1
|
Milrod B, Chambless DL, Gallop R, Busch FN, Schwalberg M, McCarthy KS, Gross C, Sharpless BA, Leon AC, Barber JP. Psychotherapies for Panic Disorder: A Tale of Two Sites. J Clin Psychiatry 2016; 77:927-35. [PMID: 27464313 DOI: 10.4088/jcp.14m09507] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), and applied relaxation training (ART) for primary DSM-IV panic disorder with and without agoraphobia in a 2-site randomized controlled trial. METHOD 201 patients were stratified for site and DSM-IV agoraphobia and depression and were randomized to CBT, PFPP, or ART (19-24 sessions) over 12 weeks in a 2:2:1 ratio at Weill Cornell Medical College (New York, New York) and University of Pennsylvania ("Penn"; Philadelphia, Pennsylvania). Any medication was held constant. RESULTS Attrition rates were ART, 41%; CBT, 25%; and PFPP, 22%. The most symptomatic patients were more likely to drop out of ART than CBT or PFPP (P = .013). Outcome analyses revealed site-by-treatment interactions in speed of Panic Disorder Severity Scale (PDSS) change over time (P = .013). At Cornell, no differences emerged on improvement on the primary outcome, estimated speed of change over time on the PDSS; at Penn, ART (P = .025) and CBT (P = .009) showed greater improvement at treatment termination than PFPP. A site-by-treatment interaction (P = .016) for a priori-defined response (40% PDSS reduction) showed significant differences at Cornell: ART 30%, CBT 65%, PFPP 71% (P = .007), but not at Penn: ART 63%, CBT 60%, PFPP 48% (P = .37). Penn patients were more symptomatic, differed demographically from Cornell patients, had a 7.2-fold greater likelihood of taking medication, and had a 28-fold greater likelihood of taking benzodiazepines. However, these differences did not explain site-by-treatment interactions. CONCLUSIONS All treatments substantially improved panic disorder with or without agoraphobia, but patients, particularly the most severely ill, found ART less acceptable. CBT showed the most consistent performance across sites; however, the results for PFPP showed the promise of psychodynamic psychotherapy for this disorder. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00353470.
Collapse
|
2
|
Leon AC, Demirtas H, Hedeker D. Bias reduction with an adjustment for participants' intent to dropout of a randomized controlled clinical trial. Clin Trials 2016; 4:540-7. [DOI: 10.1177/1740774507083871] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Attrition, which is virtually ubiquitous in randomized controlled clinical trials, introduces problems of increased bias and reduced statistical power. Although likelihood-based statistical models such as mixed-effects models can accommodate incomplete data, the assumption of ignorable attrition is usually required for valid inferences. Purpose In an effort to make the ignorability assumption more plausible, we consider the value of one readily obtained covariate that has been recommended by others, asking participants to rate their Intent to Attend the next assessment session. Methods Here we present a simulation study that compares the bias and coverage in mixed-effects outcome analyses that do and do not include Intent to Attend as a covariate. Results For the simulation specifications that we examined, the results are promising in the sense of reduced bias and greater precision. Specifically, if the time-varying Intent to Attend variable is associated with attrition, outcome and treatment group, bias is substantially reduced by including it in the outcome analyses. Limitations Analyses that are adjusted in this way will only yield unbiased estimates of efficacy if attrition is ignorable based on the self-rated intentions. Conclusions Accounting for participants' Intent to Attend the next assessment session will reduce attrition bias under conditions examined here. The item adds little burden and can be used both for data analyses and to identify participants at risk of attrition. Clinical Trials 2007; 4: 540—547. http://ctj.sagepub.com
Collapse
Affiliation(s)
- Andrew C. Leon
- Weill Medical College of Cornell University, Departments of Psychiatry and Public Health, New York, NY 10021,
| | - Hakan Demirtas
- University of Illinois at Chicago, School of Public Health, Division of Epidemiology and Biostatistics Chicago, IL 60612
| | - Donald Hedeker
- University of Illinois at Chicago, School of Public Health, Division of Epidemiology and Biostatistics Chicago, IL 60612
| |
Collapse
|
3
|
Abstract
When preparing a research protocol, an investigator must be as careful in projecting sample-size requirements as in specifying hypotheses. In this article, tables are presented that provide estimates of sample-size requirements for statistical power of 0.80 with two-tailed α-levels of 0.05 in studies with a balanced design that plan to compare two groups on time-averaged, repeated observations of a binary outcome. The estimates, which are based on the algorithm of Diggle, Heagerty, Liang, and Zeger, are a function of several features of the study, including the response rates for each group, the number of repeated observations per participant, and the strength of the association among observations within participant as quantified with an intraclass correlation coefficient.
Collapse
|
4
|
McElroy SL, Kemp DE, Friedman ES, Reilly-Harrington NA, Sylvia LG, Calabrese JR, Rabideau DJ, Ketter TA, Thase ME, Singh V, Tohen M, Bowden CL, Bernstein EE, Brody BD, Deckersbach T, Kocsis JH, Kinrys G, Bobo WV, Kamali M, McInnis MG, Leon AC, Faraone S, Nierenberg AA, Shelton RC. Obesity, but not metabolic syndrome, negatively affects outcome in bipolar disorder. Acta Psychiatr Scand 2016; 133:144-153. [PMID: 26114830 PMCID: PMC4844561 DOI: 10.1111/acps.12460] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Examine the effects of obesity and metabolic syndrome on outcome in bipolar disorder. METHOD The Comparative Effectiveness of a Second Generation Antipsychotic Mood Stabilizer and a Classic Mood Stabilizer for Bipolar Disorder (Bipolar CHOICE) study randomized 482 participants with bipolar disorder in a 6-month trial comparing lithium- and quetiapine-based treatment. Baseline variables were compared between groups with and without obesity, with and without abdominal obesity, and with and without metabolic syndrome respectively. The effects of baseline obesity, abdominal obesity, and metabolic syndrome on outcomes were examined using mixed effects linear regression models. RESULTS At baseline, 44.4% of participants had obesity, 48.0% had abdominal obesity, and 27.3% had metabolic syndrome; neither obesity, nor abdominal obesity, nor metabolic syndrome were associated with increased global severity, mood symptoms, or suicidality, or with poorer functioning or life satisfaction. Treatment groups did not differ on prevalence of obesity, abdominal obesity, or metabolic syndrome. By contrast, among the entire cohort, obesity was associated with less global improvement and less improvement in total mood and depressive symptoms, suicidality, functioning, and life satisfaction after 6 months of treatment. Abdominal obesity was associated with similar findings. Metabolic syndrome had no effect on outcome. CONCLUSION Obesity and abdominal obesity, but not metabolic syndrome, were associated with less improvement after 6 months of lithium- or quetiapine-based treatment.
Collapse
Affiliation(s)
- Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH and Lindner Center of HOPE, Mason, OH, USA
| | - David E Kemp
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Dustin J Rabideau
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Emily E Bernstein
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin D Brody
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Masoud Kamali
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Andrew C. Leon
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Stephen Faraone
- Department of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
5
|
Nierenberg AA, McElroy SL, Friedman ES, Ketter TA, Shelton RC, Deckersbach T, McInnis MG, Bowden CL, Tohen M, Kocsis JH, Calabrese JR, Kinrys G, Bobo WV, Singh V, Kamali M, Kemp D, Brody B, Reilly-Harrington NA, Sylvia LG, Shesler LW, Bernstein EE, Schoenfeld D, Rabideau DJ, Leon AC, Faraone S, Thase ME. Bipolar CHOICE (Clinical Health Outcomes Initiative in Comparative Effectiveness): a pragmatic 6-month trial of lithium versus quetiapine for bipolar disorder. J Clin Psychiatry 2016; 77:90-9. [PMID: 26845264 DOI: 10.4088/jcp.14m09349] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [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: 06/26/2014] [Accepted: 12/19/2014] [Indexed: 10/22/2022]
Abstract
BACKGROUND Bipolar disorder is among the 10 most disabling medical conditions worldwide. While lithium has been used extensively for bipolar disorder since the 1970s, second-generation antipsychotics (SGAs) have supplanted lithium since 1998. To date, no randomized comparative-effectiveness study has compared lithium and any SGA. METHOD Within the duration of the study (September 2010-September 2013), participants with bipolar I or II disorder (DSM-IV-TR) were randomized for 6 months to receive lithium (n = 240) or quetiapine (n = 242). Lithium and quetiapine were combined with other medications for bipolar disorder consistent with typical clinical practice (adjunctive personalized treatment [APT], excluding any SGA for the lithium + APT group and excluding lithium or any other SGA for the quetiapine + APT group). Coprimary outcome measures included Clinical Global Impressions-Efficacy Index (CGI-EI) and necessary clinical adjustments, which measured number of changes in adjunctive personalized treatment. Secondary measures included a full range of symptoms, cardiovascular risk, functioning, quality of life, suicidal ideation and behavior, and adverse events. RESULTS Participants improved across all measures, and over 20% had a sustained response. Primary (CGI-EI, P = .59; necessary clinical adjustments, P = .15) and secondary outcome changes were not statistically significantly different between the 2 groups. For participants with greater manic/hypomanic symptoms, CGI-EI changes were significantly more favorable with quetiapine + APT (P = .02). Among those with anxiety, the lithium + APT group had fewer necessary clinical adjustments per month (P = .02). Lithium was better tolerated than quetiapine in terms of the burden of side effects frequency (P = .05), intensity (P = .01), and impairment (P = .01). CONCLUSIONS Despite adequate power to detect clinically meaningful differences, we found outcomes with lithium + APT and quetiapine + APT were not significantly different across 6 months of treatment for bipolar disorder. TRIAL REGISTRATION ClinicalTrials.gov identifier for the Bipolar CHOICE study: NCT01331304.
Collapse
|
6
|
Ostacher MJ, Nierenberg AA, Rabideau D, Reilly-Harrington NA, Sylvia LG, Gold AK, Shesler LW, Ketter TA, Bowden CL, Calabrese JR, Friedman ES, Iosifescu DV, Thase ME, Leon AC, Trivedi MH. A clinical measure of suicidal ideation, suicidal behavior, and associated symptoms in bipolar disorder: Psychometric properties of the Concise Health Risk Tracking Self-Report (CHRT-SR). J Psychiatr Res 2015; 71:126-33. [PMID: 26476489 PMCID: PMC6778403 DOI: 10.1016/j.jpsychires.2015.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [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: 01/22/2015] [Revised: 08/11/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE People with bipolar disorder are at high risk of suicide, but no clinically useful scale has been validated in this population. The aim of this study was to evaluate the psychometric properties in bipolar disorder of the 7- and 12-item versions of the Concise Health Risk Tracking Self-Report (CHRT-SR), a scale measuring suicidal ideation, suicidal behavior, and associated symptoms. METHODS The CHRT was administered to 283 symptomatic outpatients with bipolar I or II disorder who were randomized to receive lithium plus optimized personalized treatment (OPT), or OPT without lithium in a six month longitudinal comparative effectiveness trial. Participants were assessed using structured diagnostic interviews, clinician-rated assessments, and self-report questionnaires. RESULTS The internal consistency (Cronbach α) was 0.80 for the 7-item CHRT-SR and 0.90 for the 12-item CHRT-SR with a consistent factor structure, and three independent factors (current suicidal thoughts and plans, hopelessness, and perceived lack of social support) for the 7-item version. CHRT-SR scores are correlated with measures of depression, functioning, and quality of life, but not with mania scores. CONCLUSIONS The 7- and 12-item CHRT-SR both had excellent psychometric properties in a sample of symptomatic subjects with bipolar disorder. The scale is highly correlated with depression, functioning, and quality of life, but not with mania. Future research is needed to determine whether the CHRT-SR will be able to predict suicide attempts in clinical practice.
