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Laroche D, Ivers H, Bastien CH, Vallières A. Predictability of sleep in insomnia: sleep patterns of patients from a sleep psychology clinic. J Sleep Res 2024:e14369. [PMID: 39327793 DOI: 10.1111/jsr.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 09/13/2024] [Accepted: 09/16/2024] [Indexed: 09/28/2024]
Abstract
The present study aims at identifying sleep patterns in insomnia in a clinical sample using three strategies to define poor nights. Sleep diaries and self-reported questionnaires were collected from 77 clinical patients with insomnia. The conditional probabilities of observing a poor night after 1, 2, or 3 consecutive poor nights were computed according to three strategies with same criteria for sleep onset latency, wake after sleep onset, and sleep efficiency, but varying criterion for total sleep time. Latent profile analyses were conducted to derive sleep patterns. Uni- and multivariate analyses were conducted to characterise the sleep patterns identified. A total of 1586 nights were analysed. The strategy used significantly influenced the average percentage of reported poor nights. Two to three sleep patterns were derived per strategy. Within each strategy, sleep patterns differed from each other on sleep variables and night-to-night variability. Results suggest the existence of sleep patterns in insomnia among individuals consulting in psychological clinics. Adding a total sleep time of 6-h cut-off as a criterion to define poor nights increases the accuracy of the strategy to define poor night and allows to identify sleep patterns of poor nights in insomnia.
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Affiliation(s)
- Dave Laroche
- École de psychologie, Université Laval, Quebec City, Quebec, Canada
- CERVO Brain Research Center, Quebec City, Quebec, Canada
| | - Hans Ivers
- École de psychologie, Université Laval, Quebec City, Quebec, Canada
- Centre de recherche sur la cancer, Université Laval, Quebec City, Quebec, Canada
| | - Celyne H Bastien
- École de psychologie, Université Laval, Quebec City, Quebec, Canada
- CERVO Brain Research Center, Quebec City, Quebec, Canada
| | - Annie Vallières
- École de psychologie, Université Laval, Quebec City, Quebec, Canada
- CERVO Brain Research Center, Quebec City, Quebec, Canada
- Centre de recherche du CHU de Québec-Université Laval, Quebec City, Quebec, Canada
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Affiliation(s)
- Rudolf Uher
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada.
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Leung T, Gulliver A, Sunderland M, Farrer L, Kay-Lambkin F, Trias A, Calear A. Factors Influencing Community Participation in Internet Interventions Compared With Research Trials: Observational Study in a Nationally Representative Adult Cohort. J Med Internet Res 2023; 25:e41663. [PMID: 36729613 PMCID: PMC9936370 DOI: 10.2196/41663] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Digital mental health (DMH) programs can be effective in treating and preventing mental health problems. However, community engagement with these programs can be poor. Understanding the barriers and enablers of DMH program use may assist in identifying ways to increase the uptake of these programs, which have the potential to provide broad-scale prevention and treatment in the community. OBJECTIVE In this study, we aimed to identify and compare factors that may influence participation in DMH programs in practice and research trials, identify any respondent characteristics that are associated with these factors, and assess the relationship between intentions to use DMH programs and actual uptake. METHODS Australian adults aged ≥18 years were recruited from market research panels to participate in the study. The sample was representative of the Australian adult population based on age, gender, and location. Participants completed a cross-sectional web-based survey assessing demographic characteristics, mental health symptom measures, attitudes and use of DMH programs in practice and in research studies, and the factors influencing their use in both settings. RESULTS Across both research and practice, trust in the organization delivering the service or trial was the top-ranked factor influencing participation, followed by anonymity or privacy and adequate information. There was little variation in rankings across demographic groups, including intentions to use DMH programs or mental health status. Intentions to use DMH programs were a strong predictor of both current (odds ratio 2.50, 99% CI 1.41-4.43; P<.001) and past (odds ratio 2.98, 99% CI 1.71-5.19; P<.001) use behaviors. CONCLUSIONS Efforts to increase the uptake of DMH programs or participation in research trials should focus on clearly communicating the following to users: the legitimacy of the organization delivering the program, security and use of participant data, and effectiveness of DMH programs.
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Affiliation(s)
| | - Amelia Gulliver
- Centre for Mental Health Research, College of Health and Medicine, The Australian National University, Acton ACT, Australia
| | - Matthew Sunderland
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, Australia
| | - Louise Farrer
- Centre for Mental Health Research, College of Health and Medicine, The Australian National University, Acton ACT, Australia
| | | | - Angelica Trias
- Centre for Mental Health Research, College of Health and Medicine, The Australian National University, Acton ACT, Australia
| | - Alison Calear
- Centre for Mental Health Research, College of Health and Medicine, The Australian National University, Acton ACT, Australia
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Psychological interventions for generalized anxiety disorder: Effects and predictors in a naturalistic outpatient setting. PLoS One 2023; 18:e0282902. [PMID: 36897860 PMCID: PMC10004605 DOI: 10.1371/journal.pone.0282902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/25/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Numerous randomized controlled trials (RCTs) demonstrate the efficacy of cognitive behavioral therapy (CBT), metacognitive therapy (MCT), and methods to reduce intolerance of uncertainty (IU-CBT) in the treatment of generalized anxiety disorder (GAD). However, few studies have investigated these treatments under conditions of routine clinical care. The main objective of this study was to investigate the effectiveness of psychotherapy for GAD in an outpatient setting and to identify factors influencing treatment outcome. METHODS Fifty-nine GAD patients received naturalistic CBT (including MCT and IU-CBT) in an outpatient clinic and postgraduate training center for psychotherapy. Patients completed self-report questionnaires at the beginning and end of therapy regarding the main outcome worry as well as metacognitions, intolerance of uncertainty, depression, and general psychopathology. RESULTS Worry, negative metacognitions, intolerance of uncertainty, depression, and general psychopathology decreased significantly (p's < .001) with large effect sizes for all symptoms (d = 0.83-1.49). A reliable change in the main outcome worry was observed in 80% of patients, and recovery occurred in 23%. Higher worry scores at posttreatment were predicted by higher pretreatment scores, female sex, and less change in negative metacognitive beliefs during treatment. CONCLUSIONS Naturalistic CBT for GAD appears to be effective in routine clinical care for worry as well as depressive symptoms, with particular benefits associated with altering negative metacognitions. However, a recovery rate of only 23% is lower than the rates reported in RCTs. Treatment needs to be improved, especially for patients with more severe GAD and for women.
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Ouazana-Vedrines C, Lesuffleur T, Cuerq A, Fagot-Campagna A, Rachas A, Gastaldi-Ménager C, Hoertel N, Limosin F, Lemogne C, Tuppin P. Outcomes associated with antidepressant treatment according to the number of prescriptions and treatment changes: 5-year follow-up of a nation-wide cohort study. Front Psychiatry 2022; 13:923916. [PMID: 36159949 PMCID: PMC9492934 DOI: 10.3389/fpsyt.2022.923916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Naturalistic studies regarding clinical outcomes associated with antidepressant treatment duration have yielded conflicting results, possibly because they did not consider the occurrence of treatment changes. This nation-wide population-based study examined the association between the number of filled prescriptions and treatment changes and long-term psychiatric outcomes after antidepressant treatment initiation. METHODS Based on the French national health insurance database, 842,175 adults who initiated an antidepressant treatment in 2011 were included. Cox proportional-hazard multi-adjusted regression models examined the association between the number of filled prescriptions and the occurrence of treatment changes 12 months after initiation and four outcomes during a 5-year follow-up: psychiatric hospitalizations, suicide attempts, sick leaves for a psychiatric diagnosis, new episodes of antidepressant treatment. RESULTS During a mean follow-up of 4.5 years, the incidence rates of the four above-mentioned outcomes were 13.49, 2.47, 4.57, and 92.76 per 1,000 person-years, respectively. The number of filled prescriptions was associated with each outcome (adjusted HRs [95% CI] for one additional prescription ranging from 1.01 [1.00-1.02] to 1.10 [1.09-1.11]), as was the occurrence of at least one treatment change vs. none (adjusted HRs [95% CI] ranging from 1.18 [1.16-1.21] to 1.57 [1.79-1.65]). Furthermore, the adjusted HRs [95% CI] of the number of filled prescriptions were greater in patients with (vs. without) a treatment change for psychiatric hospitalizations (1.12 [1.11-1.14] vs. 1.09 [1.08-1.10], p for interaction = 0.002) and suicide attempts (1.12 [1.09-1.15] vs. 1.06 [1.04-1.08], p for interaction = 0.006). LIMITATIONS Lack of clinical data about the disorders warranting the prescriptions or their severity. CONCLUSION Considering treatment changes is critical when using administrative claims database to examine the long-term psychiatric outcomes of antidepressant treatments in real-life settings.
