowns and unknowns of SSRI treatment in young people with depression and anxiety: efficacy, predictors, and mechanisms of action. Lancet Psychiatry 2021; 8:824-835. [PMID: 34419187 DOI: 10.1016/s2215-0366(21)00154-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/15/2021] [Accepted: 04/01/2021] [Indexed: 01/12/2023]
Abstract
The use of SSRIs for the treatment of depression and anxiety in young people is increasing. However, the effects of SSRIs in adolescence, a time when there are substantial changes in neural, cognitive, and social functioning, are not well understood. Here, we review evidence from clinical trials about the benefits and risks of SSRIs in young people and consider their mechanisms of action, as shown through human experimental work and animal models. We emphasise key outstanding questions about the effects of SSRIs in youth, identified through gaps in the literature and in consultation with young people with lived experience. It is crucial to characterise the mechanisms underpinning risks and benefits of SSRIs in this age group to progress the field, and to narrow the chasm between the widespread use of SSRIs in youth and the science on which this use is based.
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Affiliation(s)
- Susannah E Murphy
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Liliana P Capitão
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Sophie L C Giles
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Philip J Cowen
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Argyris Stringaris
- Section of Clinical and Computational Psychiatry, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Catherine J Harmer
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.
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18
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Nestoriuc Y, Pan Y, Kinitz T, Weik E, Shedden-Mora MC. Informing About the Nocebo Effect Affects Patients' Need for Information About Antidepressants-An Experimental Online Study. Front Psychiatry 2021; 12:587122. [PMID: 33986697 PMCID: PMC8112550 DOI: 10.3389/fpsyt.2021.587122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 03/15/2021] [Indexed: 11/27/2022] Open
Abstract
Relevance: Understanding patients' informational needs and adapting drug-related information are the prerequisites for a contextualized informed consent. Current information practices might rather harm by inducing nocebo effects. Objective: To investigate whether informing about the nocebo effect using a short information sheet affects patients' need for information about antidepressants. Methods: A total of 97 patients taking recently prescribed antidepressants (≤4 months intake) were recruited over the internet and randomized to receiving either a one-page written information about the nocebo effect or a control text about the history of antidepressants. After experimental manipulation, informational needs about the side effects and mechanisms of antidepressants were assessed with 3 and 7 items on categorical and 5-point Likert scales. Group differences in informational needs were calculated with Chi-square tests and ANOVAs. Results: Patients received antidepressants for depression (84.5%) and/or anxiety disorders (42.3%). Three participants (6.0%) of the nocebo group reported previous knowledge of the nocebo effect. After the experimental manipulation, participants in the nocebo group reported a reduced desire for receiving full side effect information [X ( 4 , 97 ) 2 = 12.714, Cramer's V = 0.362, p = 0.013] and agreed more frequently to the usefulness of withholding information about possible side effects [X ( 4 , 97 ) 2 = 14.878, Cramer's V = 0.392, p = 0.005]. Furthermore, they desired more information about the mechanisms of antidepressants (F = 6.373, p = 0.013, partial η2 = 0.063) and, specifically, non-pharmacological mechanisms, such as the role of positive expectations (F = 16.857, p < 0.001, partial η2 = 0.151). Conclusions: Learning about the nocebo effect can alter patients' informational needs toward desiring less information about the potential side effects of antidepressants and more information about general mechanisms, such as expectations. The beneficial effects of including nocebo information into contextualized informed consent should be studied clinically concerning more functional information-seeking behavior, which may ultimately lead to improved treatment outcomes, such as better adherence and reduced side effect burden.