Collapse
Affiliation(s)
- Michael J. Ostacher
- VA Palo Alto Health Care System, Palo Alto, CA, USA,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Corresponding author. VA Palo Alto Health Care System 3801 Miranda Ave, Mail Code 151-T Palo Alto, CA 94304, USA. (M.J. Ostacher)
| | - Andrew A. Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Dustin Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Noreen A. Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Louisa G. Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Alexandra K. Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Leah W. Shesler
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Terence A. Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles L. Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Joseph R. Calabrese
- Bipolar Disorders Research Center, University Hospital’s Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Edward S. Friedman
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dan V. Iosifescu
- Department of Psychiatry, Icahn School of medicine at Mount Sinai, New York, NY, USA
| | - Michael E. Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, USA
| | - Andrew C. Leon
- Biostatistics in Psychiatry & Public Health, Weill Cornell Medical College, New York, NY, USA
| | - Madhukar H. Trivedi
- Department of Psychiatry, The University of Texas Southwestern Medical Center, USA
| |
Collapse
|
7
|
Arnold JG, Salcedo S, Ketter TA, Calabrese JR, Rabideau DJ, Nierenberg AA, Bazan M, Leon AC, Friedman ES, Iosifescu D, Sylvia LG, Ostacher M, Thase M, Reilly-Harrington NA, Bowden CL. An exploratory study of responses to low-dose lithium in African Americans and Hispanics. J Affect Disord 2015; 178:224-8. [PMID: 25827507 PMCID: PMC4397978 DOI: 10.1016/j.jad.2015.02.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 07/25/2014] [Accepted: 02/19/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Few prospective studies examine the impact of ethnicity or race on outcomes with lithium for bipolar disorder. This exploratory study examines differences in lithium response and treatment outcomes in Hispanics, African Americans, and non-Hispanic whites with bipolar disorder in the Lithium Treatment Moderate Dose Use Study (LiTMUS). METHODS LiTMUS was a six-site randomized controlled trial of low-dose lithium added to optimized treatment (OPT; personalized, evidence-based pharmacotherapy) vs. OPT alone in outpatients with bipolar disorder. Of 283 participants, 47 African Americans, 39 Hispanics, and 175 non-Hispanic whites were examined. We predicted minority groups would have more negative medication attitudes and higher attrition rates, but better clinical outcomes. RESULTS African Americans in the lithium group improved more on depression and life functioning compared to whites over the 6 month study. African Americans in the OPT only group had marginal improvement on depression symptoms. For Hispanics, satisfaction with life did not significantly improve in the OPT only group, in contrast to whites and African Americans who improved over time on all measures. Attitudes toward medications did not differ across ethnic/racial groups. CONCLUSIONS African Americans show some greater improvements with lithium than non-Hispanic whites, and Hispanics showed more consistent improvements in the lithium group. The impact of low-dose lithium should be studied in a larger sample as there may be particular benefit for African Americans and Hispanics. Given that the control group (regardless of ethnicity/race) had significant improvements, optimized treatment may be beneficial for any ethnic group.
Collapse
Affiliation(s)
| | - Stephanie Salcedo
- Massachusetts General Hospital - Bipolar Clinic and Research Program
| | | | | | | | | | - Melissa Bazan
- University of Texas Health Science Center San Antonio
| | - Andrew C. Leon
- Massachusetts General Hospital - Bipolar Clinic and Research Program
| | | | | | - Louisa G. Sylvia
- Massachusetts General Hospital - Bipolar Clinic and Research Program
| | | | | | | | | |
Collapse
|
8
|
Bruce ML, Raue PJ, Reilly CF, Greenberg RL, Meyers BS, Banerjee S, Pickett YR, Sheeran TF, Ghesquiere A, Zukowski D, Rosas VH, McLaughlin J, Pledger L, Doyle J, Joachim P, Leon AC. Clinical effectiveness of integrating depression care management into medicare home health: the Depression CAREPATH Randomized trial. JAMA Intern Med 2015; 175:55-64. [PMID: 25384017 PMCID: PMC4516039 DOI: 10.1001/jamainternmed.2014.5835] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression. OBJECTIVE To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study. INTERVENTIONS The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week. MAIN OUTCOMES AND MEASURES Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D). RESULTS The 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005). CONCLUSION AND RELEVANCE Home health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01979302.
Collapse
Affiliation(s)
- Martha L. Bruce
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Patrick J. Raue
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Catherine F. Reilly
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | | | - Barnett S. Meyers
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- New York Presbyterian Hospital-Westchester Division, White Plains, New York
| | - Samprit Banerjee
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- Department of Health Policy and Research, Weill Cornell Medical College, New York City, New York
| | - Yolonda R. Pickett
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- New York Presbyterian Hospital-Westchester Division, White Plains, New York
- Montefiore Home Health Agency, Bronx, New York
| | - Thomas F. Sheeran
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- Rhode Island Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Angela Ghesquiere
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
- Brookdale Center for Healthy Aging, Hunter College, New York City, New York
| | | | | | | | - Lori Pledger
- Baptist Home Health Network, Little Rock, Arkansas
| | - Joan Doyle
- Penn Care at Home, Bala Cynwyd, Pennsylvania
| | | | - Andrew C. Leon
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| |
Collapse
|
9
|
Sylvia LG, Rabideau DJ, Nierenberg AA, Bowden CL, Friedman ES, Iosifescu DV, Thase ME, Ketter T, Greiter EA, Calabrese JR, Leon AC, Ostacher MJ, Reilly-Harrington N. The effect of personalized guideline-concordant treatment on quality of life and functional impairment in bipolar disorder. J Affect Disord 2014; 169:144-8. [PMID: 25194782 PMCID: PMC4172551 DOI: 10.1016/j.jad.2014.08.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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] [Received: 07/22/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The aims of this study were to evaluate correlates and predictors of life functioning and quality of life in bipolar disorder during a comparative effectiveness trial of moderate doses of lithium. METHODS In the Lithium treatment moderate-dose use study (LiTMUS), 283 symptomatic outpatients with bipolar disorder type I or II were randomized to receive lithium plus "optimal personalized treatment (OPT)", or OPT alone. Participants were assessed using structured diagnostic interviews, clinician-rated blinded assessments, and questionnaires. We employ linear mixed effects models to test the effect of treatment overall and adjunct lithium specifically on quality of life or functioning. Similar models are used to examine the association of baseline demographics and clinical features with quality of life and life functioning. RESULTS Quality of life and impaired functioning at baseline were associated with lower income, higher depressive severity, and more psychiatric comorbid conditions. Over 6 months, patients in both treatment groups improved in quality of life and life functioning (p-Values<0.0001); without a statistically significant difference between the two treatment groups (p-Values>0.05). Within the lithium group, improvement in quality of life and functioning was not associated with concurrent lithium levels at week 12 or week 24 (p-Values>0.05). Lower baseline depressive severity and younger age of onset predicted less improvement in functioning over 6 months. CONCLUSIONS Optimized care for bipolar disorder improves overall quality of life and life functioning, with no additional benefit from adjunct moderate doses of lithium. Illness burden and psychosocial stressors were associated with worse quality of life and lower functioning in individuals with bipolar disorder.
Collapse
|
10
|
Leon AC, Fiedorowicz JG, Solomonon DA, Li C, Coryell WH, Endicott J, Fawcett J, Keller MB. Risk of suicidal behavior with antidepressants in bipolar and unipolar disorders. J Clin Psychiatry 2014; 75:720-7. [PMID: 25093469 PMCID: PMC4142755 DOI: 10.4088/jcp.13m08744] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To examine the risk of suicidal behavior (suicide attempts and deaths) associated with antidepressants in participants with bipolar I, bipolar II, and unipolar major depressive disorders. DESIGN A 27-year longitudinal (1981-2008) observational study of mood disorders (Research Diagnostic Criteria diagnoses based on Schedule for Affective Disorders and Schizophrenia and review of medical records) was used to evaluate antidepressants and risk for suicidal behavior. Mixed-effects logistic regression models examined propensity for antidepressant exposure. Mixed-effects survival models that were matched on the propensity score examined exposure status as a risk factor for time until suicidal behavior. SETTING Five US academic medical centers. RESULTS Analyses of 206 participants with bipolar I disorder revealed 2,010 exposure intervals (980 exposed to antidepressants; 1,030 unexposed); 139 participants with bipolar II disorder had 1,407 exposure intervals (694 exposed; 713 unexposed); and 361 participants with unipolar depressive disorder had 2,745 exposure intervals (1,328 exposed; 1,417 unexposed). Propensity score analyses confirmed that more severely ill participants were more likely to initiate antidepressant treatment. In mixed-effects survival analyses, those with bipolar I disorder had a significant reduction in risk of suicidal behavior by 54% (HR = 0.46; 95% CI, 0.31-0.69; t = -3.74; P < .001) during periods of antidepressant exposure compared to propensity-matched unexposed intervals. Similarly, the risk was reduced by 35% (HR = 0.65; 95% CI, 0.43-0.99; t = -2.01; P = .045) in bipolar II disorder. By contrast, there was no evidence of an increased or decreased risk with antidepressant exposure in unipolar disorder. CONCLUSIONS Based on observational data adjusted for propensity to receive antidepressants, antidepressants may protect patients with bipolar disorders but not unipolar depressive disorder from suicidal behavior.