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Affiliation(s)
- Charles Ouazana-Vedrines
- UFR de Médecine, Faculté de Santé, Université Paris Cité, Paris, France.,Service de Psychiatrie de l'Adulte, AP-HP, Hôpital Hôtel-Dieu, Paris, France
| | - Thomas Lesuffleur
- Department of Pathologies and Patients, Caisse Nationale d'Assurance Maladie, Paris, France
| | - Anne Cuerq
- Department of Pathologies and Patients, Caisse Nationale d'Assurance Maladie, Paris, France
| | - Anne Fagot-Campagna
- Department of Pathologies and Patients, Caisse Nationale d'Assurance Maladie, Paris, France
| | - Antoine Rachas
- Department of Pathologies and Patients, Caisse Nationale d'Assurance Maladie, Paris, France
| | | | - Nicolas Hoertel
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université Paris Cité, Paris, France.,Service de Psychiatrie et d'Addictologie de l'Adulte et du Sujet Âgé, AP-HP, Hôpital Corentin-Celton, Issy-les-Moulineaux, France
| | - Frédéric Limosin
- INSERM U1266, Institut de Psychiatrie et Neurosciences de Paris, Université Paris Cité, Paris, France.,Service de Psychiatrie et d'Addictologie de l'Adulte et du Sujet Âgé, AP-HP, Hôpital Corentin-Celton, Issy-les-Moulineaux, France
| | - Cédric Lemogne
- Service de Psychiatrie de l'Adulte, AP-HP, Hôpital Hôtel-Dieu, Paris, France.,Service de Psychiatrie et d'Addictologie de l'Adulte et du Sujet Âgé, AP-HP, Hôpital Corentin-Celton, Issy-les-Moulineaux, France
| | - Philippe Tuppin
- Department of Pathologies and Patients, Caisse Nationale d'Assurance Maladie, Paris, France
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Evidence-Based Pharmacotherapy of Generalised Anxiety Disorder: Focus on Agomelatine. Adv Ther 2021; 38:52-60. [PMID: 34417992 PMCID: PMC8437845 DOI: 10.1007/s12325-021-01860-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/12/2021] [Indexed: 01/04/2023]
Abstract
Recent network meta-analyses support the use of pharmacotherapy in patients with generalised anxiety disorder (GAD). Compared with placebo, drug treatment can improve symptoms and quality of life, and is more effective in preventing relapse. Selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors are generally considered the first-line agents of choice in GAD, but in some patients, an alternative evidence-based treatment with a different mechanism of action may also be considered (e.g. those with severe GAD, inadequate response, adverse effects and/or contraindications). One example is agomelatine, a melatonin receptor agonist and serotonin 2C (5-HT2C) receptor antagonist, which has been shown to have efficacy that is greater than placebo in patients with GAD, and to have a tolerability profile that compares favourably with that of escitalopram. Both agomelatine and escitalopram are efficacious in treating patients with GAD, including those with severe symptoms. Video Abstract
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Stein DJ, Kazdin AE, Ruscio AM, Chiu WT, Sampson NA, Ziobrowski HN, Aguilar-Gaxiola S, Al-Hamzawi A, Alonso J, Altwaijri Y, Bruffaerts R, Bunting B, de Girolamo G, de Jonge P, Degenhardt L, Gureje O, Haro JM, Harris MG, Karam A, Karam EG, Kovess-Masfety V, Lee S, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, Nishi D, Posada-Villa J, Scott KM, Viana MC, Vigo DV, Xavier M, Zarkov Z, Kessler RC. Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report. BMC Psychiatry 2021; 21:392. [PMID: 34372811 PMCID: PMC8351147 DOI: 10.1186/s12888-021-03363-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 07/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. CONCLUSIONS The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.
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Affiliation(s)
- Dan J. Stein
- grid.7836.a0000 0004 1937 1151Department of Psychiatry & Mental Health and South African Medical Council Research Unit on Risk and Resilience in Mental Disorders, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Alan E. Kazdin
- grid.47100.320000000419368710Department of Psychology, Yale University, New Haven, CT USA
| | - Ayelet Meron Ruscio
- grid.25879.310000 0004 1936 8972Department of Psychology, University of Pennsylvania, Philadelphia, PA USA
| | - Wai Tat Chiu
- grid.38142.3c000000041936754XDepartment of Health Care Policy, Harvard Medical School, Boston, MA USA
| | - Nancy A. Sampson
- grid.38142.3c000000041936754XDepartment of Health Care Policy, Harvard Medical School, Boston, MA USA
| | - Hannah N. Ziobrowski
- grid.38142.3c000000041936754XDepartment of Health Care Policy, Harvard Medical School, Boston, MA USA
| | - Sergio Aguilar-Gaxiola
- grid.416958.70000 0004 0413 7653Center for Reducing Health Disparities, UC Davis Health System, Sacramento, California, USA
| | - Ali Al-Hamzawi
- College of Medicine, Al-Qadisiya University, Diwaniya governorate, Al Diwaniyah, Iraq
| | - Jordi Alonso
- grid.20522.370000 0004 1767 9005Health Services Research Unit, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain ,grid.413448.e0000 0000 9314 1427CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain ,grid.5612.00000 0001 2172 2676Pompeu Fabra University (UPF), Barcelona, Spain
| | - Yasmin Altwaijri
- grid.415310.20000 0001 2191 4301Epidemiology Section, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ronny Bruffaerts
- grid.5596.f0000 0001 0668 7884Universitair Psychiatrisch Centrum - Katholieke Universiteit Leuven (UPC-KUL), Campus Gasthuisberg, Leuven, Belgium
| | - Brendan Bunting
- grid.12641.300000000105519715School of Psychology, Ulster University, Londonderry, UK
| | - Giovanni de Girolamo
- grid.419422.8IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Peter de Jonge
- grid.4830.f0000 0004 0407 1981Department of Developmental Psychology, University of Groningen, Groningen, Netherlands ,grid.4494.d0000 0000 9558 4598Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, Netherlands
| | - Louisa Degenhardt
- grid.1005.40000 0004 4902 0432National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Oye Gureje
- grid.412438.80000 0004 1764 5403Department of Psychiatry, University College Hospital, Ibadan, Nigeria
| | - Josep Maria Haro
- grid.5841.80000 0004 1937 0247Parc Sanitari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain
| | - Meredith G. Harris
- grid.1003.20000 0000 9320 7537School of Public Health, The University of Queensland, Herston, QLD 4006 Australia ,grid.417162.70000 0004 0606 3563Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD 4072 Australia
| | - Aimee Karam
- grid.429040.bInstitute for Development, Research, Advocacy & Applied Care (IDRAAC), Beirut, Lebanon
| | - Elie G. Karam
- grid.429040.bInstitute for Development, Research, Advocacy & Applied Care (IDRAAC), Beirut, Lebanon ,grid.416659.90000 0004 1773 3761Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon ,grid.33070.370000 0001 2288 0342Faculty of Medicine, Balamand University, Beirut, Lebanon
| | - Viviane Kovess-Masfety
- grid.508487.60000 0004 7885 7602Ecole des Hautes Etudes en Santé Publique (EHESP), EA 4057, Paris Descartes University, Paris, France
| | - Sing Lee
- grid.10784.3a0000 0004 1937 0482Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong
| | - Maria Elena Medina-Mora
- grid.419154.c0000 0004 1776 9908National Institute of Psychiatry-Ramón de la Fuente Muñiz, Mexico City, Mexico
| | - Jacek Moskalewicz
- grid.418955.40000 0001 2237 2890Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Fernando Navarro-Mateu
- grid.419058.10000 0000 8745 438XUDIF-SM, Servicio Murciano de Salud; IMIB-Arrixaca; CIBERESP-Murcia, Región de Murcia, Murcia, Spain
| | - Daisuke Nishi
- grid.26999.3d0000 0001 2151 536XDepartment of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan ,grid.419280.60000 0004 1763 8916National Center of Neurology and Psychiatry, Tokyo, Japan
| | - José Posada-Villa
- grid.441728.c0000 0004 1779 6631Colegio Mayor de Cundinamarca University, Faculty of Social Sciences, Bogota, Colombia
| | - Kate M. Scott
- grid.29980.3a0000 0004 1936 7830Department of Psychological Medicine, University of Otago, Dunedin, Otago New Zealand
| | - Maria Carmen Viana
- grid.412371.20000 0001 2167 4168Department of Social Medicine, Postgraduate Program in Public Health, Federal University of Espírito Santo, Vitoria, Brazil
| | - Daniel V. Vigo
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, University of British Columbia, Vancouver, BC Canada ,grid.38142.3c000000041936754XDepartment of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - Miguel Xavier
- grid.10772.330000000121511713Lisbon Institute of Global Mental Health and Chronic Diseases Research Center (CEDOC), NOVA Medical School-Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Zahari Zarkov
- grid.416574.5Department of Mental Health, National Center of Public Health and Analyses, Sofia, Bulgaria
| | - Ronald C. Kessler
- grid.38142.3c000000041936754XDepartment of Health Care Policy, Harvard Medical School, Boston, MA USA
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Who Is Seeking Help for Sleep? A Clinical Profile of Patients in a Sleep Psychology Clinic. Int J Behav Med 2021; 28:207-213. [PMID: 32405918 DOI: 10.1007/s12529-020-09882-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The present study outlines a clinical profile of an ecologically valid population consulting for sleep difficulties at the Sleep Psychology Clinic of the Consultation service of the School of Psychology of Université Laval . METHOD Patients self-report to the sleep clinic. Following a phone screening interview, patients present to the clinic for a semi-structured clinical interview for sleep and psychopathology, which is conducted by psychologists and doctorate psychology students. A chart review of adult patients (56% female, Mage = 43.6 years) was conducted (between 2015 and 2018) to record diagnosed sleep, psychiatric, and medical conditions. RESULTS There was a high level of comorbidity with an average of 2.85 diagnoses (any diagnosis combined) per patient (SD = 1.76), with 27% of the patients having at least four diagnoses. Reviewing specific types of disorders, 58.5% of patients presented with at least one comorbid psychiatric disorder, 27.5% with one medical comorbidity, or 39.5% with another sleep disorder alongside their primary sleep concern. Insomnia was the main sleep disorder (76%). Anxiety (77.8%) and depression (53.8%) were the predominant psychiatric disorders, while fibromyalgia (10.9%), hypertension (10.9%), and head trauma (9.1%) were the main medical conditions. Of patients with five diagnoses and more, 77.8% were taking on average 3.2 different types of medications. The number of diagnoses predicted the use of prescribed hypnotics and the use of any type of medications. CONCLUSION This clinical profile emphasizes the reality of multiple morbidities, which may have implications for clinical decisions. Future research is required to evaluate transdiagnostic approaches for the sleep disorder patient with multiple morbidities.