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Affiliation(s)
- Yvonne Nestoriuc
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Hamburg, Germany
- Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yiqi Pan
- Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timm Kinitz
- Neuropsychology, Westerwald Clinic, Waldbreitbach, Germany
| | - Ella Weik
- Department of Psychiatry, British Columbia Mental Health and Addictions Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Meike C. Shedden-Mora
- Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Psychology, Medical School Hamburg, Hamburg, Germany
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19
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Oberman LM, Hynd M, Nielson DM, Towbin KE, Lisanby SH, Stringaris A. Repetitive Transcranial Magnetic Stimulation for Adolescent Major Depressive Disorder: A Focus on Neurodevelopment. Front Psychiatry 2021; 12:642847. [PMID: 33927653 PMCID: PMC8076574 DOI: 10.3389/fpsyt.2021.642847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/18/2021] [Indexed: 12/31/2022] Open
Abstract
Adolescent depression is a potentially lethal condition and a leading cause of disability for this age group. There is an urgent need for novel efficacious treatments since half of adolescents with depression fail to respond to current therapies and up to 70% of those who respond will relapse within 5 years. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising treatment for major depressive disorder (MDD) in adults who do not respond to pharmacological or behavioral interventions. In contrast, rTMS has not demonstrated the same degree of efficacy in adolescent MDD. We argue that this is due, in part, to conceptual and methodological shortcomings in the existing literature. In our review, we first provide a neurodevelopmentally focused overview of adolescent depression. We then summarize the rTMS literature in adult and adolescent MDD focusing on both the putative mechanisms of action and neurodevelopmental factors that may influence efficacy in adolescents. We then identify limitations in the existing adolescent MDD rTMS literature and propose specific parameters and approaches that may be used to optimize efficacy in this uniquely vulnerable age group. Specifically, we suggest ways in which future studies reduce clinical and neural heterogeneity, optimize neuronavigation by drawing from functional brain imaging, apply current knowledge of rTMS parameters and neurodevelopment, and employ an experimental therapeutics platform to identify neural targets and biomarkers for response. We conclude that rTMS is worthy of further investigation. Furthermore, we suggest that following these recommendations in future studies will offer a more rigorous test of rTMS as an effective treatment for adolescent depression.
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20
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Henn L, Zanta NC, Girardi CEN, Suchecki D. Chronic Escitalopram Treatment Does Not Alter the Effects of Neonatal Stress on Hippocampal BDNF Levels, 5-HT 1A Expression and Emotional Behaviour of Male and Female Adolescent Rats. Mol Neurobiol 2021; 58:926-943. [PMID: 33063280 DOI: 10.1007/s12035-020-02164-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
Early life stress is considered a risk factor for the development of long-term psychiatric disorders. Maternal deprivation (MD) is a useful paradigm to understand the neurobiological underpinnings of early stress-induced changes in neurodevelopment trajectory. The goal of the present study was to examine the effects of a chronic treatment with escitalopram (ESC) on the hippocampal levels of BDNF and neuropeptide Y (NPY), expression of serotonin type 1A receptor (5-HT1A), plasma corticosterone levels and emotional behaviours in male and female adolescent rats submitted to MD at 9 days of life (group DEP9) and challenged with a brief and mild stress (saline injection (SAL)) at the end of MD. Whole litters were kept with mothers (CTL) or submitted to MD (DEP9). Within each group, pups were stress-challenged (CTL-SAL and DEP9-SAL) or not (CTL-NSAL and DEP9-NSAL). ESC or vehicle treatments began at weaning and lasted 24 days, when animals were sacrificed for determination of neurobiological variables or submitted to a battery of tests for evaluation of emotional behaviours. The results showed that BDNF levels were higher in SAL-challenged males and in DEP9-SAL females, whereas 5-HT1A receptor expression was reduced in DEP9 males and in SAL-challenged females. There were no changes in NPY or corticosterone levels. In the forced swim test, SAL-challenged males and DEP9 females displayed less immobility and ESC only increased social motivation in males. The results indicated that neonatal stress led to sex-dependent changes in neurobiology and behaviour and that chronic ESC treatment had minor effects on these parameters.
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Affiliation(s)
- Lorena Henn
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925, 1° andar, São Paulo, SP, 04024-002, Brazil
| | - Natália C Zanta
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925, 1° andar, São Paulo, SP, 04024-002, Brazil
| | - Carlos Eduardo N Girardi
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925, 1° andar, São Paulo, SP, 04024-002, Brazil
| | - Deborah Suchecki
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Rua Napoleão de Barros, 925, 1° andar, São Paulo, SP, 04024-002, Brazil.