Collapse
|
11
|
Rabideau DJ, Nierenberg AA, Sylvia LG, Friedman ES, Bowden CL, Thase ME, Ketter TA, Ostacher MJ, Reilly-Harrington N, Iosifescu DV, Calabrese JR, Leon AC, Schoenfeld DA. A novel application of the Intent to Attend assessment to reduce bias due to missing data in a randomized controlled clinical trial. Clin Trials 2014; 11:494-502. [PMID: 24872362 DOI: 10.1177/1740774514531096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Missing data are unavoidable in most randomized controlled clinical trials, especially when measurements are taken repeatedly. If strong assumptions about the missing data are not accurate, crude statistical analyses are biased and can lead to false inferences. Furthermore, if we fail to measure all predictors of missing data, we may not be able to model the missing data process sufficiently. In longitudinal randomized trials, measuring a patient's intent to attend future study visits may help to address both of these problems. Leon et al. developed and included the Intent to Attend assessment in the Lithium Treatment - Moderate dose Use Study (LiTMUS), aiming to remove bias due to missing data from the primary study hypothesis. PURPOSE The purpose of this study is to assess the performance of the Intent to Attend assessment with regard to its use in a sensitivity analysis of missing data. METHODS We fit marginal models to assess whether a patient's self-rated intent predicted actual study adherence. We applied inverse probability of attrition weighting (IPAW) coupled with patient intent to assess whether there existed treatment group differences in response over time. We compared the IPAW results to those obtained using other methods. RESULTS Patient-rated intent predicted missed study visits, even when adjusting for other predictors of missing data. On average, the hazard of retention increased by 19% for every one-point increase in intent. We also found that more severe mania, male gender, and a previously missed visit predicted subsequent absence. Although we found no difference in response between the randomized treatment groups, IPAW increased the estimated group difference over time. LIMITATIONS LiTMUS was designed to limit missed study visits, which may have attenuated the effects of adjusting for missing data. Additionally, IPAW can be less efficient and less powerful than maximum likelihood or Bayesian estimators, given that the parametric model is well specified. CONCLUSIONS In LiTMUS, the Intent to Attend assessment predicted missed study visits. This item was incorporated into our IPAW models and helped reduce bias due to informative missing data. This analysis should both encourage and facilitate future use of the Intent to Attend assessment along with IPAW to address missing data in a randomized trial.
Collapse
Affiliation(s)
- Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Edward S Friedman
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Michael E Thase
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Michael J Ostacher
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Noreen Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - Dan V Iosifescu
- Department of Psychiatry, Mount Sinai School of Medicine, New York, USA
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Andrew C Leon
- Psychiatry and Public Health, Weill Cornell Medical College, New York, USA
| | | |
Collapse
|
12
|
Sylvia LG, Reilly-Harrington NA, Leon AC, Kansky CI, Calabrese JR, Bowden CL, Ketter TA, Friedman ES, Iosifescu DV, Thase ME, Ostacher MJ, Keyes M, Rabideau D, Nierenberg AA. Medication adherence in a comparative effectiveness trial for bipolar disorder. Acta Psychiatr Scand 2014; 129:359-65. [PMID: 24117232 PMCID: PMC3975824 DOI: 10.1111/acps.12202] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [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] [Accepted: 09/04/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Psychopharmacology remains the foundation of treatment for bipolar disorder, but medication adherence in this population is low (range 20-64%). We examined medication adherence in a multisite, comparative effectiveness study of lithium. METHOD The Lithium Moderate Dose Use Study (LiTMUS) was a 6-month, six-site, randomized effectiveness trial of adjunctive moderate dose lithium therapy compared with optimized treatment in adult out-patients with bipolar I or II disorder (N=283). Medication adherence was measured at each study visit with the Tablet Routine Questionnaire. RESULTS We found that 4.50% of participants reported missing at least 30% of their medications in the past week at baseline and non-adherence remained low throughout the trial (<7%). Poor medication adherence was associated with more manic symptoms and side-effects as well as lower lithium serum levels at mid- and post-treatment, but not with poor quality of life, overall severity of illness, or depressive symptoms. CONCLUSION Participants in LiTMUS were highly adherent with taking their medications. The lack of association with possible predictors of adherence, such as depression and quality of life, could be explained by the limited variance or other factors as well as by not using an objective measure of adherence.
Collapse
Affiliation(s)
- Louisa G. Sylvia
- Massachusetts General Hospital, Boston, MA USA,Corresponding author: Louisa G. Sylvia, PhD, 50 Staniford St, Suite 580, Boston, MA, , Phone: 617-643-4804, Fax: 617-643-6768
| | | | | | | | | | | | | | | | | | | | | | | | - Dustin Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA
| | | |
Collapse
|
13
|
Nierenberg AA, Sylvia LG, Leon AC, Reilly-Harrington NA, Shesler LW, McElroy SL, Friedman ES, Thase ME, Shelton RC, Bowden CL, Tohen M, Singh V, Deckersbach T, Ketter TA, Kocsis JH, McInnis MG, Schoenfeld D, Bobo WV, Calabrese JR. Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder (Bipolar CHOICE): a pragmatic trial of complex treatment for a complex disorder. Clin Trials 2014; 11:114-27. [PMID: 24346608 PMCID: PMC4495881 DOI: 10.1177/1740774513512184] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [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] [Indexed: 12/13/2022]
Abstract
BACKGROUND Classic and second-generation antipsychotic mood stabilizers are recommended for treatment of bipolar disorder, yet there are no randomized comparative effectiveness studies that have examined the 'real-world' advantages and disadvantages of these medications. PURPOSE We describe the strategic decisions in the design of the Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder (Bipolar CHOICE). This article outlines the key issues and solutions the investigators faced in designing a clinical trial that would maximize generalizability and inform real-world clinical treatment of bipolar disorder. METHODS Bipolar CHOICE was a 6-month, multi-site, prospective, randomized clinical trial of outpatients with bipolar disorder. This study compares the effectiveness of quetiapine versus lithium, each with adjunctive personalized treatments (APTs). The co-primary outcomes selected are the overall benefits and harms of the study medications (as measured by the Clinical Global Impression-Efficacy Index) and the Necessary Clinical Adjustments (a measure of the number of medication changes). Secondary outcomes are continuous measures of mood, the Framingham General Cardiovascular Risk Score, and the Longitudinal Interval Follow up Evaluation Range of Impaired Functioning Tool (LIFE-RIFT). RESULTS The final study design consisted of a single-blind, randomized comparative effectiveness trial of quetiapine versus lithium, plus APT, across 10 sites. Other important study considerations included limited exclusion criteria to maximize generalizability, flexible dosing of APT medications to mimic real-world treatment, and an intent-to-treat analysis plan. In all, 482 participants were randomized to the study, and 364 completed the study. LIMITATIONS The potential limitations of the study include the heterogeneity of APT, selection of study medications, lack of a placebo-control group, and participants' ability to pay for study medications. CONCLUSION We expect that this study will inform our understanding of the benefits and harms of lithium, a classic mood stabilizer, compared to quetiapine, a second-generation antipsychotic with broad-spectrum activity in bipolar disorder, and will provide an example of a well-designed and well-conducted randomized comparative effectiveness clinical trial.
Collapse
|
14
|
Kemp DE, Sylvia LG, Calabrese JR, Nierenberg AA, Thase ME, Reilly-Harrington NA, Ostacher MJ, Leon AC, Ketter TA, Friedman ES, Bowden CL, Pencina M, Iosifescu DV. General medical burden in bipolar disorder: findings from the LiTMUS comparative effectiveness trial. Acta Psychiatr Scand 2014; 129:24-34. [PMID: 23465084 PMCID: PMC3789858 DOI: 10.1111/acps.12101] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [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] [Accepted: 01/21/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study examined general medical illnesses and their association with clinical features of bipolar disorder. METHOD Data were cross-sectional and derived from the Lithium Treatment - Moderate Dose Use Study (LiTMUS), which randomized symptomatic adults (n = 264 with available medical comorbidity scores) with bipolar disorder to moderate doses of lithium plus optimized treatment (OPT) or to OPT alone. Clinically significant high and low medical comorbidity burden were defined as a Cumulative Illness Rating Scale (CIRS) score ≥4 and <4 respectively. RESULTS The baseline prevalence of significant medical comorbidity was 53% (n = 139). Patients with high medical burden were more likely to present in a major depressive episode (P = .04), meet criteria for obsessive-compulsive disorder (P = .02), and experience a greater number of lifetime mood episodes (P = 0.02). They were also more likely to be prescribed a greater number of psychotropic medications (P = .002). Sixty-nine per cent of the sample was overweight or obese as defined by body mass index (BMI), with African Americans representing the racial group with the highest proportion of stage II obesity (BMI ≥35; 31%, n = 14). CONCLUSION The burden of comorbid medical illnesses was high in this generalizable sample of treatment-seeking patients and appears associated with worsened course of illness and psychotropic medication patterns.
Collapse
Affiliation(s)
- David E. Kemp
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH USA
| | | | - Joseph R. Calabrese
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Friedman ES, Calabrese JR, Ketter TA, Leon AC, Thase ME, Bowden CL, Sylvia LG, Ostracher MJ, Severe J, Iosifescu DV, Nierenberg AA, Reilly-Harrington NA. Using comparative effectiveness design to improve the generalizability of bipolar treatment trials data: contrasting LiTMUS baseline data with pre-existing placebo controlled trials. J Affect Disord 2014; 152-154:97-104. [PMID: 23845385 DOI: 10.1016/j.jad.2013.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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] [Received: 01/24/2013] [Revised: 03/11/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Efficacy-based double-blind placebo controlled trials were conducted to establish efficacy and safety for FDA approval. Such designs allowed and encouraged the use of exclusion criteria to improve assay sensitivity and internal validity. The LiTMUS trial increased the representation of real-world individuals with bipolar disorder despite the acknowledgment that this compromises assay sensitivity. METHOD To maximize generalizability, LiTMUS used broad inclusion and narrow exclusion criteria: participants experiencing mood symptoms of sufficient intensity (at least with a CGI-BP ≥ 3) that would warrant a change in treatment, and that lithium treatment would be a reasonable therapeutic option if they were randomized to it. At baseline demographic, illness, clinical, and treatment characteristics were collected. The LiTMUS study design and baseline sociodemographic data were compared to previous efficacy studies. RESULTS As compared to the previous bipolar disorder efficacy studies, LiTMUS participants were of similar age, gender, weight and illness severity; however LiTMUS participants were more racially and ethnically representative of the general population, had a greater number of mood episodes in the past 12 months, more Axis I/II comorbidity, a greater number of prior suicide attempts, and higher functional capacity. CONCLUSIONS LiTMUS was a comparative effectiveness trial that had broad inclusion and minimal exclusion criteria that produced a more representative sample comprised of real-world participants. This design enables the results of the LiTMUS study to be a more representative of real world pharmacotherapuetic outcomes. LIMITATIONS Limitations include possible selection bias, paucity of sociodemographic data in efficacy trials, and lack of a placebo.