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Stein DJ, Khoo JP, Picarel-Blanchot F, Olivier V, Van Ameringen M. Efficacy of Agomelatine 25-50 mg for the Treatment of Anxious Symptoms and Functional Impairment in Generalized Anxiety Disorder: A Meta-Analysis of Three Placebo-Controlled Studies. Adv Ther 2021; 38:1567-1583. [PMID: 33537871 PMCID: PMC7932987 DOI: 10.1007/s12325-020-01583-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/19/2020] [Indexed: 12/15/2022]
Abstract
Introduction The purpose of this study is to investigate the effects of agomelatine on anxious symptoms and functional impairment in a pooled dataset from randomized placebo-controlled trials for generalized anxiety disorder (GAD). Methods Data from three randomized, placebo-controlled trials that evaluated the efficacy of agomelatine 25–50 mg were pooled. The short-term (12 weeks) efficacy of agomelatine was assessed in regards to (1) anxious symptoms using the Hamilton Anxiety Scale (HAM-A), and (2) functional impairment using the Sheehan Disability Scale (SDS). Meta-analysis using a random effect model was used to assess differences between groups. Remission and response rates for the HAM-A and SDS were calculated, and analyses were repeated in participants with more severe anxiety symptoms. Results In total, 669 patients (340 on agomelatine; 329 on placebo) were included in the analyses. Compared to placebo, the agomelatine group had a significant reduction in HAM-A total score at week 12 (between group difference: 6.30 ± 2.51, p = 0.012). Significant effects were also found for symptom response on the HAM-A (67.1% of patients on agomelatine vs. 32.5% on placebo) and symptom remission (38.8% of patients on agomelatine vs. 17.3% on placebo). Compared to placebo, there was a significant difference in favour of the agomelatine group at week 12 on the SDS total score (5.11 ± 1.81, p = 0.005). Significant effects were also found for functional response on the SDS (79.1% of patients on agomelatine vs. 43.2% of placebo) and functional remission (55.2% of patients on agomelatine vs. 25.4% on placebo). All findings for anxious symptoms and functional impairment were confirmed in the subset of more severely anxious patients. Agomelatine was well tolerated by patients. Conclusion This meta-analysis confirms that agomelatine reduces anxiety symptoms and improves the global functioning of GAD patients. Supplementary Information The online version of this article (10.1007/s12325-020-01583-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dan J Stein
- SAMRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - Jon-Paul Khoo
- Toowong Specialist Clinic, Toowong, Brisbane, Australia
| | | | - Valérie Olivier
- Institut de Recherches Internationales Servier (IRIS), Suresnes Cedex, France
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neuroscience, McMaster University-MacAnxiety Research Centre, Hamilton, ON, Canada
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Sugarman DE, Horvitz LE, Greenfield SF, Busch AB. Clinicians' Perceptions of Rapid Scale-up of Telehealth Services in Outpatient Mental Health Treatment. Telemed J E Health 2021; 27:1399-1408. [PMID: 33600272 DOI: 10.1089/tmj.2020.0481] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Little is known about specialty mental health and/or substance use disorder (MH/SUD) clinicians' experiences transitioning from in-person to telehealth care, to treat a diagnostically diverse population during the COVID-19 pandemic. Methods: Survey of outpatient MH/SUD clinicians (psychiatrists, nurse practitioners, psychologists, and licensed clinical social workers; N = 107) at a psychiatric hospital. Clinician satisfaction and experiences using telehealth across a variety of services (individual, group or family therapy, initial assessments, evaluation and management, and neuropsychological assessment) were assessed using a mixed-methods approach. Results: Across services, a majority agreed/strongly agreed that telehealth provided an opportunity to build rapport with patients (67-88%) and they could treat their patients' needs well (71-88%). The interest in continuing to use telehealth when in-person visits resume varied by type of service provided (50-71%). Group therapy and initial assessment were lowest (50% and 51%, respectively). Clinicians noted telehealth improved access to care for patients with logistical barriers, competing demands, mobility difficulties, and medical concerns; but was more challenging to care for patients with certain psychiatric characteristics (e.g., psychosis, paranoia, catatonia, high distractibility, and avoidance), high symptom severity, or who needed to improve social skills. Telehealth influenced the therapeutic process (e.g., observations of family dynamic, increased patient/clinician therapeutic alliance). Discussion and Conclusions: MH/SUD clinicians who quickly transitioned to telehealth care during the pandemic were largely satisfied with telehealth, but also identified challenges related to specific patient characteristics, or types of MH/SUD services. These observations warrant additional study to better delineate the role for an expanded use of telehealth postpandemic.
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Affiliation(s)
- Dawn E Sugarman
- McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Shelly F Greenfield
- McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Alisa B Busch
- McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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11
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Lesko CR, Ackerman B, Webster-Clark M, Edwards JK. Target validity: Bringing treatment of external validity in line with internal validity. CURR EPIDEMIOL REP 2021; 7:117-124. [PMID: 33585162 DOI: 10.1007/s40471-020-00239-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Purpose of Review "Target bias" is the difference between an estimate of association from a study sample and the causal effect in the target population of interest. It is the sum of internal and external bias. Given the extensive literature on internal validity, here, we review threats and methods to improve external validity. Recent findings External bias may arise when the distribution of modifiers of the effect of treatment differs between the study sample and the target population. Methods including those based on modeling the outcome, modeling sample membership, and doubly robust methods are available, assuming data on the target population is available. Summary The relevance of information for making policy decisions is dependent on both the actions that were studied and the sample in which they were evaluated. Combining methods for addressing internal and external validity can improve the policy relevance of study results.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Benjamin Ackerman
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, MD
| | | | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
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12
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Hoertel N, Rotenberg L, Schuster JP, Blanco C, Lavaud P, Hanon C, Hozer F, Teruel E, Manetti A, Costemale-Lacoste JF, Seigneurie AS, Limosin F. Generalizability of pharmacologic and psychotherapy trial results for late-life unipolar depression. Aging Ment Health 2021; 25:367-377. [PMID: 31726850 DOI: 10.1080/13607863.2019.1691146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Despite evidence of low representativeness of clinical trial results for depression in adults, the generalizability of clinical trial results for late-life depression is unknown. This study sought to quantify the representativeness of pharmacologic and psychotherapy clinical trial results for late-life unipolar depression. METHOD Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults from the United States population. To assess the generalizability of clinical trial results for late-life depression, we applied a standard set of eligibility criteria representative of pharmacologic and psychotherapy clinical trials to all individuals aged 65 years and older in NESARC with a DSM-IV diagnosis of MDE and no lifetime history of mania/hypomania (n = 273) and in a subsample of individuals seeking help for depression (n = 78). RESULTS More than four of ten respondents and about two of ten respondents would have been excluded by at least one exclusion criterion in a typical pharmacologic and psychotherapy efficacy trial, respectively. Similar results (i.e.41.1% and 25.9%, respectively) were found in the subsample of individuals seeking help for depression. Excess percentage of exclusion in typical pharmacologic studies was accounted for by the criterion "significant medical condition". We also found that populations typically included in pharmacologic and psychotherapy clinical trials for late-life unipolar depression may substantially differ. CONCLUSION Psychotherapy trial results may be representative of most patients with late-life unipolar depression in routine clinical practice. By contrast, pharmacologic clinical trials may not be readily generalizable to community samples.
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Affiliation(s)
- Nicolas Hoertel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France.,Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France.,Centre Psychiatrie et Neurosciences, Inserm Umr 894, Paris, France.,Université de Paris, Université Paris Descartes, Paris, France
| | - Léa Rotenberg
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Jean-Pierre Schuster
- Service of Old Age Psychiatry, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerland
| | - Carlos Blanco
- Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, Bethesda, MD, USA
| | - Pierre Lavaud
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Cécile Hanon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Franz Hozer
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Elisabeth Teruel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Aude Manetti
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | | | - Anne-Sophie Seigneurie
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Frédéric Limosin
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France.,Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France.,Centre Psychiatrie et Neurosciences, Inserm Umr 894, Paris, France.,Université de Paris, Université Paris Descartes, Paris, France
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13
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Venegas A, Meredith LR, Cooper ZD, Towns B, Ray LA. Inclusion of Cannabis Users in Alcohol Research Samples: Screening In, Screening Out, and Implications. Alcohol Alcohol 2020; 55:416-423. [PMID: 32328657 PMCID: PMC7307319 DOI: 10.1093/alcalc/agaa023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 03/10/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Alcohol and cannabis are frequently co-used, as 20-50% of those who drink alcohol report co-using cannabis. This study is based on the argument that alcohol researchers should enroll cannabis users in human laboratory studies of alcohol use disorder (AUD) to strengthen generalizability. This study examines how heavy drinking cannabis users differ from non-cannabis using heavy drinkers. METHODS In a community sample of non-treatment-seeking heavy drinkers (n = 551, 35% female), cannabis users were identified through: (a) self-reported cannabis use in the past 6 months and (b) positive urine toxicology test for tetrahydrocannabinol (THC). Cannabis users, identified as described previously, were compared with non-cannabis users on demographic and clinical characteristics. RESULTS Those who endorsed cannabis use in the past 6 months reported more binge drinking days. Participants who tested positive for THC had higher Alcohol Use Disorder Identification Test scores and more binge drinking days. Younger age and being a tobacco smoker were associated with an increased likelihood of cannabis use in the past 6 months, whereas male gender and being a tobacco use were associated with a greater likelihood of testing positive for THC. Individuals with cannabis use disorder (CUD) endorsed more depression and anxiety and had higher AUD symptom counts than cannabis users without CUD. CONCLUSIONS The inclusion of cannabis users in AUD samples allows for increased clinical severity. Excluding cannabis users from AUD studies may limit representativeness and expend unnecessary study resources. Lastly, tobacco use may explain a large portion of the effects of cannabis use on sample characteristics. SHORT SUMMARY Alcohol and cannabis are frequently co-used substances. In a sample of non-treatment-seeking heavy drinkers (n = 551, 35% female), cannabis users reported higher alcohol use and higher likelihood of tobacco use than non-cannabis users. Including cannabis users in alcohol research studies will improve representativeness and likely increase clinical severity.