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Hebebrand J, Antel J, Tan S, Wabitsch M, Wiesing U, Barth N, Ludwig C, Bühlmeier J, Libuda L, Milos G, Hinney A. Kurzzeitige Behandlung von Patient_innen mit Anorexia nervosa mit rekombinant hergestelltem Human-Leptin (Metreleptin): Rasch einsetzende positive Effekte auf Stimmung, Kognition und Verhalten. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie 2021; 49:1-5. [DOI: 10.1024/1422-4917/a000775] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Johannes Hebebrand
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, LVR-Klinikum, Kliniken/Institut der Universität Duisburg-Essen, Essen, Deutschland
| | - Jochen Antel
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, LVR-Klinikum, Kliniken/Institut der Universität Duisburg-Essen, Essen, Deutschland
| | - Susanne Tan
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinik Essen, Essen, Deutschland
| | - Martin Wabitsch
- Zentrum für Seltene Endokrine Erkrankungen (ZSEE), Sektion Pädiatrische Endokrinologie und Diabetologie, Universitätsklinik für Kinder- und Jugendmedizin, Ulm, Deutschland
| | - Urban Wiesing
- Institut für Ethik und Geschichte der Medizin, Universität Tübingen, Tübingen, Deutschland
| | - Nikolaus Barth
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, LVR-Klinikum, Kliniken/Institut der Universität Duisburg-Essen, Essen, Deutschland
| | - Christine Ludwig
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, LVR-Klinikum, Kliniken/Institut der Universität Duisburg-Essen, Essen, Deutschland
| | - Judith Bühlmeier
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, LVR-Klinikum, Kliniken/Institut der Universität Duisburg-Essen, Essen, Deutschland
| | - Lars Libuda
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, LVR-Klinikum, Kliniken/Institut der Universität Duisburg-Essen, Essen, Deutschland
| | - Gabriella Milos
- Klinik für Endokrinologie, Diabetologie und Stoffwechsel, Universitätsklinik Essen, Essen, Deutschland
| | - Anke Hinney
- Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, LVR-Klinikum, Kliniken/Institut der Universität Duisburg-Essen, Essen, Deutschland
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22
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Libuda L, Timmesfeld N, Antel J, Hirtz R, Bauer J, Führer D, Zwanziger D, Öztürk D, Langenbach G, Hahn D, Ring S, Peters T, Hinney A, Bühlmeier J, Hebebrand J, Grasemann C, Föcker M. Effect of vitamin D deficiency on depressive symptoms in child and adolescent psychiatric patients: results of a randomized controlled trial. Eur J Nutr 2020; 59:3415-3424. [PMID: 32108263 PMCID: PMC7669774 DOI: 10.1007/s00394-020-02176-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/03/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE While observational studies revealed inverse associations between serum vitamin D levels [25(OH)D] and depression, randomized controlled trials (RCT) in children and adolescents are lacking. This RCT examined the effect of an untreated vitamin D deficiency compared to an immediate vitamin D3 supplementation on depression scores in children and adolescents during standard day and in-patient psychiatric treatment. METHODS Patients with vitamin D deficiency [25(OH)D ≤ 30 nmol/l] and at least mild depression [Beck Depression Inventory II (BDI-II) > 13] (n = 113) were 1:1 randomized into verum (VG; 2640 IU vitamin D3/d) or placebo group (PG) in a double-blind manner. During the intervention period of 28 days, both groups additionally received treatment as usual. BDI-II scores were assessed as primary outcome, DISYPS-II (Diagnostic System for Mental Disorders in Childhood and Adolescence, Self- and Parent Rating) and serum total 25(OH)D were secondary outcomes. RESULTS At admission, 49.3% of the screened patients (n = 280) had vitamin D deficiency. Although the intervention led to a higher increase of 25(OH)D levels in the VG than in the PG (treatment difference: + 14 ng/ml; 95% CI 4.86-23.77; p = 0.003), the change in BDI-II scores did not differ (+ 1.3; 95% CI - 2.22 to 4.81; p = 0.466). In contrast, DISYPS parental ratings revealed pronounced improvements of depressive symptoms in the VG (- 0.68; 95% CI - 1.23 to - 0.13; p = 0.016). CONCLUSION Whereas this study failed to show a vitamin D supplementation effect on self-rated depression in adolescent in- or daycare patients, parents reported less depressive symptoms in VG at the end of our study. Future trials should consider clinician-rated depressive symptoms as primary outcome. TRIAL REGISTRATION "German Clinical Trials Register" ( https://www.drks.de ), registration number: DRKS00009758.