Collapse
Affiliation(s)
- E S Friedman
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Reilly-Harrington NA, Sylvia LG, Leon AC, Shesler LW, Ketter TA, Bowden CL, Calabrese JR, Friedman ES, Ostacher MJ, Iosifescu DV, Rabideau DJ, Thase ME, Nierenberg AA. The Medication Recommendation Tracking Form: a novel tool for tracking changes in prescribed medication, clinical decision making, and use in comparative effectiveness research. J Psychiatr Res 2013; 47:1686-93. [PMID: 23911057 DOI: 10.1016/j.jpsychires.2013.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 03/08/2013] [Revised: 06/12/2013] [Accepted: 07/03/2013] [Indexed: 10/26/2022]
Abstract
This paper describes the development and use of the Medication Recommendation Tracking Form (MRTF), a novel method for capturing physician prescribing behavior and clinical decision making. The Bipolar Trials Network developed and implemented the MRTF in a comparative effectiveness study for bipolar disorder (LiTMUS). The MRTF was used to assess the frequency, types, and reasons for medication adjustments. Changes in treatment were operationalized by the metric Necessary Clinical Adjustments (NCA), defined as medication adjustments to reduce symptoms, optimize treatment response and functioning, or to address intolerable side effects. Randomized treatment groups did not differ in rates of NCAs, however, responders had significantly fewer NCAs than non-responders. Patients who had more NCAs during their previous visit had significantly lower odds of responding at the current visit. For each one-unit increase in previous CGI-BP depression score and CGI-BP overall severity score, patients had an increased NCA rate of 13% and 15%, respectively at the present visit. Ten-unit increases in previous Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) scores resulted in an 18% and 14% increase in rates of NCAs, respectively. Patients with fewer NCAs had increased quality of life and decreased functional impairment. The MRTF standardizes the reporting and rationale for medication adjustments and provides an innovative metric for clinical effectiveness. As the first tool in psychiatry to track the types and reasons for medication changes, it has important implications for training new clinicians and examining clinical decision making. (ClinicalTrials.gov number NCT00667745).
Collapse
Affiliation(s)
- Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Suite 580, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Sylvia LG, Iosifescu D, Friedman ES, Bernstein EE, Bowden CL, Ketter TA, Reilly-Harrington NA, Leon AC, Calabrese JR, Ostacher MJ, Rabideau DJ, Thase ME, Nierenberg AA. Use of treatment services in a comparative effectiveness study of bipolar disorder. Psychiatr Serv 2013; 64:1119-26. [PMID: 23945956 DOI: 10.1176/appi.ps.201200479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Bipolar disorder is a severe, chronic mental illness with a high incidence of medical and psychological comorbidities that make treatment and prevention of future episodes challenging. This study investigated the use of services among outpatients with bipolar disorder to further understanding of how to maximize and optimize personalization and accessibility of services for this difficult-to-treat population. METHODS The Lithium Treatment-Moderate Dose Use Study (LiTMUS) was a six-month multisite, comparative effectiveness trial that randomly assigned 283 individuals to receive lithium plus optimized care-defined as personalized, guideline-informed care-or optimized care without lithium. Relationships between treatment service utilization, captured by the Cornell Service Index, and demographic and illness characteristics were examined with generalized linear marginal models. RESULTS Analyses with complete data (week 12, N=246; week 24, N=236) showed that increased service utilization was related to more severe bipolar disorder symptoms, physical side effects, and psychiatric and general medical comorbidities. Middle-aged individuals and those living in the United States longer tended to use more services than younger individuals or recent immigrants, respectively. CONCLUSIONS These data suggest that not all individuals with bipolar disorder seek treatment services at the same rate. Instead, specific clinical or demographic features may affect the degree to which one seeks treatment, conveying clinical and public health implications and highlighting the need for specific approaches to correct such discrepancies. Future research is needed to elucidate potential moderators of service utilization in bipolar disorder to ensure that those most in need of additional services utilize them.
Collapse
|
18
|
Affiliation(s)
- Barbara Milrod
- Department of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York
| | - Theodore Shapiro
- Department of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York
| | - Charles Gross
- Department of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York
| | - Gabrielle Silver
- Department of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York
| | - Sabina Preter
- Department of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York
| | - Adam Libow
- New York Psychoanalytic Institute, New York
| | - Andrew C. Leon
- Department of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York
- deceased
| |
Collapse
|
19
|
Leon AC, Demirtas H, Li C, Hedeker D. Subject-level matching for imbalance in cluster randomized trials with a small number of clusters. Pharm Stat 2013; 12:268-74. [DOI: 10.1002/pst.1580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 05/15/2013] [Accepted: 05/16/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew C. Leon
- Department of Psychiatry; Weill Cornell Medical College; New York NY USA
| | - Hakan Demirtas
- Division of Epidemiology and Biostatistics; University of Illinois at Chicago; Chicago IL USA
| | - Chunshan Li
- Department of Psychiatry; Weill Cornell Medical College; New York NY USA
| | - Donald Hedeker
- Division of Epidemiology and Biostatistics; University of Illinois at Chicago; Chicago IL USA
| |
Collapse
|
20
|
Keefe RSE, Kraemer HC, Epstein RS, Frank E, Haynes G, Laughren TP, McNulty J, Reed SD, Sanchez J, Leon AC. Defining a clinically meaningful effect for the design and interpretation of randomized controlled trials. Innov Clin Neurosci 2013; 10:4S-19S. [PMID: 23882433 PMCID: PMC3719483] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE This article captures the proceedings of a meeting aimed at defining clinically meaningful effects for use in randomized controlled trials for psychopharmacological agents. DESIGN Experts from a variety of disciplines defined clinically meaningful effects from their perspectives along with viewpoints about how to design and interpret randomized controlled trials. SETTING The article offers relevant, practical, and sometimes anecdotal information about clinically meaningful effects and how to interpret them. PARTICIPANTS The concept for this session was the work of co-chairs Richard Keefe and the late Andy Leon. Faculty included Richard Keefe, PhD; James McNulty, AbScB; Robert S. Epstein, MD, MS; Shelby D. Reed, PhD; Juan Sanchez, MD; Ginger Haynes, PhD; Andrew C. Leon, PhD; Helena Chmura Kraemer, PhD; Ellen Frank, PhD, and Kenneth L. Davis, MD. RESULTS The term clinically meaningful effect is an important aspect of designing and interpreting randomized controlled trials but can be particularly difficult in the setting of psychopharmacology where effect size may be modest, particularly over the short term, because of a strong response to placebo. Payers, regulators, patients, and clinicians have different concerns about clinically meaningful effects and may describe these terms differently. The use of moderators in success rate differences may help better delineate clinically meaningful effects. CONCLUSION There is no clear consensus on a single definition for clinically meaningful differences in randomized controlled trials, and investigators must be sensitive to specific concerns of stakeholders in psychopharmacology in order to design and execute appropriate clinical trials.
Collapse
Affiliation(s)
- Richard S E Keefe
- Dr. Keefe is Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; Dr. Kraemer is with Stanford University (Emerita), Stanford, California, and University of Pittsburgh, Pittsburgh, Pennsylvania; Dr. Epstein is with Epstein Health, Woodcliff Lake, New Jersey; Dr. Frank is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Dr. Haynes is with Eli Lilly and Company, Indianapolis, Indiana; Dr. Laughren is with Laughren Psychopharm Consulting, LLC, Rockville, Maryland; Dr. McNulty is Executive Director at MHCA/OASIS-RI, Providence, Rhode Island; Dr. Reed is with Duke Clinical Research Institute, Durham, North Carolina; Dr. Sanchez is Analyst, Ladenburg Thalmann & Co., New York, New York; and Dr. Leon was Professor of Biostatistics in Psychiatry at Weill Cornell Medical College, New York, New York
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Spinelli MG, Endicott J, Leon AC, Goetz RR, Kalish RB, Brustman LE, Carmona YR, Meyreles Q, Vega M, Schulick JL. A controlled clinical treatment trial of interpersonal psychotherapy for depressed pregnant women at 3 New York City sites. J Clin Psychiatry 2013; 74:393-9. [PMID: 23656847 DOI: 10.4088/jcp.12m07909] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [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: 05/25/2012] [Accepted: 10/29/2012] [Indexed: 10/26/2022]
Abstract
OBJECTIVE While treatment decisions for antepartum depression must be personalized to each woman and her illness, guidelines from the American Psychiatric Association and the American College of Obstetrics and Gynecology include the recommendation of psychotherapy for mild-to-moderate depression in pregnant women. Although we previously demonstrated the efficacy of interpersonal psychotherapy for antepartum depression in a sample of Hispanic women, this study provides a larger, more diverse sample of African American, Hispanic, and white pregnant women from 3 New York City sites in order to provide greater generalizability. METHOD A 12-week bilingual, parallel-design, controlled clinical treatment trial compared interpersonal psychotherapy for antepartum depression to a parenting education program control group. An outpatient sample of 142 women who met DSM-IV criteria for major depressive disorder was randomly assigned to interpersonal psychotherapy or the parenting education program from September 2005 to May 2011. The 17-item Hamilton Depression Rating Scale (HDRS-17) was the primary outcome measure of mood. Other outcome scales included the Edinburgh Postnatal Depression Scale (EPDS) and the Clinical Global Impressions scale (CGI). The Maternal Fetal Attachment Scale (MFAS) assessed mother's interaction with the fetus. RESULTS Although this study replicated previous findings that interpersonal psychotherapy is a beneficial treatment for antepartum depression, the parenting education program control condition showed equal benefit as measured by the HDRS-17, EPDS, CGI, and MFAS. CONCLUSIONS This study supports the recommendation for the use of interpersonal psychotherapy for mild-to-moderate major depressive disorder in pregnancy. The parenting education program may be an alternative treatment that requires further study. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00251043
Collapse
Affiliation(s)
- Margaret G Spinelli
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Drive, Box 123, New York, NY 10032, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Solomon DA, Fiedorowicz JG, Leon AC, Coryell W, Endicott J, Li C, Boland RJ, Keller MB. Recovery from multiple episodes of bipolar I depression. J Clin Psychiatry 2013; 74:e205-11. [PMID: 23561241 PMCID: PMC3837577 DOI: 10.4088/jcp.12m08049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [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: 07/25/2012] [Accepted: 10/25/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe the duration of bipolar I major and minor depressive episodes and factors associated with time to recovery. METHOD As part of the National Institute of Mental Health Collaborative Depression Study, 219 participants with bipolar I disorder based on Research Diagnostic Criteria analogs to DSM-IV-TR criteria were recruited at 5 academic medical centers from 1978 to 1981 and followed for up to 25 years with the Longitudinal Interval Follow-Up Evaluation. The probability of recovery over time from depressive episodes, the primary outcome measure, was examined with mixed-effects grouped-time survival models. RESULTS The median duration of major depressive episodes was 14 weeks, and over 70% of participants recovered within 12 months of episode onset. The median duration of minor depressive episodes was 8 weeks, and approximately 90% of participants recovered within 6 months of onset of the episode. Aggregated data demonstrated similar durations of the first 3 major depressive episodes. However, for each participant with multiple episodes of major depression or minor depression, the duration of each episode was not consistent (intraclass correlation coefficient = 0.07 and 0.25 for major and minor depression, respectively). The total number of years in episode over follow-up with major plus minor depression prior to onset of a major depressive episode was significantly associated with a decreased probability of recovery from that episode; with each additional year, the likelihood of recovery was reduced by 7% (hazard ratio = 0.93; 95% CI, 0.89-0.98; P = .002). CONCLUSIONS Bipolar I major depression generally lasts longer than minor depression, and the duration of multiple episodes within an individual varies. However, the probability of recovery over time from an episode of major depression appears to decline with each successive episode.