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Affiliation(s)
- Alexandra Venegas
- University of California, Los Angeles, Department of Psychology, Los Angeles, CA, USA
| | - Lindsay R Meredith
- University of California, Los Angeles, Department of Psychology, Los Angeles, CA, USA
| | - Ziva D Cooper
- University of California, Los Angeles, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA
- University of California, Los Angeles, Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
| | - Brandon Towns
- University of California, Los Angeles, Department of Psychology, Los Angeles, CA, USA
| | - Lara A Ray
- University of California, Los Angeles, Department of Psychology, Los Angeles, CA, USA
- University of California, Los Angeles, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA
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14
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He Z, Tang X, Yang X, Guo Y, George TJ, Charness N, Quan Hem KB, Hogan W, Bian J. Clinical Trial Generalizability Assessment in the Big Data Era: A Review. Clin Transl Sci 2020; 13:675-684. [PMID: 32058639 PMCID: PMC7359942 DOI: 10.1111/cts.12764] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/25/2020] [Indexed: 01/04/2023] Open
Abstract
Clinical studies, especially randomized, controlled trials, are essential for generating evidence for clinical practice. However, generalizability is a long‐standing concern when applying trial results to real‐world patients. Generalizability assessment is thus important, nevertheless, not consistently practiced. We performed a systematic review to understand the practice of generalizability assessment. We identified 187 relevant articles and systematically organized these studies in a taxonomy with three dimensions: (i) data availability (i.e., before or after trial (a priori vs. a posteriori generalizability)); (ii) result outputs (i.e., score vs. nonscore); and (iii) populations of interest. We further reported disease areas, underrepresented subgroups, and types of data used to profile target populations. We observed an increasing trend of generalizability assessments, but < 30% of studies reported positive generalizability results. As a priori generalizability can be assessed using only study design information (primarily eligibility criteria), it gives investigators a golden opportunity to adjust the study design before the trial starts. Nevertheless, < 40% of the studies in our review assessed a priori generalizability. With the wide adoption of electronic health records systems, rich real‐world patient databases are increasingly available for generalizability assessment; however, informatics tools are lacking to support the adoption of generalizability assessment practice.
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Affiliation(s)
- Zhe He
- School of Information, Florida State University, Tallahassee, Florida, USA
| | - Xiang Tang
- Department of Statistics, Florida State University, Tallahassee, Florida, USA
| | - Xi Yang
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Thomas J George
- Hematology & Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Neil Charness
- Department of Psychology, Florida State University, Tallahassee, Florida, USA
| | - Kelsa Bartley Quan Hem
- Calder Memorial Library, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - William Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
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15
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Munkholm K, Boesen K, Paludan-Müller AS. Pharmacological treatments for generalised anxiety disorder. Lancet 2019; 394:1229. [PMID: 31591981 DOI: 10.1016/s0140-6736(19)31626-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/10/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Klaus Munkholm
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen 2100, Denmark.
| | - Kim Boesen
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen 2100, Denmark
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16
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Susukida R, Crum RM, Hong H, Stuart EA, Mojtabai R. Comparing pharmacological treatments for cocaine dependence: Incorporation of methods for enhancing generalizability in meta-analytic studies. Int J Methods Psychiatr Res 2018; 27:e1609. [PMID: 29464791 PMCID: PMC6103900 DOI: 10.1002/mpr.1609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/13/2017] [Accepted: 01/05/2018] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Few head-to-head comparisons of cocaine dependence medications exist, and combining data from different randomized controlled trials (RCTs) is fraught with methodological challenges including limited generalizability of the RCT findings. This study applied a novel meta-analytic approach to data of cocaine dependence medications. METHODS Data from 4 placebo-controlled RCTs (Reserpine, Modafinil, Buspirone, and Ondansetron) were obtained from the National Institute of Drug Abuse Clinical Trials Network (n = 456). The RCT samples were weighted to resemble treatment-seeking patients (Treatment Episodes Data Set-Admissions) and individuals with cocaine dependence in general population (National Survey on Drug Use and Health). We synthesized the generalized outcomes with pairwise meta-analysis using individual-level data and compared the generalized outcomes across the 4 RCTs with network meta-analysis using study-level data. RESULTS Weighting the data by the National Survey on Drug Use and Health generalizability weight made the overall population effect on retention significantly larger than the RCT sample effect. However, there was no significant difference between the population effect and the RCT sample effect on abstinence. Weighting changed the ranking of the effectiveness across treatments. CONCLUSIONS Applying generalizability weights to meta-analytic studies is feasible and potentially provides a useful tool in assessing comparative effectiveness of treatments for substance use disorders in target populations.
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Affiliation(s)
- Ryoko Susukida
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Mental Health Policy and Evaluation, National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Rosa M Crum
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hwanhee Hong
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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17
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Lorenzo-Luaces L, Johns E, Keefe JR. The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review and Meta-Regression Analysis. J Med Internet Res 2018; 20:e10113. [PMID: 30413400 PMCID: PMC6251981 DOI: 10.2196/10113] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/11/2018] [Accepted: 07/19/2018] [Indexed: 01/23/2023] Open
Abstract
Background Self-guided internet-based cognitive behavioral therapies (iCBTs) for depressive symptoms may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT. Objective We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore the criteria’s effects on study outcomes, and compare the frequency of use of these criteria with their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample toward those with a less complex clinical profile, thus inflating treatment outcomes. Methods We updated a recently published meta-analysis by conducting a systematic literature search in PubMed, MEDLINE, PsycINFO, and EMBASE. We conducted a meta-regression analysis to test the effect of the different commonly used psychiatric entry criteria on the treatment-control differences. We also compared the frequency with which exclusion criteria were used in the self-guided iCBT studies versus studies of face-to-face psychotherapy and antidepressants from a recently published review. Results Our search yielded 5 additional studies, which we added to the 16 studies identified by Karyotaki and colleagues in 2017. Few self-guided iCBT studies excluded patients with severe depressive symptoms (6/21, 29%), but self-guided iCBT studies were more likely than antidepressant (14/170, 8.2%) studies to use this criterion. However, self-guided iCBT studies did not use this criterion more frequently than face-to-face psychotherapy studies (6/16, 38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were actually less likely to use most entry criteria, especially exclusions on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes. Conclusions A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided cognitive behavioral therapy may sample from a more heterogeneous and representative patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies.
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Affiliation(s)
- Lorenzo Lorenzo-Luaces
- Department of Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, IN, United States
| | - Emily Johns
- Department of Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, IN, United States
| | - John R Keefe
- Department of Psychology, University of Pennsylvania, Philadelphia, PA, United States
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18
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Stein DJ, Khoo JP, Ahokas A, Jarema M, Van Ameringen M, Vavrusova L, Hӧschl C, Bauer M, Bitter I, Mosolov SN, Olivier V, Matharan S, Picarel-Blanchot F, de Bodinat C. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol 2018; 28:970-979. [PMID: 30135032 DOI: 10.1016/j.euroneuro.2018.05.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 05/02/2018] [Accepted: 05/17/2018] [Indexed: 12/18/2022]
Abstract
Treatment of severely symptomatic patients with generalized anxiety disorder (GAD) raises particular concerns for clinicians. This 12-week double-blind study evaluated the efficacy of agomelatine (25-50 mg/day) in the treatment of patients with severe GAD, using escitalopram (10-20 mg) as active comparator. The primary outcome measure was the change from baseline of the total score on the Hamilton Anxiety scale (HAM-A) at week 12. Secondary outcome measures included rate of response to treatment (at least 50% score reduction from baseline) in the HAM-A psychic and somatic anxiety sub-scores, Clinical Global Impression severity and change scores, the Toronto Hospital Alertness Test, the Snaith-Hamilton Pleasure Scale, and the Leeds Sleep Evaluation Questionnaire Scores. Sixty one clinical centers (Australia, Canada, Czech Republic, Finland, Germany, Hungary, Poland, Russia, Slovakia) participated from April 2013 to February 2015. Patient characteristics and demographic data were comparable between treatment groups. Both treatments were associated with a clinically significant decrease in HAM-A total score at week 12; the non-inferiority of agomelatine versus escitalopram was not demonstrated (E(SE) = -0.91(0.69), 95%CI = [-2.26, 0.44], p = 0.195). At week 12, the response rate was 60.9% in the agomelatine group, and 64.8% in the escitalopram group. In both treatment arms, HAM-A psychic and somatic anxiety scores decreased, alertness and sleep parameters improved, and ability to experience pleasure increased. In these secondary outcome measures, there were no significant differences between the treatment groups. Agomelatine was well-tolerated, with a lower incidence of adverse events than escitalopram. Agomelatine and escitalopram are efficacious in treating GAD patients with severe symptoms.
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Affiliation(s)
- Dan J Stein
- University of Cape Town Department of Psychiatry & MRC Unit on Risk and Resilience in Mental Disorders, Groote Schuur Hospital, Anzio Road, Cape Town 7925, South Africa.
| | - Jon-Paul Khoo
- Toowong Specialist Clinic - Level 2, 54 Jephson Street, Toowong, QLD 4066 Australia
| | - Antti Ahokas
- Mehilainen Clinic, Runeberginkatu, 47 A, 00260 Helsinki, Finland
| | - Marek Jarema
- Institute of Psychiatry and Neurology, 3rd Department of Psychiatry, Sobieskiego 9, 02-0957 Warszawa, Poland
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1057 Main St. West, Suite L02, Hamilton, Ontario L8S 1B7, Canada
| | - Livia Vavrusova
- Private Psychiatric Practice - Vavrušová Consulting s.r.o., Záporožská 12, 851 01 Bratislava, Slovakia
| | - Cyril Hӧschl
- National Institute of Mental Health, Topolová 748, 250 67 Klecany, Czechia
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Fetscherstr. 74, 01307 Dresden, Germany
| | - Istvan Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Balassa u. 6, H-1083 Budapest Hungary
| | - Sergey N Mosolov
- Department for Therapy of Mental Disorders, Moscow Research Institute of Psychiatry, 3, Poteshnaya street, 107076 Moscow, Russia
| | - Valérie Olivier
- Institut de Recherches Internationales Servier (IRIS), 50 rue Carnot, 92284 Suresnes Cedex, France
| | - Sophie Matharan
- Institut de Recherches Internationales Servier (IRIS), 50 rue Carnot, 92284 Suresnes Cedex, France
| | | | - Christian de Bodinat
- Institut de Recherches Internationales Servier (IRIS), 50 rue Carnot, 92284 Suresnes Cedex, France
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19
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Lorenzo-Luaces L, Zimmerman M, Cuijpers P. Are studies of psychotherapies for depression more or less generalizable than studies of antidepressants? J Affect Disord 2018. [PMID: 29522947 DOI: 10.1016/j.jad.2018.02.066] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The generalizability of findings from studies exploring the efficacy of psychotherapy and antidepressants has been called into question in part because studies exclude many patients. Despite this, the frequency with which psychotherapy and antidepressant studies use specific inclusion and exclusion criteria has never been compared. We explored the exclusion criteria used in psychotherapy and pharmacotherapy studies from 1995 to 2014. METHOD Systematic literature searches were conducted in PubMed, Medline, PsycINFO, and Embase of published randomized controlled trials (RCTs) of the treatment of major depressive disorder (MDD) in adults with either antidepressants (vs. placebos) or psychotherapy (vs. placebos, treatments as usual, or other controls). RESULTS Most psychotherapy (81%) and antidepressant (100%) trials excluded patients with milder symptoms as well as patients with elevated suicidal risk (56-75%), psychotic symptoms (84-88%), or substance misuse (75-81%). Psychotherapy studies were less likely to exclude patients on the basis of brief episode duration (0% vs. 48%) and co-morbid Axis I disorders (6% vs. 27%). However, psychotherapy studies excluded patients with more severe symptoms more frequently (38%) than antidepressant studies (8%). CONCLUSIONS Overall, psychotherapy studies appear somewhat more inclusive than antidepressant studies. On average, antidepressant studies appear to target patients with more chronic and severe, as well as more purely depressive presentations.