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Affiliation(s)
- Lars Libuda
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany.
- Research Institute for the Prevention of Allergies and Respiratory Diseases in Childhood, Department of Pediatrics, Marien-Hospital Wesel, Wesel, Germany.
| | - Nina Timmesfeld
- Institute of Medical Biometry and Epidemiology, Philipps-University Marburg, Marburg, Germany
- Department of Medical Informatics, Biometrics and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Jochen Antel
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Raphael Hirtz
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
- Pediatric Endocrinology and Diabetology, Klinik für Kinderheilkunde II, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jens Bauer
- Pediatric Endocrinology and Diabetology, Klinik für Kinderheilkunde II, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, Division of Laboratory Research, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Denise Zwanziger
- Department of Endocrinology, Diabetes and Metabolism, Division of Laboratory Research, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dana Öztürk
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Gina Langenbach
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Denise Hahn
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Stefanie Ring
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Triinu Peters
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Anke Hinney
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Judith Bühlmeier
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Johannes Hebebrand
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
| | - Corinna Grasemann
- Pediatric Endocrinology and Diabetology, Klinik für Kinderheilkunde II, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Children's Hospital, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Manuel Föcker
- Department of Child and Adolescent Psychiatry, University Hospital Essen, University of Duisburg-Essen, Virchowstr. 174, 45147, Essen, Germany
- Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
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23
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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: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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24
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Zhou X, Teng T, Zhang Y, Del Giovane C, Furukawa TA, Weisz JR, Li X, Cuijpers P, Coghill D, Xiang Y, Hetrick SE, Leucht S, Qin M, Barth J, Ravindran AV, Yang L, Curry J, Fan L, Silva SG, Cipriani A, Xie P. Comparative efficacy and acceptability of antidepressants, psychotherapies, and their combination for acute treatment of children and adolescents with depressive disorder: a systematic review and network meta-analysis. Lancet Psychiatry 2020; 7:581-601. [PMID: 32563306 PMCID: PMC7303954 DOI: 10.1016/s2215-0366(20)30137-1] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Depressive disorders are common in children and adolescents. Antidepressants, psychotherapies, and their combination are often used in routine clinical practice; however, available evidence on the comparative efficacy and safety of these interventions is inconclusive. Therefore, we sought to compare and rank all available treatment interventions for the acute treatment of depressive disorders in children and adolescents. METHODS We did a systematic review and network meta-analysis. We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, PsycINFO, ProQuest, CINAHL, LiLACS, international trial registries, and the websites of regulatory agencies for published and unpublished randomised controlled trials from database inception until Jan 1, 2019. We included placebo-controlled and head-to-head trials of 16 antidepressants, seven psychotherapies, and five combinations of antidepressant and psychotherapy that are used for the acute treatment of children and adolescents (≤18 years old and of both sexes) with depressive disorder diagnosed according to standard operationalised criteria. Trials recruiting participants with treatment-resistant depression, bipolar disorder, psychotic depression, treatment duration of less than 4 weeks, or an overall sample size of fewer than ten patients were excluded. We extracted data following a predefined hierarchy of outcome measures, and assessed risk of bias and certainty of evidence using validated methods. Primary outcomes were efficacy (change in depressive symptoms) and acceptability (treatment discontinuation due to any cause). We estimated summary standardised mean differences (SMDs) or odds ratios (ORs) with credible intervals (CrIs) using network meta-analysis with random effects. This study was registered with PROSPERO, number CRD42015020841. FINDINGS From 20 366 publications, we included 71 trials (9510 participants). Depressive disorders in most studies were moderate to severe. In terms of efficacy, fluoxetine plus cognitive behavioural therapy (CBT) was more effective than CBT alone (-0·78, 95% CrI -1·55 to -0·01) and psychodynamic therapy (-1·14, -2·20 to -0·08), but not more effective than fluoxetine alone (-0·22, -0·86 to 0·42). No