Collapse
Affiliation(s)
- David A Solomon
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA, UpToDate, Waltham, MA, USA
| | - Jess G. Fiedorowicz
- Department of Psychiatry, College of Public Health, The University of Iowa, Iowa City, IA, USA,Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, College of Public Health, The University of Iowa, Iowa City, IA, USA,Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Andrew C. Leon
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - William Coryell
- Department of Psychiatry, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Jean Endicott
- New York State Psychiatric Institute, New York, NY, USA
| | - Chunshan Li
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Robert J. Boland
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA, UpToDate, Waltham, MA, USA
| | - Martin B. Keller
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA, UpToDate, Waltham, MA, USA
| |
Collapse
|
23
|
Nierenberg AA, Friedman ES, Bowden CL, Sylvia LG, Thase ME, Ketter T, Ostacher MJ, Leon AC, Reilly-Harrington N, Iosifescu DV, Pencina M, Severe JB, Calabrese JR. Lithium treatment moderate-dose use study (LiTMUS) for bipolar disorder: a randomized comparative effectiveness trial of optimized personalized treatment with and without lithium. Am J Psychiatry 2013; 170:102-10. [PMID: 23288387 DOI: 10.1176/appi.ajp.2012.12060751] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Lithium salts, once the mainstay of therapy for bipolar disorder, have tolerability issues at a higher dosage that often limit adherence. The authors investigated the comparative effectiveness of more tolerable dosages of lithium as part of optimized personalized treatment (OPT). METHOD The authors randomly assigned 283 bipolar disorder outpatients to 6 months of open, flexible, moderate dosages of lithium plus OPT or to 6 months of OPT alone. The primary outcome measures were the Clinical Global Impression Scale for Bipolar Disorder-Severity (CGI-BP-S) and "necessary clinical adjustments" (medication adjustments per month). Secondary outcome measures included mood symptoms and functioning. The authors also assessed sustained remission (defined as a CGI-BP-S score ≤2 for 2 months) and treatment with second-generation antipsychotics. The authors hypothesized that lithium plus OPT would result in greater clinical improvement and fewer necessary clinical adjustments. RESULTS The authors observed no statistically significant advantage of lithium plus OPT on CGI-BP-S scores, necessary clinical adjustments, or proportion with sustained remission. Both groups had similar outcomes across secondary clinical and functional measures. Fewer patients in the lithium-plus-OPT group received second-generation antipsychotics compared with the OPT-only group (48.3% and 62.5%, respectively). CONCLUSIONS In this pragmatic comparative effectiveness study, a moderate but tolerated dosage of lithium plus OPT conferred no symptomatic advantage when compared with OPT alone, but the lithium-plus-OPT group had less exposure to second-generation antipsychotics. Only about one-quarter of patients in both groups achieved sustained remission of symptoms. These findings highlight the persistent and chronic nature of bipolar disorder as well as the magnitude of unmet needs in its treatment.
Collapse
|
24
|
Shankman SA, Campbell ML, Klein DN, Leon AC, Arnow BA, Manber R, Keller MB, Markowitz JC, Rothbaum BO, Thase ME, Kocsis JH. Dysfunctional attitudes as a moderator of pharmacotherapy and psychotherapy for chronic depression. J Psychiatr Res 2013; 47:113-21. [PMID: 23102821 PMCID: PMC3501539 DOI: 10.1016/j.jpsychires.2012.09.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 06/05/2012] [Revised: 08/23/2012] [Accepted: 09/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Individuals with chronic depression exhibit heterogeneous responses to treatment. Important individual differences may therefore exist within this particularly difficult to treat population that act as moderators of treatment response. METHOD The present study examined whether pretreatment levels of dysfunctional attitudes (DA) moderated treatment response in a large sample of chronically depressed individuals. Data were taken from the Research Evaluating the Value of Augmenting Medication with Psychotherapy (REVAMP) treatment study--a multi-site treatment and augmentation study of 808 chronically depressed individuals. REVAMP comprised two phases: 1) a 12-week open-label antidepressant trial and 2), a subsequent phase, in which phase 1 non-remitters (N = 491) were randomized to either receive an ongoing medication algorithm alone, medication plus cognitive behavioral analysis system of psychotherapy, or medication plus brief supportive psychotherapy. RESULT In phase 1, compared to the pharmacotherapy response of patients with lower DA scores, the response for patients with higher DA scores was steeper, but leveled off toward the end of the phase. In phase 2, DA predicted a differential response in the medication only arm, but not in the two psychotherapy + medication conditions. Specifically, in the phase 2 medication only condition, patients with higher DA improved while those with lower DA scores did not. CONCLUSION These results indicate that the relation between DA and treatment response in chronic depression is complex, but suggest that greater DA may be associated with a steeper reduction and/or better response to pharmacotherapy.
Collapse
Affiliation(s)
| | | | | | | | - Bruce A. Arnow
- Department of Psychiatry, Stanford University School of Medicine
| | - Rachel Manber
- Department of Psychiatry, Stanford University School of Medicine
| | | | - John C. Markowitz
- Department of Psychiatry, Columbia University College of Physicians and Surgeons
| | | | - Michael E. Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine
| | | |
Collapse
|
25
|
Leon AC, Demirtas H, Li C, Hedeker D. Two propensity score-based strategies for a three-decade observational study: investigating psychotropic medications and suicide risk. Stat Med 2012; 31:3255-60. [DOI: 10.1002/sim.5339] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 01/11/2012] [Indexed: 11/05/2022]
Affiliation(s)
- Andrew C. Leon
- Department of Psychiatry; Weill Cornell Medical College; New York NY U.S.A
| | - Hakan Demirtas
- Division of Epidemiology and Biostatistics, School of Public Health; University of Illinois at Chicago; Chicago IL U.S.A
| | - Chunshan Li
- Department of Psychiatry; Weill Cornell Medical College; New York NY U.S.A
| | - Donald Hedeker
- Division of Epidemiology and Biostatistics, School of Public Health; University of Illinois at Chicago; Chicago IL U.S.A
| |
Collapse
|
26
|
Leon AC, Hedeker D, Li C, Demirtas H. Performance of a propensity score adjustment in longitudinal studies with covariate-dependent representation. Stat Med 2012; 31:2262-74. [DOI: 10.1002/sim.5332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 01/10/2012] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Chunshan Li
- Weill Cornell Medical College; New York City, NY USA
| | | |
Collapse
|
27
|
Leon AC, Solomon DA, Li C, Fiedorowicz JG, Coryell WH, Endicott J, Keller MB. Antiepileptic drugs for bipolar disorder and the risk of suicidal behavior: a 30-year observational study. Am J Psychiatry 2012; 169:285-91. [PMID: 22193537 PMCID: PMC3643204 DOI: 10.1176/appi.ajp.2011.11060948] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In 2009 the U.S. Food and Drug Administration issued a warning regarding suicidality and antiepileptic drugs based on meta-analyses of 199 randomized trials (over 43,000 subjects with different illnesses) of 11 antiepileptics. The present study examines the hypothesis that the three antiepileptics approved for bipolar disorder (carbamazepine, lamotrigine, and valproate) are associated with an elevated risk of suicide attempts and suicides. METHOD A prospective observational study was conducted at five U.S. academic medical centers from 1978 to 2009. Analyses included 199 participants with bipolar disorder for whom 1,077 time intervals were classified as either exposed to an antiepileptic (carbamazepine, lamotrigine, or valproate) or not exposed to an antiepileptic, an antidepressant, or lithium during 30 years of follow-up. RESULTS Participants who had more severe manic symptoms were more likely to receive antiepileptic drugs. Mixed-effects grouped-time survival models revealed no elevation in risk of suicide attempt or suicide during periods when participants were receiving antiepileptics relative to periods when they were not (hazard ratio=0.93, 95% CI=0.45-1.92), controlling for demographic and clinical variables through propensity score matching. CONCLUSIONS In this longitudinal observational study, the risk of suicide attempts or suicides was not associated with the antiepileptics approved for bipolar disorder.
Collapse
|
28
|
Abstract
BACKGROUND It is well established that the presence of prominent anxiety within depressive episodes portends poorer outcomes. Important questions remain as to which anxiety features are important to outcome and how sustained their prognostic effects are over time. AIMS To examine the relative prognostic importance of specific anxiety features and to determine whether their effects persist over decades and apply to both unipolar and bipolar conditions. METHOD Participants with unipolar (n = 476) or bipolar (n = 335) depressive disorders were intensively followed for a mean of 16.7 years (s.d. = 8.5). RESULTS The number and severity of anxiety symptoms, but not the presence of pre-existing anxiety disorders, showed a robust and continuous relationship to the subsequent time spent in depressive episodes in both unipolar and bipolar depressive disorder. The strength of this relationship changed little over five successive 5-year periods. CONCLUSIONS The severity of current anxiety symptoms within depressive episodes correlates strongly with the persistence of subsequent depressive symptoms and this relationship is stable over decades.
Collapse
Affiliation(s)
- William Coryell
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins, Iowa City, IA 52242, USA.
| | - Jess G. Fiedorowicz
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa
| | - David Solomon
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew C. Leon
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York
| | - John P. Rice
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | - Martin B. Keller
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| |
Collapse
|
29
|
|
30
|
Leon AC. Independent data and safety monitoring in psychiatric intervention research. J Clin Psychiatry 2012; 73:e257-63. [PMID: 22401486 DOI: 10.4088/jcp.11com06903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 05/25/2011] [Indexed: 10/28/2022]
Abstract
A data and safety monitoring board (DSMB) is a multidisciplinary group of scientists that monitors a randomized clinical trial. Although DSMBs have been used for clinical trials in cardiology, oncology, and infectious disease for decades, it was not until the late 1990s that the National Institute of Mental Health (NIMH) initially required a DSMB for some of its larger trials. The NIMH mandate expanded during the succeeding decade to require DSMBs for many of the clinical trials in psychiatry. In turn, the need for board members has grown quickly. The objective of this commentary is to consider the purpose of a DSMB and to describe its roles, responsibilities, composition, and implementation. The rationale for a DSMB is to ensure the integrity and validity of the trial and, most importantly, to protect the safety of trial participants. A board conducts comprehensive reviews of accumulating unblinded data for safety and, in some trials, for efficacy. Reviewers examine adverse events and serious adverse events at regular intervals during the course of the trial. In addition, a DSMB monitors recruitment, randomization, retention, adherence, and follow-up in an effort to evaluate the validity of a trial. Because it is unethical to expose a participant to the risks of an experiment that will be unable to answer the scientific question that was postulated, a board should also evaluate the study protocol prior to trial commencement. Ultimately, a DSMB's responsibilities are broader than that of the trial being monitored. It will protect potential study participants and eventually could affect patients seeking clinical treatment for the disorder being studied.