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Affiliation(s)
- Lorenzo Lorenzo-Luaces
- Indiana University, Department of Psychological and Brain Sciences, 1101 E 10th St, Bloomington, IN 47405, United States.
| | - Mark Zimmerman
- Brown University School of Medicine, Department of Psychiatry and Human Behavior, United States
| | - Pim Cuijpers
- VU University Amsterdam, Department of Clinical, Neuro, and Developmental Psychology, The Netherlands
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20
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Blanco C, Hoertel N, Franco S, Olfson M, He JP, López S, González-Pinto A, Limosin F, Merikangas KR. Generalizability of Clinical Trial Results for Adolescent Major Depressive Disorder. Pediatrics 2017; 140:e20161701. [PMID: 29097612 PMCID: PMC5703774 DOI: 10.1542/peds.2016-1701] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Although there have been a number of clinical trials evaluating treatments for adolescents with major depressive disorder (MDD), the generalizability of those trials to samples of depressed adolescents who present for routine clinical care is unknown. Examining the generalizability of clinical trials of pharmacological and psychotherapy interventions for adolescent depression can help administrators and frontline practitioners determine the relevance of these studies for their patients and may also guide eligibility criteria for future clinical trials in this clinical population. METHODS Data on nationally representative adolescents were derived from the National Comorbidity Survey: Adolescent Supplement. To assess the generalizability of adolescent clinical trials for MDD, we applied a standard set of eligibility criteria representative of clinical trials to all adolescents in the National Comorbidity Survey: Adolescent Supplement with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of MDD (N = 592). RESULTS From the overall MDD sample, 61.9% would have been excluded from a typical pharmacological trial, whereas 42.2% would have been excluded from a psychotherapy trial. Among those who sought treatment (n = 412), the corresponding exclusion rates were 72.7% for a pharmacological trial and 52.2% for a psychotherapy trial. The criterion leading to the largest number of exclusions was "significant risk of suicide" in both pharmacological and psychotherapy trials. CONCLUSIONS Pharmacological and, to a lesser extent, psychotherapy clinical trials likely exclude most adolescents with MDD. Careful consideration should be given to balancing eligibility criteria and internal validity with applicability in routine clinical care while ensuring patient safety.
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Affiliation(s)
- Carlos Blanco
- Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, Bethesda, Maryland
| | - Nicolas Hoertel
- Paris Descartes University, Pôles de recherche et d'enseignement supérieur Sorbonne Paris Cité, Paris, France;
- Department of Psychiatry, Assistance Publique-Hôpitaux de Paris, Hôpital Corentin-Celton, Issy-les-Moulineaux, France
- Institut national de la santé et de la recherche médicale unité mixte de recherche 894, Psychiatry and Neurosciences Center, Paris, France
| | - Silvia Franco
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University, New York, New York; and
| | - Mark Olfson
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University, New York, New York; and
| | - Jian-Ping He
- Genetic Epidemiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Saioa López
- Hospital Universitario de Alava (Santiago), Centre for Biomedical Research in Mental Health Network, Vitoria, Spain
| | - Ana González-Pinto
- Hospital Universitario de Alava (Santiago), Centre for Biomedical Research in Mental Health Network, Vitoria, Spain
| | - Frédéric Limosin
- Paris Descartes University, Pôles de recherche et d'enseignement supérieur Sorbonne Paris Cité, Paris, France
- Department of Psychiatry, Assistance Publique-Hôpitaux de Paris, Hôpital Corentin-Celton, Issy-les-Moulineaux, France
- Institut national de la santé et de la recherche médicale unité mixte de recherche 894, Psychiatry and Neurosciences Center, Paris, France
| | - Kathleen R Merikangas
- Genetic Epidemiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
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Chung JW, Bilimoria KY, Stulberg JJ, Quinn CM, Hedges LV. Estimation of Population Average Treatment Effects in the FIRST Trial: Application of a Propensity Score-Based Stratification Approach. Health Serv Res 2017; 53:2567-2590. [PMID: 28833067 DOI: 10.1111/1475-6773.12752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE/STUDY QUESTION To estimate and compare sample average treatment effects (SATE) and population average treatment effects (PATE) of a resident duty hour policy change on patient and resident outcomes using data from the Flexibility in Duty Hour Requirements for Surgical Trainees Trial ("FIRST Trial"). DATA SOURCES/STUDY SETTING Secondary data from the National Surgical Quality Improvement Program and the FIRST Trial (2014-2015). STUDY DESIGN The FIRST Trial was a cluster-randomized pragmatic noninferiority trial designed to evaluate the effects of a resident work hour policy change to permit greater flexibility in scheduling on patient and resident outcomes. We estimated hierarchical logistic regression models to estimate the SATE of a policy change on outcomes within an intent-to-treat framework. Propensity score-based poststratification was used to estimate PATE. DATA COLLECTION/EXTRACTION METHODS This study was a secondary analysis of previously collected data. PRINCIPAL FINDINGS Although SATE estimates suggested noninferiority of outcomes under flexible duty hour policy versus standard policy, the noninferiority of a policy change was inconclusively noninferior based on PATE estimates due to imprecision. CONCLUSIONS Propensity score-based poststratification can be valuable tools to address trial generalizability but may yield imprecise estimates of PATE when sparse strata exist.
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Affiliation(s)
- Jeanette W Chung
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Karl Y Bilimoria
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jonah J Stulberg
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christopher M Quinn
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Larry V Hedges
- Department of Statistics, Department of Psychology, Department of Medical Social Sciences, School of Education and Social Policy, Institute for Policy Research, Northwestern University, Evanston, IL
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Susukida R, Crum RM, Ebnesajjad C, Stuart EA, Mojtabai R. Generalizability of findings from randomized controlled trials: application to the National Institute of Drug Abuse Clinical Trials Network. Addiction 2017; 112:1210-1219. [PMID: 28191694 PMCID: PMC5461185 DOI: 10.1111/add.13789] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/27/2016] [Accepted: 02/06/2017] [Indexed: 11/30/2022]
Abstract
AIMS To compare randomized controlled trial (RCT) sample treatment effects with the population effects of substance use disorder (SUD) treatment. DESIGN Statistical weighting was used to re-compute the effects from 10 RCTs such that the participants in the trials had characteristics that resembled those of patients in the target populations. SETTINGS Multi-site RCTs and usual SUD treatment settings in the United States. PARTICIPANTS A total of 3592 patients in 10 RCTs and 1 602 226 patients from usual SUD treatment settings between 2001 and 2009. MEASUREMENTS Three outcomes of SUD treatment were examined: retention, urine toxicology and abstinence. We weighted the RCT sample treatment effects using propensity scores representing the conditional probability of participating in RCTs. FINDINGS Weighting the samples changed the significance of estimated sample treatment effects. Most commonly, positive effects of trials became statistically non-significant after weighting (three trials for retention and urine toxicology and one trial for abstinence); also, non-significant effects became significantly positive (one trial for abstinence) and significantly negative effects became non-significant (two trials for abstinence). There was suggestive evidence of treatment effect heterogeneity in subgroups that are under- or over-represented in the trials, some of which were consistent with the differences in average treatment effects between weighted and unweighted results. CONCLUSIONS The findings of randomized controlled trials (RCTs) for substance use disorder treatment do not appear to be directly generalizable to target populations when the RCT samples do not reflect adequately the target populations and there is treatment effect heterogeneity across patient subgroups.
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Affiliation(s)
- Ryoko Susukida
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Rosa M. Crum
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St. Baltimore, MD 21287
| | - Cyrus Ebnesajjad
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- The Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 N. Broadway, Baltimore, MD, 21205, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe St. Baltimore, MD 21287
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Humphreys K. A Review of the Impact of Exclusion Criteria on the Generalizability of Schizophrenia Treatment Research. ACTA ACUST UNITED AC 2017; 11:49-57. [PMID: 28548580 DOI: 10.3371/1935-1232-11.1.49] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Treatment research studies employ criteria that determine which patients are eligible to participate and which are not. When such exclusion criteria produce a treatment research sample that is a small and unrepresentative subset of all patients with a particular disease, clinicians may be hesitant to apply the research results in front-line clinical practice. Accordingly, the present paper reviews the English-language literature on exclusion criteria in schizophrenia treatment research and draws initial conclusions about their impact. Empirically derived estimates of the rate of exclusion vary widely (31.0-98.2%), but the best available evidence suggests that about 4 in 5 patients with schizophrenia would be ineligible to enroll in a typical treatment research study. Women are particularly likely to be excluded from schizophrenia treatment research, which is problematic from both a clinical and social justice viewpoint. Excluded patients also tend to be older than eligible patients, and, though it has been examined in only a few studies, they also tend to have more severe problems at baseline and different outcomes over time than patients who are allowed to participate in research. More limited use of exclusion criteria in schizophrenia treatment research would be beneficial in terms of increasing generalizability, but would also potentially involve costs, particularly a need for larger samples. More modest steps that would improve treatment outcome research reports include requiring a full description of the rationale for, and nature of, any exclusion criteria, and, having a designated place in the discussion section which draws attention to the proper scope of generalization.
