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Bredemeier K, Larsen S, Shivakumar G, Grubbs K, McLean C, Tress C, Rosenfield D, DeRubeis R, Xu C, Foa E, Morland L, Pai A, Tsao C, Crawford J, Weitz E, Mayinja L, Feler B, Wachsman T, Lupo M, Hooper V, Cook R, Thase M. A comparison of prolonged exposure therapy, pharmacotherapy, and their combination for PTSD: What works best and for whom; study protocol for a randomized trial. Contemp Clin Trials 2022; 119:106850. [PMID: 35842108 DOI: 10.1016/j.cct.2022.106850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/22/2022] [Accepted: 07/10/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Several efficacious psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available; however, the comparative effectiveness of these treatments represents a major gap in the literature. The proposed study will compare the effectiveness of two leading PTSD treatments - Prolonged Exposure (PE) therapy and pharmacotherapy with paroxetine or venlafaxine extended release - as well as the combination of PE and medication. METHODS In a randomized clinical trial, veterans with PTSD (N = 450) recruited across six Veterans Affairs Medical Centers will complete assessments at baseline, mid-treatment (Week 7), post-treatment (Week 14), and follow-up (Weeks 27 and 40). The primary outcome will be change in (both clinician-rated and self-reported) PTSD severity. Depression symptoms, quality of life, and functioning will also be measured and examined as secondary outcomes. Baseline demographic and clinical data will be used to develop "personalized advantage indices" (PAIs), with the goal of identifying who is most likely to benefit from which treatment. CONCLUSIONS This planned trial will yield findings to directly inform clinical practice guidelines for PTSD, by providing comparative effectiveness data to support recommendations about what can be considered the "first-line" treatment option(s) for PTSD. Further, findings from this trial have the potential to guide treatment planning for individual patients, through implementation of PAIs developed from study data, in service of "personalized medicine." TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT04961190.
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Affiliation(s)
- Keith Bredemeier
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Sadie Larsen
- Milwaukee VA Medical Center, 5000 West National Avenue, Milwaukee, WI 53295-1000, USA; Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
| | - Geetha Shivakumar
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Kathleen Grubbs
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161-0002, USA; University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
| | - Carmen McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Stanford University, 450 Serra Mall, Stanford, CA 94305, USA.
| | - Carmella Tress
- Coatesville VA Medical Center, 1400 Black Horse Hill Road, Coatesville, PA 19320-2096, USA.
| | - David Rosenfield
- Southern Methodist University, 6425 Boaz Lane, Dallas, TX 75205, USA.
| | - Rob DeRubeis
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Colin Xu
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Edna Foa
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Leslie Morland
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161-0002, USA; University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
| | - Anushka Pai
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Carol Tsao
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
| | - Jaclyn Crawford
- Coatesville VA Medical Center, 1400 Black Horse Hill Road, Coatesville, PA 19320-2096, USA.
| | - Erica Weitz
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Lindiwe Mayinja
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA; Coatesville VA Medical Center, 1400 Black Horse Hill Road, Coatesville, PA 19320-2096, USA.
| | - Bridget Feler
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Tamara Wachsman
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161-0002, USA.
| | - Margaret Lupo
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA.
| | - Vaughan Hooper
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA.
| | - Riley Cook
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA.
| | - Michael Thase
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA; Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
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McGorry PD, Mei C, Hartmann J, Yung AR, Nelson B. Intervention strategies for ultra-high risk for psychosis: Progress in delaying the onset and reducing the impact of first-episode psychosis. Schizophr Res 2021; 228:344-356. [PMID: 33545668 DOI: 10.1016/j.schres.2020.12.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 10/02/2020] [Accepted: 12/31/2020] [Indexed: 12/26/2022]
Abstract
Over a quarter of a century ago, the formulation of the "at risk mental state" and operational criteria to prospectively identify individuals at "clinical" or "ultra-high risk" (UHR) for psychosis created a global wave of research momentum aimed at predicting and preventing first-episode psychosis. A substantial number of randomized controlled trials (RCTs) were conducted to determine if transition to psychosis could be delayed or even prevented. The efficacy of a range of interventions was examined, with standard meta-analyses clearly indicating that these could at least delay transition for 1-2 years and that outcomes improve. Recently, network meta-analyses have attempted to identify the most effective intervention. These highlighted the fact that no one form of intervention is superior to the rest, a finding interpreted in such a way as to create doubts concerning the value of intervening. These doubts have been reinforced by a subsequent Cochrane review which judged the quality of the evidence as low or very low. Here, we report a narrative review of findings from RCTs and meta-analyses on the efficacy of interventions in UHR. We also critique the network meta-analyses and the Cochrane review, and indicate that many of the trials were of the highest possible quality for such research, and were published in top ranked psychiatry journals, which demand such quality. Although outcomes vary, and the UHR group is clearly heterogeneous, we highlight the clinical benefits of psychosocial treatment. The next generation of clinical trials seek to elucidate the optimal type, duration and sequence of interventions.