Collapse
|
31
|
Davis LL, Leon AC, Toscano R, Drebing CE, Ward LC, Parker PE, Kashner TM, Drake RE. A randomized controlled trial of supported employment among veterans with posttraumatic stress disorder. Psychiatr Serv 2012; 63:464-70. [PMID: 22307881 DOI: 10.1176/appi.ps.201100340] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is a potentially disabling mental illness that can cause occupational dysfunction. Although vocational rehabilitation is often prescribed for patients with PTSD, standard vocational services are far from adequate in helping them obtain and maintain competitive employment. This study is the first to examine the outcome of evidence-based supported employment for veterans with PTSD. METHODS Unemployed veterans with PTSD were randomly assigned to either individual placement and support (IPS) supported employment (N = 42) or a Veterans Health Administration Vocational Rehabilitation Program (VRP) treatment as usual (N = 43). Employment rates and occupational outcomes were followed for 12 months. RESULTS During the 12-month study, 76% of the IPS participants gained competitive employment, compared with 28% of the VRP participants (number needed to treat = 2.07; χ(2) = 19.84, df = 1, p<.001). Veterans assigned to IPS also worked substantially more weeks than those assigned to VRP (42% versus 16% of the eligible weeks, respectively; Mann-Whitney z test p<.001) and earned higher 12-month income (mean ± SD income of $9,264 ± $13,294 for IPS versus $2,601 ± $6,009 for VRP; Mann-Whitney z test p<.001) during the 12-month period. CONCLUSIONS Veterans with PTSD who received IPS were 2.7 times more likely to gain competitive employment than those who received VRP. Because work is central to recovery, these results should assist stakeholders in planning improved services for veterans with PTSD.
Collapse
Affiliation(s)
- Lori L Davis
- Research and Development Service, Tuscaloosa Veterans Affairs Medical Center, 3701 Loop Road East, Tuscaloosa, AL 35404, USA..
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Affiliation(s)
- Benjamin Brody
- Department of Psychiatry, Weill Medical College of Cornell University, New York, USA.
| | | | | |
Collapse
|
33
|
Sylvia LG, Reilly-Harrington NA, Leon AC, Kansky CI, Ketter TA, Calabrese JR, Thase ME, Bowden CL, Friedman ES, Ostacher MJ, Iosifescu DV, Severe J, Keyes M, Nierenberg AA. Methods to limit attrition in longitudinal comparative effectiveness trials: lessons from the Lithium Treatment - Moderate dose Use Study (LiTMUS) for bipolar disorder. Clin Trials 2011; 9:94-101. [PMID: 22076437 DOI: 10.1177/1740774511427324] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High attrition rates, which occur frequently in longitudinal clinical trials of interventions for bipolar disorder, limit the interpretation of results. PURPOSE The aim of this article is to present design approaches that limited attrition in the Lithium Treatment - Moderate dose Use Study (LiTMUS) for bipolar disorder. METHODS LiTMUS was a 6-month randomized, longitudinal multisite comparative effectiveness trial that enrolled bipolar participants who were at least mildly ill. Participants were randomized to either low to moderate doses of lithium or no lithium; other treatments needed for mood stabilization were administered in a guideline-informed, empirically supported, and personalized fashion to participants in both treatment arms. RESULTS Components of the study design that may have contributed to low attrition (16%) among 283 participants randomized included the use of (1) an intent-to-treat design, (2) a randomized adjunctive single-blind design, (3) participant reimbursement, (4) assessment of intent to attend the next study visit (included a discussion of attendance obstacles when intention was low), (5) quality care with limited participant burden, and (6) target windows for study visits. LIMITATIONS The relationships between attrition and effectiveness and tolerability of treatment have not been analyzed yet. CONCLUSIONS These components of the LiTMUS design may have limited attrition and may inform the design of future randomized comparative effectiveness trials among similar patients and those from other difficult-to-follow populations.
Collapse
|
34
|
Leon AC. Comparative effectiveness clinical trials in psychiatry: superiority, noninferiority, and the role of active comparators. J Clin Psychiatry 2011; 72:1344-9. [PMID: 21367350 DOI: 10.4088/jcp.10m06089whi] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [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: 03/03/2010] [Accepted: 05/10/2010] [Indexed: 10/18/2022]
Abstract
UNLABELLED The Agency for Healthcare Research and Quality, part of the US Department of Health and Human Services, has issued several Requests for Applications to conduct comparative effectiveness research (CER). Many of the applications will involve randomized controlled clinical trials that include an active comparator. The inclusion of an active comparator has implications for clinical trial design. Despite a common misperception, a clinical trial result of no significant difference between active treatment groups does not imply equivalence or noninferiority. A noninferiority trial, on the other hand, can directly test whether one active treatment group is noninferior to the other. For example, noninferiority of an inexpensive generic could be tested in comparison with a novel, more costly intervention. Although seldom used in psychiatry, noninferiority clinical trials could play a fundamental role in CER. Features of noninferiority and the nearly ubiquitous superiority designs are contrasted. The noninferiority margin is defined and its application and interpretation are discussed. CONCLUSIONS Evidence of noninferiority can only come from well-designed and conducted noninferiority CER. Sample sizes needed in noninferiority trials and in superiority trials that include an active comparator are substantially larger than those needed in trials that can utilize a placebo control in their scientific design. As a result, trials with active comparators are more costly, require longer recruitment duration, and expose more participants to the risks of an experiment than do trials in which the only comparator is placebo.
Collapse
Affiliation(s)
- Andrew C Leon
- Weill Cornell Medical College, Departments of Psychiatry and Public Health, New York, NY 10065, USA.
| |
Collapse
|
35
|
Abstract
Characteristics of randomized controlled clinical trials (RCTs) and observational studies of psychiatric intervention effectiveness are contrasted. Randomization drives treatment assignment in an RCT, whereas clinician and patient selection determine treatment in an observational study. Strengths and weaknesses of randomized and observational designs are considered. The propensity adjustment, a statistical approach that allows for intervention evaluation in a nonrandomized observational study, is described here. The plausibility of propensity adjustment assumptions must be carefully evaluated. This data analytic strategy is illustrated with the longitudinal observational data from the National Institute of Mental Health Collaborative Depression Study. Evaluations presented here examine acute and maintenance antidepressant effectiveness and demonstrate effectiveness of the higher categorical doses.
Collapse
Affiliation(s)
- Andrew C Leon
- Weill Cornell Medical College, Department of Psychiatry, Box 140, 525 East 68th Street, New York, NY 10065, USA.
| |
Collapse
|
36
|
Klein DN, Leon AC, Li C, D'Zurilla TJ, Black SR, Vivian D, Dowling F, Arnow BA, Manber R, Markowitz JC, Kocsis JH. Social problem solving and depressive symptoms over time: a randomized clinical trial of cognitive-behavioral analysis system of psychotherapy, brief supportive psychotherapy, and pharmacotherapy. J Consult Clin Psychol 2011; 79:342-52. [PMID: 21500885 PMCID: PMC3109172 DOI: 10.1037/a0023208] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [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] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Depression is associated with poor social problem solving, and psychotherapies that focus on problem-solving skills are efficacious in treating depression. We examined the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy (Kocsis et al., 2009). METHOD Participants with chronic depression (n = 491) received cognitive-behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), which emphasizes interpersonal problem solving, plus medication; brief supportive psychotherapy (BSP) plus medication; or medication alone for 12 weeks. RESULTS CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions. CONCLUSIONS It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches.
Collapse
Affiliation(s)
- Daniel N Klein
- Department of Psychology, Stony Brook University, Stony Brook, NY 11794-2500, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Leon AC, Solomon DA, Li C, Fiedorowicz JG, Coryell WH, Endicott J, Keller MB. Antidepressants and risks of suicide and suicide attempts: a 27-year observational study. J Clin Psychiatry 2011; 72:580-6. [PMID: 21658345 PMCID: PMC3643209 DOI: 10.4088/jcp.10m06552] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 12/21/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The 2007 revision of the black box warning for suicidality with antidepressants states that patients of all ages who initiate antidepressants should be monitored for clinical worsening or suicidality. The objective of this study was to examine the association of antidepressants with suicide attempts and with suicide deaths. METHOD A longitudinal, observational study of mood disorders with prospective assessments for up to 27 years was conducted at 5 US academic medical centers. The study sample included 757 participants who enrolled from 1979 to 1981 during an episode of mania, depression, or schizoaffective disorder, each based on Research Diagnostic Criteria. Unlike randomized controlled clinical trials of antidepressants, the analyses included participants with psychiatric and other medical comorbidity and those receiving acute or maintenance therapy, polypharmacy, or no psychopharmacologic treatment at all. Over follow-up, these participants had 6,716 time periods that were classified as either exposed to an antidepressant or not exposed. Propensity score-adjusted mixed-effects survival analyses were used to examine risk of suicide attempt or suicide, the primary outcome. RESULTS The propensity model showed that antidepressant therapy was significantly more likely when participants' symptom severity was greater (odds ratio [OR] = 1.16; 95% CI, 1.12-1.21; z = 8.22; P < .001) or when it was worsening (OR = 1.69; 95% CI, 1.50-1.89; z = 9.02; P < .001). Quintile-stratified, propensity-adjusted safety analyses using mixed-effects grouped-time survival models indicate that the risk of suicide attempts or suicides was reduced by 20% among participants taking antidepressants (hazard ratio, 0.80; 95% CI, 0.68-0.95; z = -2.54; P = .011). CONCLUSIONS This longitudinal study of a broadly generalizable cohort found that, although those with more severe affective syndromes were more likely to initiate treatment, antidepressants were associated with a significant reduction in the risk of suicidal behavior. Nonetheless, we believe that clinicians must closely monitor patients when an antidepressant is initiated.
Collapse
Affiliation(s)
- Andrew C Leon
- Department of Psychiatry, Weill Cornell Medical College, New York, NY 10065, USA.
| | | | | | | | | | | | | |
Collapse
|
38
|
Abstract
The National Institute of Mental Health Strategic Plan calls for the development of personalized treatment strategies for mental disorders. In an effort to achieve that goal, several investigators have conducted exploratory analyses of randomized controlled clinical trial (RCT) data to examine the association between baseline subject characteristics, the putative moderators, and the magnitude of treatment effect sizes. Exploratory analyses are used to generate hypotheses, not to confirm them. For that reason, independent replication is needed. Here, 2 general approaches to designing confirmatory RCTs are described that build on the results of exploratory analyses. These approaches address distinct questions. For example, a 2 × 2 factorial design provides an empirical test of the question, "Is there a greater treatment effect for those with the single-nucleotide polymorphism than for those without that polymorphism?" and the hypothesis test involves a moderator-by-treatment interaction. In contrast, a main effects strategy evaluates the intervention in subgroups and involves separate hypothesis-testing studies of treatment for subjects with the genotypes hypothesized to have enhanced and adverse response. These designs require widely disparate sample sizes to detect a given effect size. The former could need as many as 4-fold the number of subjects. As such, the choice of design impacts the research costs, clinical trial duration, and number of subjects exposed to risk of an experiment, as well as the generalizability of results. When resources are abundant, the 2 × 2 design is the preferable approach for identifying personalized interventions because it directly tests the differential treatment effect, but its demand on research funds is extraordinary.