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Stein DJ, Ahokas A, Jarema M, Avedisova AS, Vavrusova L, Chaban O, Gruget C, Olivier V, Picarel-Blanchot F, de Bodinat C. Efficacy and safety of agomelatine (10 or 25 mg/day) in non-depressed out-patients with generalized anxiety disorder: A 12-week, double-blind, placebo-controlled study. Eur Neuropsychopharmacol 2017; 27:526-537. [PMID: 28298261 DOI: 10.1016/j.euroneuro.2017.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/27/2017] [Accepted: 02/21/2017] [Indexed: 11/25/2022]
Abstract
Agomelatine is efficacious in reducing symptoms and preventing relapse in placebo-controlled trials in generalised anxiety disorder (GAD). Nevertheless, fixed dose studies of agomelatine in GAD have not been undertaken. To determine the minimally effective optimal dose of agomelatine in GAD, the efficacy of two doses of agomelatine (10 and 25mg/day) was investigated in a 12-week, placebo-controlled, double-blind, international study in patients with a primary diagnosis of GAD. The primary outcome measure was the Hamilton Anxiety scale (HAM-A). The study was undertaken in 35 clinical centers in Finland, Russia, Poland, Slovakia and Ukraine from August 2013 to January 2015. 131 out-patients were included in the agomelatine 10mg group, 139 in the agomelatine 25mg group, and 142 in the placebo group. Both doses of agomelatine were associated with significant decreases in the HAM-A at week 12 (difference versus placebo of 7.16±1.00 at 10mg and 11.08±0.98 at 25mg, p<0.0001). Significant effects on all secondary measures were found for both doses at week 12; including psychic and somatic HAM-A subscales, response rate, remission on the HAM-A, and functional impairment. Findings were confirmed in subsets of more severely ill patients on all endpoints. The low placebo response rate observed in this study was consistent with an increase in the quality of data collected. Agomelatine was well-tolerated by patients, with minimal distinctions from placebo. There was a dose effect of agomelatine, with a greater placebo-agomelatine difference in the agomelatine 25mg group, compared to the agomelatine 10mg group.The present data support early work indicating the efficacy and tolerability of agomelatine in the treatment of GAD.
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Affiliation(s)
- Dan J Stein
- University of Cape Town Department of Psychiatry & MRC Unit on Anxiety & Stress Disorders, Groote Schuur Hospital, J-Block, Anzio Road, Cape Town 7925, South Africa.
| | - Antti Ahokas
- Mehilainen Clinic, Runeberginkatu 47 A, 00260 Helsinki, Finland
| | - Marek Jarema
- Institute of Psychiatry and Neurology, 3rd Department of Psychiatry, Warszawa, Poland
| | - Alla S Avedisova
- Serbsky National Research Centre for Social and Forensic Psychiatry, Moscow, Russia
| | - Livia Vavrusova
- Private Psychiatric Practice - VAVRUŠOVÁ CONSULTING s.r.o., Záporožská 12, 851 01 Bratislava, Slovakia
| | - Oleg Chaban
- Psychosomatic Medicine and Psychotherapy, National Medical University Named After O.O. Bogomolets, M. Kotsyubynskogo 8A str., 01030 Kiev, Ukraine
| | - Céline Gruget
- Institut de Recherches Internationales Servier (IRIS), 50 rue Carnot, 92284 Suresnes Cedex, France
| | - Valérie Olivier
- Institut de Recherches Internationales Servier (IRIS), 50 rue Carnot, 92284 Suresnes Cedex, France
| | | | - Christian de Bodinat
- Institut de Recherches Internationales Servier (IRIS), 50 rue Carnot, 92284 Suresnes Cedex, France
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Blanco C, Campbell AN, Wall MM, Olfson M, Wang S, Nunes EV. Toward National Estimates of Effectiveness of Treatment for Substance Use. J Clin Psychiatry 2017; 78:e64-e70. [PMID: 28129499 PMCID: PMC5490656 DOI: 10.4088/jcp.15m10333] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 03/09/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To estimate how results would have varied if a substance abuse clinical trial had been conducted with nationally representative adults with substance use and with representative adults receiving substance use treatment. METHODS Results were analyzed from a multisite clinical trial comparing the effectiveness of the Therapeutic Education System to treatment as usual for outpatient addiction treatment (n = 507). Patients were recruited between June 2010 and August 2011. Abstinence was the primary outcome. The general population sample and general population-treated samples were derived from Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (n = 43,093). Propensity scores provided a standardized measure of the difference between clinical trial participants and the 2 NESARC samples. The clinical trial was reanalyzed by reweighting the sample with propensity scores derived from the 2 samples to obtain generalizable estimates of treatment effects. RESULTS Before the clinical trial sample was reweighted, the odds ratio (OR) of response to Therapeutic Education System versus treatment as usual in the trial was 1.62 (95% CI, 1.12-2.35). After the sample was reweighted to be representative of the 2 NESARC groups, ORs were 1.33 (95% CI, 0.34-5.26) for the representative sample with any substance use and 1.64 (95% CI, 0.82-3.27) for the representative treated sample. CONCLUSIONS Applying propensity score weighting to clinical trial results provides a method for estimating the population generalizability of clinical trial findings that relies on effect moderators observed in the study sample and population. Broader confidence intervals in the reweighted samples do not necessarily indicate lack of efficacy of the Therapeutic Education System but rather greater uncertainty concerning effectiveness in general population samples.
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Affiliation(s)
| | - Aimee N. Campbell
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY
| | - Melanie M. Wall
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY,Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
| | - Mark Olfson
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, 1051 Riverside Dr, Unit 24, New York, NY 10032. .,Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, New York, USA
| | - Shuai Wang
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY
| | - Edward V. Nunes
- Department of Psychiatry, New York State Psychiatric Institute/Columbia University, New York, NY
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Goldstein-Piekarski AN, Williams LM, Humphreys K. A trans-diagnostic review of anxiety disorder comorbidity and the impact of multiple exclusion criteria on studying clinical outcomes in anxiety disorders. Transl Psychiatry 2016; 6:e847. [PMID: 27351601 PMCID: PMC4931606 DOI: 10.1038/tp.2016.108] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 03/23/2016] [Indexed: 01/20/2023] Open
Abstract
Anxiety disorders are highly comorbid with each other and with other serious mental disorders. As our field progresses, we have the opportunity to pursue treatment study designs that consider these comorbidities. In this perspective review, we first characterized the prevalence of multiple anxiety disorder comorbidity by reanalyzing national survey data, then conducted an English-language PubMed search of studies analyzing the impact of exclusion criteria on treatment outcome data. In the prevalence data, 60% of people with an anxiety disorder had one or more additional anxiety or depression diagnosis. Because our commonly applied exclusion criteria focus on a single diagnosis and do not consider a multiple comorbidity profile, the impact of the criteria may be to exclude up to 92% of anxiety disorder treatment seekers. Moreover, the findings do not suggest a consistent relationship between the number of exclusion criteria and the effect size of treatment outcomes. Thus, future studies might consider a more trans-diagnostic rationale for determining exclusion criteria, one that is generalizable to real-world settings in which multiple diagnoses commonly co-occur. The findings also encourage a more systematic reporting of rationales for the choice of-and the implications of-each exclusion criterion.
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Affiliation(s)
- A N Goldstein-Piekarski
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Department of Sierra-Pacific MIRECC, VA Palo Alto (Sierra-Pacific MIRECC), Palo Alto, CA, USA
| | - L M Williams
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Department of Sierra-Pacific MIRECC, VA Palo Alto (Sierra-Pacific MIRECC), Palo Alto, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA. E-mail:
| | - K Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,VA Center for Innovation to Implementation, Menlo Park, CA, USA
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27
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Trial participant representativeness compared to ordinary service users in a work rehabilitation setting. Contemp Clin Trials Commun 2016; 2:12-15. [PMID: 29736442 PMCID: PMC5935858 DOI: 10.1016/j.conctc.2015.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 11/20/2015] [Accepted: 12/02/2015] [Indexed: 11/25/2022] Open
Abstract
Background Study representativeness is a major concern for generalizations from trials. The extent of the problem varies with study design and context. There is a strong emphasis on developing interventions to help people remain in the work force despite mental illness. We need to know if results from upcoming trials in this area are valid for those that later might receive the services. Method The AWaC trial was a multicenter RCT conducted at six different treatment centers (n = 1193). After the trial was over, the centers were upheld and run as ordinary services. At that time, we surveyed 80 ordinary service users with the same baseline questionnaire as used in the trial, and compared them with those who participated in the trial. Results There were a higher proportion of people with the highest level of education (4 years or more at university/college) in the post-trial comparison sample. This sample also reported to be “dissatisfied” with their job more often, but rated their chances for return to work as “bad” less often than the ordinary trial participants. No further significant differences between the two samples in any of the other education categories, or for any of the other demographic, health or work related comparisons were found. Discussion Participation bias is likely to depend on study context, but in the setting of a trial to help improve work participation among people who struggle with common mental disorders, the trial participants were overall very similar to those who sought the same services as ordinary practice.
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28
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Hoertel N, López S, Wang S, González-Pinto A, Limosin F, Blanco C. Generalizability of pharmacological and psychotherapy clinical trial results for borderline personality disorder to community samples. Personal Disord 2016; 6:81-7. [PMID: 25580674 DOI: 10.1037/per0000091] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The present study sought to quantify the generalizability of clinical trial results in individuals with a Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) diagnosis of borderline personality disorder (BPD) to a large representative community sample. Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large nationally representative sample of 34,653 adults from the United States population. We applied a standard set of exclusion criteria representative of pharmacological and psychotherapy clinical trials to all adults with a DSM-IV diagnosis of BPD (n = 2,231). Our aim was to assess how many participants with BPD would not fulfill typical eligibility criteria. We found that more than 7 of 10 respondents in a typical pharmacological efficacy trial and more than 5 of 10 participants in a typical psychotherapy efficacy trial would have been excluded by at least 1 criterion. Having a current history of alcohol or drug use disorder and a lifetime history of bipolar disorder explained a large proportion of ineligibility in both pharmacological and psychotherapy efficacy trials. Clinical trials should carefully consider the impact of exclusion criteria on the generalizability of their results. As required by CONSORT guidelines, reporting exclusion rate estimate and reasons of eligibility should be mandatory in both clinical trials and meta-analyses. As treatment trials of borderline personality disorder move from efficacy to effectiveness to better inform clinical practice, the eligibility rate must be increased by imposing less stringent eligibility criteria to allow for more generalizable results.