pharmacotherapy alone was more effective than psychotherapy alone. Only fluoxetine plus CBT and fluoxetine were significantly more effective than pill placebo or psychological controls (SMDs ranged from -1·73 to -0·51); and only interpersonal therapy was more effective than all psychological controls (-1·37 to -0·66). Nortriptyline (SMDs ranged from 1·04 to 2·22) and waiting list (SMDs ranged from 0·67 to 2·08) were less effective than most active interventions. In terms of acceptability, nefazodone and fluoxetine were associated with fewer dropouts than sertraline, imipramine, and desipramine (ORs ranged from 0·17 to 0·50); imipramine was associated with more dropouts than pill placebo, desvenlafaxine, fluoxetine plus CBT, and vilazodone (2·51 to 5·06). Most of the results were rated as "low" to "very low" in terms of confidence of evidence according to Confidence In Network Meta-Analysis. INTERPRETATION Despite the scarcity of high-quality evidence, fluoxetine (alone or in combination with CBT) seems to be the best choice for the acute treatment of moderate-to-severe depressive disorder in children and adolescents. However, the effects of these interventions might vary between individuals, so patients, carers, and clinicians should carefully balance the risk-benefit profile of efficacy, acceptability, and suicide risk of all active interventions in young patients with depression on a case-by-case basis. FUNDING National Key Research and Development Program of China.
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Affiliation(s)
- Xinyu Zhou
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Teng Teng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuqing Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and School of Public Health, Kyoto, Japan
| | - John R Weisz
- Department of Psychology, Harvard University, Cambridge, MA, USA
| | - Xuemei Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - David Coghill
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Yajie Xiang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sarah E Hetrick
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technische Universität München, Munich, Germany
| | - Mengchang Qin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jürgen Barth
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Arun V Ravindran
- Department of Psychiatry, University of Toronto and Division of Mood and Anxiety Disorders, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Lining Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - John Curry
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Li Fan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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25
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Boaden K, Tomlinson A, Cortese S, Cipriani A. Antidepressants in Children and Adolescents: Meta-Review of Efficacy, Tolerability and Suicidality in Acute Treatment. Front Psychiatry 2020; 11:717. [PMID: 32982805 PMCID: PMC7493620 DOI: 10.3389/fpsyt.2020.00717] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/07/2020] [Indexed: 01/04/2023] Open
Abstract
Antidepressants are prescribed for the treatment of a number of psychiatric disorders in children and adolescents, however there is still controversy about whether they should be used in this population. This meta-review aimed to assess the effects of antidepressants for the acute treatment of attention-deficit/hyperactivity disorder (ADHD), anxiety disorders (ADs), autistic spectrum disorder (ASD), enuresis, major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD) in children and adolescents. Efficacy was measured as response to treatment (either as mean overall change in symptoms or as a dichotomous outcome) and tolerability was measured as the proportion of patients discontinuing treatment due to adverse events. Suicidality was measured as suicidal ideation, behavior (including suicide attempts) and completed suicide. PubMed, EMBASE, and Web of Science were systematically searched (until 31 October 2019) for existing systematic reviews and/or meta-analyses of double-blind randomized controlled trials. The quality of the included reviews was appraised using AMSTAR-2. Our meta-review included nine systematic reviews/meta-analyses (2 on ADHD; 1 on AD; 2 on ASD; 1 on enuresis; 1 on MDD, 1 on OCD and 1 on PTSD). In terms of efficacy this review found that, compared to placebo: fluoxetine was more efficacious in the treatment of MDD, fluvoxamine and paroxetine were better in the treatment of AD; fluoxetine and sertraline were more efficacious in the treatment of OCD; bupropion and desipramine improved clinician and teacher-rated ADHD symptoms; clomipramine and tianeptine were superior on some of the core symptoms of ASD; and no antidepressant was more efficacious for PTSD and enuresis. With regard to tolerability: imipramine, venlafaxine, and duloxetine were less well tolerated in MDD; no differences were found for any of the antidepressants in the treatment of anxiety disorders (ADs), ADHD, and PTSD; tianeptine and citalopram, but not clomipramine, were less well tolerated in children and adolescents with ASD. For suicidal behavior/ideation, venlafaxine (in MDD) and paroxetine (in