Collapse
Affiliation(s)
- Andrew C Leon
- Department of Psychiatry, Weill Cornell Medical College, New York, NY 10065, USA.
| |
Collapse
|
39
|
Kemp DE, Ganocy SJ, Brecher M, Carlson BX, Edwards SE, Eudicone JM, Evoniuk G, Jansen W, Leon AC, Minkwitz M, Pikalov A, Stassen HH, Szegedi A, Tohen M, Van Willigenburg AP, Calabrese JR. Clinical value of early partial symptomatic improvement in the prediction of response and remission during short-term treatment trials in 3369 subjects with bipolar I or II depression. J Affect Disord 2011; 130:171-9. [PMID: 21071096 PMCID: PMC3073691 DOI: 10.1016/j.jad.2010.10.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [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: 09/26/2010] [Accepted: 10/12/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the clinical value of early partial symptomatic improvement in predicting the probability of response during the short-term treatment of bipolar depression. METHODS Blinded data from 10 multicenter, randomized, double-blind, placebo-controlled trials in bipolar I or II depression were used to determine if early improvement (≥20% reduction in depression symptom severity after 14 days of treatment) predicted later short-term response or remission. Sensitivity, specificity, efficiency, and positive and negative predictive values (PPV, NPV) were calculated using an intent to treat analysis of individual and pooled study data. RESULTS 1913 patients were randomized to active compounds (aripiprazole, lamotrigine, olanzapine/olanzapine-fluoxetine, and quetiapine), and 1456 to placebo. In the pooled positive studies, early improvement predicted response and remission with high sensitivity (86% and 88%, respectively), but rates of false positives were high (53% and 59%, respectively). Pooled negative predictive values for response/remission (i.e. confidence in knowing the drug will not result in response or remission) were 74% and 82%, respectively, with low rates of false negatives (14% and 12%, respectively). CONCLUSION Early improvement in an individual patient does not appear to be a reliable predictor of eventual response or remission due to an unacceptably high false positive rate. However, the absence of early improvement appears to be a highly reliable predictor of eventual non-response, suggesting that clinicians can have confidence in knowing when a drug is not going to work during short-term treatment. Patients who fail to demonstrate early improvement within the first two weeks of treatment may benefit from a change in therapy.
Collapse
Affiliation(s)
- David E. Kemp
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Stephen J. Ganocy
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH, USA
| | | | | | | | | | | | | | | | | | - Andrei Pikalov
- Dainippon Sumitomo Pharma America, Inc., Fort Lee, NJ, USA
| | | | | | - Mauricio Tohen
- University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Joseph R. Calabrese
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH, USA
| |
Collapse
|
40
|
Abstract
OBJECTIVE The evolution of trial design and analysis during the lifespan of psychopharmacology is examined. BACKGROUND The clinical trial methodology used to evaluate psychopharmacologic agents has evolved considerably over the past 6 decades. The first and most productive decade was characterized by case series, each with a small number of patients. These trials used nonstandardized clinical observation as outcomes and seldom had a comparison group. The crossover design became widely used to examine acute psychiatric treatments in the 1950s and 1960s. Although this strategy provided comparison data, it introduced problems in study implementation and interpretation. In 1962, the US Food and Drug Administration began to require "substantial evidence of effectiveness from adequate and well-controlled studies." Subsequent decades saw remarkable advances in clinical trial design, assessment, and statistical analyses. Standardized instruments were developed and parallel groups, double-blinding, and placebo controls became the benchmark. Sample sizes increased and data analytic procedures were developed that could accommodate the problems of attrition. Randomized withdrawal designs were introduced in the 1970s to examine maintenance therapies. Ethical principles for research became codified in the United States at that time. A wave of regulatory approvals of novel antipsychotics, antidepressants, and anticonvulsants came in the 1980s and 1990s, each based on data from randomized double-blind, parallel-group, placebo-controlled clinical trials. These trial designs often involved fixed-dose comparisons based, in part, on a greater appreciation that much of the benefit and harm in psychopharmacology was dose related. CONCLUSIONS Despite the progress in randomized controlled trial (RCT) design, the discovery of new mechanisms of action and blockbuster interventions has slowed during the past decade.
Collapse
|
41
|
Abstract
Andrew A. Nierenberg, MD, assembled a group of experts to discuss recent research and lay media reports about the safety and efficacy of antidepressants for treating mild-to-moderate depression, including recent controversy surrounding antidepressant-related suicidality. The panel agreed that the data regarding the efficacy of antidepressants are complex, making it easy to misinterpret meta-analysis results. Additionally, the issue of suicidality is quite complicated, but the risk is not great enough to abandon the use of antidepressants, although patients should be monitored carefully. The panel discussed that patients who have mild or moderate depression may benefit from receiving evidence-based psychotherapy first, instead of antidepressants. The panel stressed that additional research and novel treatments are needed to improve outcomes for patients with depression. However, measurement-based pharmacotherapy is an effective tool for helping many patients with depression achieve remission and recovery. Clear communication with the public, the media, and nonpsychiatric clinicians about the safety and efficacy of antidepressants will encourage those who need treatment to seek it.
Collapse
Affiliation(s)
- Andrew A Nierenberg
- Department of Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston, USA
| | | | | | | | | |
Collapse
|
42
|
Zhang RY, Leon AC, Chuang-Stein C, Romano SJ. A new proposal for randomized start design to investigate disease-modifying therapies for Alzheimer disease. Clin Trials 2011; 8:5-14. [DOI: 10.1177/1740774510392255] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Andrew C Leon
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
- Department of Public Health, Weill Cornell Medical College, New York, NY, USA
| | | | | |
Collapse
|
43
|
Heo M, Leon AC. Sample sizes required to detect two-way and three-way interactions involving slope differences in mixed-effects linear models. J Biopharm Stat 2011; 20:787-802. [PMID: 20496206 DOI: 10.1080/10543401003618819] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Based on maximum likelihood estimates obtained from mixed-effects linear models, closed-form power functions are derived to detect two-way and three-way interactions that involve longitudinal course of outcome over time in clinical trials. Sample size estimates are shown to decrease with increasing within-subject correlations. It is further shown that when clinical trial designs are balanced in group sizes, the sample size required to detect an effect size for a three-way interaction is exactly fourfold that required to detect the same effect size of a two-way interaction. Furthermore, this fourfold relationship virtually holds for unbalanced allocations of subjects if one factor is balanced in the three-way interaction model. Simulations are presented that verify the sample size estimates for two-way and three-way interactions.
Collapse
Affiliation(s)
- Moonseong Heo
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
| | | |
Collapse
|
44
|
Gerber AJ, Kocsis JH, Milrod BL, Roose SP, Barber JP, Thase ME, Perkins P, Leon AC. A quality-based review of randomized controlled trials of psychodynamic psychotherapy. Am J Psychiatry 2011; 168:19-28. [PMID: 20843868 DOI: 10.1176/appi.ajp.2010.08060843] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The Ad Hoc Subcommittee for Evaluation of the Evidence Base for Psychodynamic Psychotherapy of the APA Committee on Research on Psychiatric Treatments developed the Randomized Controlled Trial Psychotherapy Quality Rating Scale (RCT-PQRS). The authors report results from application of the RCT-PQRS to 94 randomized controlled trials of psychodynamic psycho-therapy published between 1974 and May 2010. METHOD Five psychotherapy researchers from a range of therapeutic orientations rated a single published paper from each study. RESULTS The RCT-PQRS had good interrater reliability and internal consistency. The mean total quality score was 25.1 (SD=8.8). More recent studies had higher total quality scores. Sixty-three of 103 comparisons between psychodynamic psychotherapy and a nondynamic comparator were of "adequate" quality. Of 39 comparisons of a psychodynamic treatment and an "active" comparator, six showed dynamic treatment to be superior, five showed dynamic treatment to be inferior, and 28 showed no difference (few of which were powered for equivalence). Of 24 adequate comparisons of psychodynamic psychotherapy with an "inactive" comparator, 18 found dynamic treatment to be superior. CONCLUSIONS Existing randomized controlled trials of psychodynamic psychotherapy are promising but mostly show superiority of psychodynamic psychotherapy to an inactive comparator. This would be sufficient to make psychodynamic psychotherapy an "empirically validated" treatment (per American Psychological Association Division 12 standards) only if further randomized controlled trials of adequate quality and sample size replicated findings of existing positive trials for specific disorders. We do not yet know what will emerge when other psychotherapies are subjected to this form of quality-based review.
Collapse
Affiliation(s)
- Andrew J Gerber
- Columbia College of Physicians and Surgeons, New York State Psychiatric Institute, New York, 10032, USA.
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Nierenberg AA, Leon AC, Price LH, Shelton RC, Trivedi MH. The current crisis of confidence in antidepressants. J Clin Psychiatry 2011; 72:27-33. [PMID: 21272514 DOI: 10.4088/jcp.10035colc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Affiliation(s)
- Andrew A Nierenberg
- Department of Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | | |
Collapse
|
46
|
Fiedorowicz JG, Endicott J, Leon AC, Solomon DA, Keller MB, Coryell WH. Subthreshold hypomanic symptoms in progression from unipolar major depression to bipolar disorder. Am J Psychiatry 2011; 168:40-8. [PMID: 21078709 PMCID: PMC3042431 DOI: 10.1176/appi.ajp.2010.10030328] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [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: 11/30/2022]
Abstract
OBJECTIVE The authors assessed whether subthreshold hypomanic symptoms in patients with major depression predicted new-onset mania or hypomania. METHOD The authors identified 550 individuals followed for at least 1 year in the National Institute of Mental Health Collaborative Depression Study with a diagnosis of major depression at intake. All participants were screened at baseline for five manic symptoms: elevated mood, decreased need for sleep, unusually high energy, increased goal-directed activity, and grandiosity. Participants were followed prospectively for a mean of 17.5 years and up to 31 years. The Longitudinal Interval Follow-up Examination was used to monitor course of illness and to identify any hypomania or mania. The association of subthreshold hypomanic symptoms at baseline with subsequent hypomania or mania was determined in survival analyses using Cox proportional hazards regression. RESULTS With a cumulative probability of one in four on survival analysis, 19.6% (N=108) of the sample experienced hypomania or mania, resulting in revision of diagnoses for 12.2% to bipolar II disorder and 7.5% to bipolar I disorder. Number of subthreshold hypomanic symptoms, presence of psychosis, and age at illness onset predicted progression to bipolar disorder. Decreased need for sleep, unusually high energy, and increased goal-directed activity were specifically implicated. CONCLUSIONS Symptoms of hypomania, even when of low intensity, were frequently associated with subsequent progression to bipolar disorder, although the majority of patients who converted did not have any symptoms of hypomania at baseline. These results suggest that continued monitoring for the possibility of progression to bipolar disorder is necessary over the long-term course of major depressive disorder.