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Affiliation(s)
- Nicolas Hoertel
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
| | - Saioa López
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
| | - Shuai Wang
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
| | | | - Frédéric Limosin
- Department of Psychiatry, Assistance Publique-Hôpitaux de Paris (APHP), Corentin Celton Hospital
| | - Carlos Blanco
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
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29
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Hasin DS, Grant BF. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1609-40. [PMID: 26210739 PMCID: PMC4618096 DOI: 10.1007/s00127-015-1088-0] [Citation(s) in RCA: 274] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/28/2015] [Indexed: 01/12/2023]
Abstract
PURPOSE The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking. METHOD NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized. RESULT The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers. CONCLUSIONS Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.
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Affiliation(s)
- Deborah S Hasin
- Department of Psychiatry, College of Physicians and Surgeons, New York, NY, 10032, USA
- Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
- New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Bridget F Grant
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 5635 Fishers Lane, Room 3077, Rockville, MD, 20852, USA.
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Barton S, Karner C, Salih F, Baldwin DS, Edwards SJ. Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review. Health Technol Assess 2015; 18:1-59, v-vi. [PMID: 25110830 DOI: 10.3310/hta18500] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Anxiety and related disorders include generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder and phobic disorders (intense fear of an object or situation). These disorders share the psychological and physical symptoms of anxiety, but each disorder has its own set of characteristic symptoms. Anxiety disorders can be difficult to recognise, particularly in older people (those aged over 65 years). Older people tend to be more reluctant to discuss mental health issues and there is the perception that older people are generally more worried than younger adults. It is estimated that between 3 and 14 out of every 100 older people have an anxiety disorder. Despite treatment, some people will continue to have symptoms of anxiety. People are generally considered to be 'resistant' or 'refractory' to treatment if they have an inadequate response or do not respond to their first treatment. Older adults with an anxiety disorder find it difficult to manage their day-to-day lives and are at an increased risk of comorbid depression, falls, physical and functional disability, and loneliness. OBJECTIVE To evaluate the effectiveness of pharmacological, psychological and alternative therapies in older adults with an anxiety disorder who have not responded, or have responded inadequately, to treatment. DATA SOURCES Electronic databases (MEDLINE, MEDLINE In-Process and Other Non-Indexed citations, EMBASE, The Cochrane Library databases, PsycINFO and Web of Science) were searched from inception to September 2013. Bibliographies of relevant systematic reviews were hand-searched to identify additional potentially relevant studies. ClinicalTrials.gov was searched for ongoing and planned studies. REVIEW METHODS A systematic review of the clinical effectiveness of treatments for treatment-resistant anxiety in older adults was carried out. RESULTS No randomised controlled trial or prospective comparative observational study was identified meeting the prespecified inclusion criteria. Therefore, it was not possible to draw any conclusions on clinical effectiveness. LIMITATIONS As no study was identified in older adults, there is uncertainty as to which treatments are clinically effective for older adults with an anxiety disorder who have not responded to prior treatment. The comprehensive methods implemented to carry out this review are a key strength of the research presented. However, this review highlights the extreme lack of research in this area, identifying no comparative studies, which is a marked limitation. CONCLUSIONS Specific studies evaluating interventions in older adults with an anxiety disorder who have not responded to first-line treatment are needed to address the lack of evidence. The lack of evidence in this area means that older adults are perhaps receiving inappropriate treatment or are not receiving a particular treatment because there is limited evidence to support its use. At this time there is scope to develop guidance on service provision and, as a consequence, to advance the standard of care received by older adults with a treatment-resistant anxiety disorder in primary and secondary care. Evaluation of the relative clinical effectiveness and acceptability of pharmacological and psychological treatment in older adults with an anxiety disorder that has not responded to first-line treatment is key future research to inform decision-making of clinicians and patients. An important consideration would be the enrolment of older adults who would be representative of older adults in general, i.e. those with multiple comorbid physical and mental disorders who might require polypharmacy. STUDY REGISTRATION The protocol for the systematic review is registered on PROSPERO (registration number CRD42013005612). FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | | | | | - David S Baldwin
- Faculty of Medicine, University of Southampton, Southampton, UK
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Stratford HJ, Cooper MJ, Di Simplicio M, Blackwell SE, Holmes EA. Psychological therapy for anxiety in bipolar spectrum disorders: A systematic review. Clin Psychol Rev 2015; 35:19-34. [DOI: 10.1016/j.cpr.2014.11.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 10/29/2014] [Accepted: 11/01/2014] [Indexed: 01/12/2023]
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Ipser JC, Wilson D, Akindipe TO, Sager C, Stein DJ. Pharmacotherapy for anxiety and comorbid alcohol use disorders. Cochrane Database Syst Rev 2015; 1:CD007505. [PMID: 25601826 PMCID: PMC8931612 DOI: 10.1002/14651858.cd007505.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Anxiety disorders are a potentially disabling group of disorders that frequently co-occur with alcohol use disorders. Comorbid anxiety and alcohol use disorders are associated with poorer outcomes, and are difficult to treat with standard psychosocial interventions. In addition, improved understanding of the biological basis of the conditions has contributed to a growing interest in the use of medications for the treatment of people with both diagnoses. OBJECTIVES To assess the effects of pharmacotherapy for treating anxiety in people with comorbid alcohol use disorders, specifically: to provide an estimate of the overall effects of medication in improving treatment response and reducing symptom severity in the treatment of anxiety disorders in people with comorbid alcohol use disorders; to determine whether specific medications are more effective and tolerable than other medications in the treatment of particular anxiety disorders; and to identify which factors (clinical, methodological) predict response to pharmacotherapy for anxiety disorders. SEARCH METHODS Review authors searched the specialized registers of The Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDANCTR, to January 2014) and the Cochrane Drugs and Alcohol Group (CDAG, to March 2013) for eligible trials. These registers contain reports of relevant randomized controlled trials (RCT) from: the Cochrane Central Register of Controlled Trials (CENTRAL, all years), MEDLINE (1950 to date), EMBASE (1974 to date) and PsycINFO (1967 to date). Review authors ran complementary searches on EMBASE, PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database (ETOH) (to August 2013). We located unpublished trials through the National Institutes of Health (NIH) RePORTER service and the World Health Organization (WHO) International Clinical Trials Registry Platform (to August 2013). We screened reference lists of retrieved articles for additional studies. SELECTION CRITERIA All true RCTs of pharmacotherapy for treating anxiety disorders with comorbid alcohol use disorders. Trials assessing drugs administered for the treatment of drinking behaviour, such as naltrexone, disulfiram and acomprosate were not eligible for inclusion in this systematic review. DATA COLLECTION AND ANALYSIS A systematic review is a standardised evaluation of all research studies that address a particular clinical issue.Two review authors independently assessed RCTs for inclusion in the review, collated trial data and assessed trial quality. We contacted investigators to obtain missing data. We calculated categorical and continuous treatment effect estimates and their 95% confidence intervals (CI) for treatment using a random-effects model with effect-size variability expressed using Chi(2) and I(2) heterogeneity statistics. MAIN RESULTS We included five placebo-controlled pharmacotherapy RCTs (with 290 participants) in the review. Most of the trials provided little information on how randomization was performed or on whether both participants and study personnel were blinded to the intervention. Two of the three trials reporting superiority of medication compared with placebo on anxiety symptom outcomes were industry funded. We regarded one trial as being at high risk of bias due to selective reporting.Study participants had Diagnostic and Statistical Manual (DSM) III- and DSM IV-diagnosed alcohol use disorders and post-traumatic stress disorder (two studies), social anxiety disorder (SAD; two studies) or generalized anxiety disorder (GAD; one study). Four trials assessed the efficacy of the selective serotonin re-uptake inhibitors (SSRIs: sertraline, paroxetine); one RCT investigated the efficacy of buspirone, a 5-hydroxytryptamine (5-HT) partial agonist. Treatment duration lasted between eight and 24 weeks. Overall, 70% of participants included in the review were male.There was very low quality evidence for an effect of paroxetine on global clinical response to treatment, as assessed by the Clinical Global Impressions - Improvement scale (CGI-I). Global clinical response was observed in more than twice as many participants with paroxetine than with placebo (57.7% with paroxetine versus 25.8% with placebo; risk ratio (RR) 2.23, 95% CI 1.13 to 4.41; 2 trials, 57 participants). However, there was substantial uncertainty regarding the size of the effect of paroxetine due to the small number of studies providing data on clinically diverse patient samples. The second primary outcome measure was reduction of anxiety symptom severity. Although study investigators reported that buspirone (one trial) was superior to placebo in reducing the severity of anxiety symptoms over 12 weeks, no evidence of efficacy was observed for paroxetine (mean difference (MD) -14.70, 95% CI -33.00 to 3.60, 2 trials, 44 participants) and sertraline (one trial). Paroxetine appeared to be equally effective in reducing the severity of post-traumatic stress disorder (PTSD) symptoms as the tricyclic antidepressant desipramine in one RCT. The maximal reduction in anxiety disorder symptom severity was achieved after six weeks with paroxetine (two RCTs) and 12 weeks with buspirone (one RCT), with maintenance of medication efficacy extending to 16 with paroxetine and 24 weeks with buspirone. There was no evidence of an effect for any of the medications tested on abstinence from alcohol use or depression symptoms. There was very low quality evidence that paroxetine was well tolerated, based on drop-out due to treatment-emergent adverse effects. Nevertheless, levels of treatment discontinuation were high, with 43.1% of the participants in the studies withdrawing from medication treatment. Certain adverse effects, such as sexual problems, were commonly reported after treatment with paroxetine and sertraline. AUTHORS' CONCLUSIONS The evidence-base for the effectiveness of medication in treating anxiety disorders and comorbid alcohol use disorders is currently inconclusive. There was a small amount of evidence for the efficacy of medication, but this was limited and of very low quality. The majority of the data for the efficacy and tolerability of medication were for SSRIs; there were insufficient data to establish differences in treatment efficacy between medication classes or patient subgroups. There was a small amount of very low quality evidence that medication was well tolerated. There was no evidence that alcohol use was responsive to medication.Large, rigorously conducted RCTs would help supplement the small evidence-base for the efficacy and tolerability of pharmacotherapy for anxiety and comorbid alcohol use disorders. Further research on patient subgroups who may benefit from pharmacological treatment, as well as novel pharmacological interventions, is warranted.