AD) were associated with a significantly increased risk; by contrast, sertraline (in AD) was associated with a reduced risk. The majority of included systematic reviews/meta-analyses were rated as being of high or moderate in quality by the AMSTAR-2 critical appraisal tool (one and five, respectively). One included study was of low quality and two were of critically low quality. Compared to placebo, selected antidepressants can be efficacious in the acute treatment of some common psychiatric disorders, although statistically significant differences do not always translate into clinically significant results. Little information was available about tolerability of antidepressants in RCTs of OCD and in the treatment of ADHD, ASD, MDD, and PTSD. There is a paucity of data on suicidal ideation/behavior, but paroxetine may increase the risk of suicidality in the treatment of AD and venlafaxine for MDD. Findings from this review must be considered in light of potential limitations, such as the lack of comparative information about many antidepressants, the short-term outcomes and the quality of the available evidence.
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Affiliation(s)
- Katharine Boaden
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Anneka Tomlinson
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom.,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Samuele Cortese
- Center for Innovation in Mental Health, Faculty of Environmental and Life Sciences and Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, School of Psychology, University of Southampton, Southampton, United Kingdom.,Solent NHS Trust, Southampton, United Kingdom.,Division of Psychiatry and Applied Psychology, School of Medicine and National Institute for Health Research MindTech Mental Health MedTech Cooperative and Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom.,New York University Child Study Center, New York, NY, United States
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom.,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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26
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Li Y, Huang J, He Y, Yang J, Lv Y, Liu H, Liang L, Li H, Zheng Q, Li L. The Impact of Placebo Response Rates on Clinical Trial Outcome: A Systematic Review and Meta-Analysis of Antidepressants in Children and Adolescents with Major Depressive Disorder. J Child Adolesc Psychopharmacol 2019; 29:712-720. [PMID: 31368787 DOI: 10.1089/cap.2019.0022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective: The high placebo response rate may hamper the discovery of antidepressants in children and adolescents with major depressive disorder (MDD). The aim of the study was to clarify the relationship between the placebo response rate and clinical trial outcomes of the use of antidepressants in children and adolescents, and distinguish main factors responsible to placebo response rate. Methods: The PubMed and Cochrane Library databases were searched for double-blind randomized placebo-controlled trials of the new-generation antidepressants for the acute treatment of MDD in children and adolescents. The response rate differences (RDs) between placebo group and treatment group under different level of placebo response rate were pooled by random-effects meta-analysis. The classification thresholds for low, medium, and high placebo response rate were set at <40%, 40%-50%, and ≥50%, respectively. Predictors of placebo response rate were explored using meta-regression. Results: The analysis included 18 trials with 4365 participants. This study found that the lower the placebo response rate, the greater the efficacy differences between antidepressants and placebo. In the high, moderate, and low placebo response rate subgroups, the response RDs (95% CI) between antidepressants and placebo were 8 (1-14)%, 10 (2-17)%, and 21 (9-32)%, respectively. The meta-regression showed that the number of study sites was the factor most associated with placebo response rate, and that response rate increased 3% with every additional 10 study sites. Conclusions: The clinical outcome was related to the placebo response rates in the clinical trials of antidepressants in children and adolescents with MDD. The efficacy differences between antidepressants and placebo will be maximized when placebo response rates are reduced. The number of study sites was the factor most associated with the placebo response rates.
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Affiliation(s)
- Yanfei Li
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jihan Huang
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yingchun He
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Juan Yang
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yinghua Lv
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hongxia Liu
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Liyu Liang
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Huafang Li
- Shanghai Mental Health Center, Shanghai, China
| | - Qingshan Zheng
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lujin Li
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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