Collapse
Affiliation(s)
- Jess G. Fiedorowicz
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, 200 Hawkins Drive, Iowa City, Iowa, 52242, Department of Epidemiology, College of Public Health, The University of Iowa, 200 Hawkins Drive, Iowa City, Iowa, 52242,Corresponding author. Address: 200 Hawkins Drive W278GH, Iowa City, IA 52242 Phone: (319) 384-9267, Fax (319) 353-8656 (J. G. Fiedorowicz)
| | - Jean Endicott
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute
| | - Andrew C. Leon
- Department of Psychiatry, Weill Medical College of Cornell University, New York, New York, 10021
| | - David A. Solomon
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University Providence, Rhode Island, 02912
| | - Martin B. Keller
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University Providence, Rhode Island, 02912
| | - William H. Coryell
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, 200 Hawkins Drive, Iowa City, Iowa, 52242
| |
Collapse
|
47
|
Abstract
OBJECTIVES The Interactive Computer Interview for Mania (ICI-M) is a computer-administered interview that presents probes to assess symptom severity and utilizes a scoring algorithm to select follow-up questions and rate subject responses in accordance with rating scale anchor points. The current study examines the acceptability, feasibility, and reliability of the ICI-M as a potential method for evaluating the performance of human raters. METHODS Participants with a diagnosis of bipolar I or II disorder completed both a live interview of the Young Mania Rating Scale with a human rater (LR) and the ICI-M. A panel of three expert raters reviewed each videotaped LR and assigned a consensus rating (CR). Participants completed a modified version of the Client Satisfaction Questionnaire to assess each method. RESULTS Intraclass correlation coefficients were 0.91 between the ICI-M and CR and 0.97 between the LR and CR (n = 100), providing empirical support for the inter-rater reliability of each approach. Coefficient alphas indicated comparable internal consistency reliability: ICI-M = 0.82, LR = 0.83, and CR = 0.84. The ICI-M was significantly more sensitive in detecting symptomatology than the LR (p < 0.001) and the CR (p < 0.001), and resulted in significantly higher ratings than CR on mood, speech, psychotic content, and disruptive-aggressive behavior. While participants endorsed significantly higher overall satisfaction with LR, no significant differences emerged between ICI-M and LR regarding willingness to participate again or ability to understand the questions. CONCLUSIONS The ICI-M is a well-accepted and reliable method for assessing manic symptoms. The ICI-M is a tool with adequate sensitivity to elicit symptoms and rate severity and is recommended as a tool to monitor and improve rater performance, not as a replacement of a human rater.
Collapse
Affiliation(s)
| | | | - Andrew C Leon
- Weill Medical College of Cornell University, New York, NY, USA
| | - Louisa Sylvia
- Concordant Rater Systems, Boston, MA,Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Roy Perlis
- Concordant Rater Systems, Boston, MA,Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Gary S Sachs
- Concordant Rater Systems, Boston, MA,Massachusetts General Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
48
|
Kemp AS, Schooler NR, Kalali AH, Alphs L, Anand R, Awad G, Davidson M, Dubé S, Ereshefsky L, Gharabawi G, Leon AC, Lepine JP, Potkin SG, Vermeulen A. What is causing the reduced drug-placebo difference in recent schizophrenia clinical trials and what can be done about it? Schizophr Bull 2010; 36:504-9. [PMID: 18723840 PMCID: PMC2879679 DOI: 10.1093/schbul/sbn110] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [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] [Indexed: 11/14/2022]
Abstract
On September 18, 2007, a collaborative session between the International Society for CNS Clinical Trials and Methodology and the International Society for CNS Drug Development was held in Brussels, Belgium. Both groups, with membership from industry, academia, and governmental and nongovernmental agencies, have been formed to address scientific, clinical, regulatory, and methodological challenges in the development of central nervous system therapeutic agents. The focus of this joint session was the apparent diminution of drug-placebo differences in recent multicenter trials of antipsychotic medications for schizophrenia. To characterize the nature of the problem, some presenters reported data from several recent trials that indicated higher rates of placebo response and lower rates of drug response (even to previously established, comparator drugs), when compared with earlier trials. As a means to identify the possible causes of the problem, discussions covered a range of methodological factors such as participant characteristics, trial designs, site characteristics, clinical setting (inpatient vs outpatient), inclusion/exclusion criteria, and diagnostic specificity. Finally, possible solutions were discussed, such as improving precision of participant selection criteria, improving assessment instruments and/or assessment methodology to increase reliability of outcome measures, innovative methods to encourage greater subject adherence and investigator involvement, improved rater training and accountability metrics at clinical sites to increase quality assurance, and advanced methods of pharmacokinetic/pharmacodynamic modeling to optimize dosing prior to initiating large phase 3 trials. The session closed with a roundtable discussion and recommendations for data sharing to further explore potential causes and viable solutions to be applied in future trials.
Collapse
Affiliation(s)
- Aaron S. Kemp
- Psychiatry and Human Behavior, University of California, Irvine, CA,To whom correspondence should be addressed; tel: 714-456-8690; fax: 714-456-5967, UCI Neuropsychiatric Center, 101 The City Drive South, Orange, CA 92868; e-mail:
| | - Nina R. Schooler
- Psychiatry, Downstate Medical Center, State University of New York, Brooklyn, NY
| | - Amir H. Kalali
- Quintiles Inc, San Diego, CA,Psychiatry, University of California, San Diego, CA
| | - Larry Alphs
- Ortho-McNeil Janssen Scientific Affairs, Titusville, NJ
| | - Ravi Anand
- Anand Pharma Consulting, Oberwil, Switzerland
| | - George Awad
- Clarke Institute of Psychiatry, University of Toronto and Mental Health Program, Humber River Regional Hospital, Toronto, Canada
| | | | - Sanjay Dubé
- Lilly Development Laboratories, Eli Lilly and Company, Indianapolis, IN
| | | | | | - Andrew C. Leon
- Psychiatry and Public Health, Weill Medical College of Cornell University, New York, NY
| | - Jean-Pierre Lepine
- Service de Psychiatrie, Hôpital Lariboisière Fernand Widal, Paris, France
| | - Steven G. Potkin
- Psychiatry and Human Behavior, University of California, Irvine, CA
| | - An Vermeulen
- Johnson and Johnson Pharmaceutical Research and Development, Beerse, Belgium
| |
Collapse
|
49
|
Solomon DA, Leon AC, Coryell WH, Endicott J, Li C, Fiedorowicz JG, Boyken L, Keller MB. Longitudinal course of bipolar I disorder: duration of mood episodes. ACTA ACUST UNITED AC 2010; 67:339-47. [PMID: 20368510 DOI: 10.1001/archgenpsychiatry.2010.15] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT The phenomenology of bipolar I disorder affects treatment and prognosis. OBJECTIVE To describe the duration of bipolar I mood episodes and factors associated with recovery from these episodes. DESIGN Subjects with Research Diagnostic Criteria bipolar I disorder were prospectively followed up for as long as 25 years. The probability of recovery over time from multiple successive mood episodes was examined with survival analytic techniques, including a mixed-effects grouped-time survival model. SETTING Five US academic medical centers. PARTICIPANTS Two hundred nineteen subjects with bipolar I disorder. MAIN OUTCOME MEASURES Level of psychopathology was assessed with the Longitudinal Interval Follow-up Evaluation every 6 months for the first 5 years of follow-up and annually thereafter. RESULTS The median duration of bipolar I mood episodes was 13 weeks. More than 75% of the subjects recovered from their mood episodes within 1 year of onset. The probability of recovery was significantly less for an episode with severe onset (psychosis or severe psychosocial impairment in week 1 of the episode) (hazard ratio [HR] = 0.746; 95% confidence interval [CI], 0.578-0.963; P = .02) and for subjects with greater cumulative morbidity (total number of years spent ill with any mood episode) (HR = 0.917; 95% CI, 0.886-0.948; P < .001). Compared with the probability of recovery from a major depressive episode, there was a significantly greater probability of recovery from an episode of mania (HR = 1.713; 95% CI, 1.373-2.137; P < .001), hypomania (HR = 4.502; 95% CI, 3.466-5.849; P < .001), or minor depression (HR = 2.027; 95% CI, 1.622-2.534; P < .001) and, conversely, a significantly reduced probability of recovery from a cycling episode (switching from one pole to the other without an intervening period of recovery) (HR = 0.438; 95% CI, 0.351-0.548; P < .001). CONCLUSIONS The median duration of bipolar I mood episodes was 13 weeks, and the probability of recovery was significantly decreased for cycling episodes, mood episodes with severe onset, and subjects with greater cumulative morbidity.
Collapse
|
50
|
Kobak KA, Leuchter A, DeBrota D, Engelhardt N, Williams JBW, Cook IA, Leon AC, Alpert J. Site versus centralized raters in a clinical depression trial: impact on patient selection and placebo response. J Clin Psychopharmacol 2010; 30:193-7. [PMID: 20520295 DOI: 10.1097/jcp.0b013e3181d20912] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [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] [Indexed: 01/18/2023]
Abstract
The use of centralized raters who are remotely linked to sites and interview patients via videoconferencing or teleconferencing has been suggested as a way to improve interrater reliability and interview quality. This study compared the effect of site-based and centralized ratings on patient selection and placebo response in subjects with major depressive disorder. Subjects in a 2-center placebo and active comparator controlled depression trial were interviewed twice at each of 3 time points: baseline, 1-week postbaseline, and end point--once by the site rater and once remotely via videoconference by a centralized rater. Raters were blind to each others' scores. A site-based score of greater than 17 on the 17-item Hamilton Depression Rating Scale (HDRS-17) was required for study entry. When examining all subjects entering the study, site-based raters' HDRS-17 scores were significantly higher than centralized raters' at baseline and postbaseline but not at end point. At baseline, 35% of subjects given an HDRS-17 total score of greater than 17 by a site rater were given an HDRS total score of lower than 17 by a centralized rater and would have been ineligible to enter the study if the centralized rater's score was used to determine study entry. The mean placebo change for site raters (7.52) was significantly greater than the mean placebo change for centralized raters (3.18, P < 0.001). Twenty-eight percent were placebo responders (>50% reduction in HDRS) based on site ratings versus 14% for central ratings (P < 0.001). When examining data only from those subjects whom site and centralized raters agreed were eligible for the study, there was no significant difference in the HDRS-17 scores. Findings suggest that the use of centralized raters could significantly change the study sample in a major depressive disorder trial and lead to significantly less change in mood ratings among those randomized to placebo.
Collapse
|