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Affiliation(s)
- Patrick D McGorry
- Orygen, Parkville, Victoria, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia.
| | - Cristina Mei
- Orygen, Parkville, Victoria, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Jessica Hartmann
- Orygen, Parkville, Victoria, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Alison R Yung
- Orygen, Parkville, Victoria, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia; School of Health Sciences, University of Manchester, Manchester, UK
| | - Barnaby Nelson
- Orygen, Parkville, Victoria, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
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de Moraes Costa G, Zanatta FB, Ziegelmann PK, Soares Barros AJ, Mello CF. Pharmacological treatments for adults with post-traumatic stress disorder: A network meta-analysis of comparative efficacy and acceptability. J Psychiatr Res 2020; 130:412-420. [PMID: 32891916 DOI: 10.1016/j.jpsychires.2020.07.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The purpose of this study was to compare efficacy and acceptability among drug treatments for adults with post-traumatic stress disorder (PTSD) through a systematic review, random-effects pairwise and network meta-analyses. METHODS Double-blind randomized controlled trials comparing pharmacological interventions for adults with PTSD were searched from database inception through Aug. 28, 2018, on Cochrane (Central), Embase, LILACS, PILOTS, PsycINFO, PubMed, and Web of Science. Clinical trial registries and the websites of pharmaceutical companies were also searched. The GRADE system was used to assess the quality of the evidence. RESULTS The systematic review included 58 studies comprising 6766 patients randomized to 26 different interventions. Regarding efficacy, topiramate (SMD = -0.57; 95%CrI: -1.07,-0.10), risperidone (SMD = -0.53; 95%CrI: -0.93,-0.15), quetiapine (SMD = -0.59; 95%CrI: -1.06,-0.11), paroxetine (SMD = -0.35; 95%CrI: -0.48,-0.21), venlafaxine (SMD = -0.25; 95%CrI: -0.44,-0.05), fluoxetine (SMD = -0.28; 95%CrI: -0.46,-0.08), and sertraline (SMD = -0.21; 95%CrI: -0.33,-0.09) outperformed placebo. Moreover, phenelzine (RR = 3.39; 95%CrI: 1.43,11.09), lamotrigine (RR = 4.39; 95%CrI: 1.18,26.38), and fluoxetine (RR = 1.28%CrI: 1.01,1.59) outperformed placebo in terms of acceptability. CONCLUSIONS The NMA supports topiramate, risperidone, quetiapine, paroxetine, venlafaxine, fluoxetine and sertraline as effective pharmacological choices for the treatment of PTSD. Quetiapine and topiramate have the shortcoming of relying on a few small studies, but the clinically meaningful change in symptoms is noteworthy and merits further investigation. Among the pharmacological treatments with evidence of efficacy compared to placebo, fluoxetine achieved a relatively high rank regarding acceptability. To the best of our knowledge, this is the largest contemporary NMA on the subject and the addition of new medications is an important extension of previous meta-analyses, enabling a larger number of drug comparisons.
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Affiliation(s)
- Gabriela de Moraes Costa
- Department of Neuropsychiatry, Center of Health Sciences, Assistant Professor, Federal University of Santa Maria (UFSM), Roraima Avenue, nº1000, Building 26, room 1445, Zip code 97105-900, Santa Maria, Rio Grande do Sul, Brazil.
| | - Fabricio Batistin Zanatta
- Department of Stomatology, Postgraduate Program in Dentistry, Adjunct Professor, Federal University of Santa Maria (UFSM), Roraima Avenue, nº1000, Building 26 F, Zip code 97105-900, Santa Maria, Rio Grande do Sul, Brazil.
| | - Patricia Klarmann Ziegelmann
- Statistics Department, Postgraduate Program in Epidemiology, Full Professor, Federal University of Rio Grande do Sul (UFRGS), Ramiro Barcelos Street, no 2400, Zip code 90035003, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Alcina Juliana Soares Barros
- Postgraduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul (UFRGS), Ramiro Barcelos Street, nº 2400, Zip code 90035003, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Carlos Fernando Mello
- Department of Physiology and Pharmacology, Center of Health Sciences, Postgraduate Program in Pharmacology, Full Professor, Federal University of Santa Maria (UFSM), Roraima Avenue, nº1000, Building 21, room 5118, Zip code 97105-900, Santa Maria, Rio Grande do Sul, Brazil.
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McGorry PD, Nelson B, Wood SJ, Shah JL, Malla A, Yung A. Transcending false dichotomies and diagnostic silos to reduce disease burden in mental disorders. Soc Psychiatry Psychiatr Epidemiol 2020; 55:1095-1103. [PMID: 32683471 DOI: 10.1007/s00127-020-01913-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 06/30/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Patrick D McGorry
- Orygen, 35 Poplar Rd (Locked Bag 10), Parkville, VIC, 3052, Australia. .,Centre for Youth Mental Health, The University of Melbourne, Parkville, Australia.
| | - Barnaby Nelson
- Orygen, 35 Poplar Rd (Locked Bag 10), Parkville, VIC, 3052, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Australia
| | - Stephen J Wood
- Orygen, 35 Poplar Rd (Locked Bag 10), Parkville, VIC, 3052, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Australia.,School of Psychology, University of Birmingham, Birmingham, UK
| | - Jai L Shah
- Department of Psychiatry, McGill University, Montreal, Canada.,Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Canada.,ACCESS Open Minds, Douglas Mental Health University Institute, Montreal, Canada
| | - Ashok Malla
- Department of Psychiatry, McGill University, Montreal, Canada.,Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montreal, Canada.,ACCESS Open Minds, Douglas Mental Health University Institute, Montreal, Canada
| | - Alison Yung
- Orygen, 35 Poplar Rd (Locked Bag 10), Parkville, VIC, 3052, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Australia.,School of Health Sciences, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK
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Øien RA, Cicchetti DV, Nordahl-Hansen A, Schjølberg S. A Commentary to "Toddler Screening for Autism Spectrum Disorder: A Meta-Analysis of Diagnostic Accuracy". J Autism Dev Disord 2019; 50:3440-3441. [PMID: 31522307 DOI: 10.1007/s10803-019-04226-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Roald A Øien
- Department of Education, UiT - The Arctic University of Norway, PB 6050, N-9037, Tromsø, Norway. .,Child Study Center, Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Domenic V Cicchetti
- Child Study Center, Yale School of Medicine, Yale University, New Haven, CT, USA
| | | | - Synnve Schjølberg
- Department of child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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