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Affiliation(s)
- Jonathan C Ipser
- Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town, South Africa, 7925
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Levitan MN, Papelbaum M, Nardi AE. Profile of agomelatine and its potential in the treatment of generalized anxiety disorder. Neuropsychiatr Dis Treat 2015; 11:1149-55. [PMID: 25999720 PMCID: PMC4427071 DOI: 10.2147/ndt.s67470] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although many generalized anxiety disorder (GAD) patients respond to the available pharmacological treatments, nearly half of them do not present the expected results. Besides, the side effects associated to some drugs have a negative impact on treatment adherence. Therefore, the aim of this review was to report the clinical profile of agomelatine, a selective melatonergic MT1/MT2 receptor agonist with serotonin 5-HT2c receptor antagonist activities, as a potential pharmacological option in the treatment of GAD. METHODS We performed a literature review regarding studies that evaluated the use of agomelatine in GAD treatment. RESULTS Two short-term, double-blinded studies and one prevention-treatment trial evaluated the efficacy of agomelatine in the treatment of GAD. Agomelatine was associated with higher rates of clinical response and remission, when compared to placebo. In addition, the long-term use of agomelatine decreased the risk of relapse of anxiety symptoms, even for the severely ill patients. Besides, the tolerability was satisfactory with the absence of discontinuation symptoms, as observed in previous studies. CONCLUSION The efficacy and tolerability profiles of agomelatine in the treatment of GAD were good. However, the scarce number of trials, the small sample sizes, and the use of patients without any comorbid conditions were some limitations that impaired the generalization of the results in the general population. Nevertheless, agomelatine is an attractive off-label option in the treatment of GAD that needs more conclusive evidences to establish its role in future guidelines.
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Affiliation(s)
- Michelle Nigri Levitan
- Laboratory of Panic and Respiration, Institute of Psychiatry of the Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Papelbaum
- Laboratory of Panic and Respiration, Institute of Psychiatry of the Federal University of Rio de Janeiro, Rio de Janeiro, Brazil ; State Institute of Diabetes and Endocrinology of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio Egidio Nardi
- Laboratory of Panic and Respiration, Institute of Psychiatry of the Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Post-Marketing Surveillance of Fluvoxamine Maleate Used Long-Term in Patients with Social Anxiety Disorder in Japan. Drugs Real World Outcomes 2014; 1:7-19. [PMID: 27747476 PMCID: PMC4883186 DOI: 10.1007/s40801-014-0005-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background No data on the long-term ‘real-world’ use of fluvoxamine for the treatment of social anxiety disorder (SAD) in Japanese patients are currently available. Objective To evaluate the long-term safety and efficacy of fluvoxamine for SAD in the clinical setting. Methods Japanese patients with SAD who initiated treatment with fluvoxamine were enrolled in this 53-week post-marketing survey from 407 institutions nationwide. Data including rates of adverse drug reactions (ADRs) and efficacy were collected. Overall improvement was assessed using the Clinical Global Impression for Improvement. SAD symptoms and treatment responses were assessed with the Japanese version of the Liebowitz Social Anxiety Scale. Results From the 1,974 patients surveyed, 1,790 and 1,504 patients were eligible for analysis of safety and efficacy, respectively. ADRs were reported in 18.2 % of patients, with nausea, somnolence, and constipation the most common. Over 50 % of these ADRs developed in the first 4 weeks of treatment. Serious ADRs were reported in 0.8 % of patients and included six cases of suicide attempt and three cases of suicidal ideation. Response to fluvoxamine was reported in 78.4 % of patients. In patients comorbid with depression, improvement in SAD symptoms with fluvoxamine treatment was significantly affected by clinical improvement in the depression. Conclusions These findings support the long-term safety and efficacy of fluvoxamine in patients with SAD. Most ADRs developed during the early treatment phase, and higher doses during the later phase were not associated with an increase in ADRs. Electronic supplementary material The online version of this article (doi:10.1007/s40801-014-0005-2) contains supplementary material, which is available to authorized users.
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Hoertel N, Peyre H, Wall MM, Limosin F, Blanco C. Examining sex differences in DSM-IV borderline personality disorder symptom expression using Item Response Theory (IRT). J Psychiatr Res 2014; 59:213-9. [PMID: 25258339 DOI: 10.1016/j.jpsychires.2014.08.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 08/20/2014] [Accepted: 08/28/2014] [Indexed: 10/24/2022]
Abstract
Limited literature suggests that there may be differences in how women and men experience borderline personality disorder (BPD) symptoms. The aim of the current study was to use methods based on item response theory (IRT) to examine whether, when equating for levels of BPD symptom severity, there are sex differences in the likelihood of reporting DSM-IV BPD symptoms. We conducted these analyses using a large, nationally representative sample from the USA (n = 34,653), the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Data from women and men were compared. There were statistically and clinically significant sex differences for 3 out of the 9 DSM-IV BPD symptoms. We found that women were more likely to experience suicidal/self-mutilation behavior, affective instability and chronic feelings of emptiness and tended to be less likely to endorse impulsivity at lower levels of borderline personality disorder severity than men, while affective instability and chronic feelings of emptiness appeared to be significantly less discriminant in terms of severity in men than in women. There were no significant differences between women and men on the remaining DSM-IV symptoms. Overall, our findings indicate substantial sex differences in borderline personality disorder symptom expression. Although our results may reflect sex-bias in diagnostic criteria, they are in keeping with recent arguments suggesting that BPD could be understood as a clinical phenomenon that may partially differ in men and women.
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Affiliation(s)
- Nicolas Hoertel
- Department of Psychiatry, New York State Psychiatric Institute/ Columbia University, New York, USA; Assistance Publique-Hôpitaux de Paris (APHP), Corentin Celton Hospital, Department of Psychiatry, 92130 Issy-les-Moulineaux, France; Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France; INSERM UMR 894, Psychiatry and Neurosciences Center, Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France.
| | - Hugo Peyre
- Assistance Publique Hôpitaux de Paris (APHP), Robert Debré Hospital, Child and Adolescent Psychiatry Department, Paris, France; Cognitive Sciences and Psycholinguistic Laboratory, Ecole Normale Supérieure, CNRS, EHESS, Paris, France
| | - Melanie M Wall
- Department of Psychiatry, New York State Psychiatric Institute/ Columbia University, New York, USA; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, USA
| | - Frédéric Limosin
- Assistance Publique-Hôpitaux de Paris (APHP), Corentin Celton Hospital, Department of Psychiatry, 92130 Issy-les-Moulineaux, France; Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France; INSERM UMR 894, Psychiatry and Neurosciences Center, Paris Descartes University, PRES Sorbonne Paris Cité, Paris, France
| | - Carlos Blanco
- Department of Psychiatry, New York State Psychiatric Institute/ Columbia University, New York, USA
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Are participants in pharmacological and psychotherapy treatment trials for social anxiety disorder representative of patients in real-life settings? J Clin Psychopharmacol 2014; 34:697-703. [PMID: 25154011 DOI: 10.1097/jcp.0000000000000204] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The present study sought to quantify the generalizability of clinical trial results in individuals with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of social anxiety disorder (SAD) to a large representative community sample. METHODS Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions, a large nationally representative sample of 34,653 adults from the US population. We applied a standard set of exclusion criteria representative of pharmacological and psychotherapy clinical trials to all adults with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of SAD (n = 965) in the past 12 months and then to a subsample of participants seeking treatment (n = 363). Our aim was to assess how many participants with SAD would fulfill typical eligibility criteria. RESULTS We found that more than 7 of 10 respondents from the overall SAD sample in a typical pharmacological efficacy trial and more than 6 of 10 participants in a typical psychotherapy efficacy trial would have been excluded by at least 1 criterion. In addition, more than 8 of 10 respondents seeking treatment for SAD would have been excluded from participation in a typical pharmacological or psychotherapy efficacy trial. Having a current major depression explained a large proportion of ineligibility. CONCLUSIONS Clinical trials should carefully consider the impact of exclusion criteria on the generalizability of their results and explain the rationale for their use. For SAD treatment trials to adequately inform clinical practice, the eligibility rate must be increased through a general relaxation of overly stringent eligibility criteria.
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Manetti A, Hoertel N, Le Strat Y, Schuster JP, Lemogne C, Limosin F. Comorbidity of late-life depression in the United States: a population-based study. Am J Geriatr Psychiatry 2014; 22:1292-306. [PMID: 23988281 DOI: 10.1016/j.jagp.2013.05.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 04/29/2013] [Accepted: 05/02/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study sought to determine the clinical and sociodemographic correlates and the treatment-seeking rate of major depressive disorder (MDD), diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, among older adults and its association with comorbid psychiatric disorders and perceived health status. METHODS Data were drawn from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a large cross-sectional survey (N = 43,093) representative of the US population. RESULTS Compared with participants aged 65 years and older without a 12-month diagnosis of MDD, those with MDD were more likely to have lifetime and 12-month comorbid psychiatric disorders. Except for lifetime dysthymia, we found no significant interaction between rates of current somatic comorbidity, lifetime and 12-month psychiatric comorbidity, and age groups. Compared with younger participants with a 12-month MDD, they had an older age at onset, reported a similar number of lifetime major depressive episodes and perceived health status, and had lower mental health service utilization rates. CONCLUSIONS Current major depression in the elderly seems to be as disabling as in younger adults in terms of comorbid psychiatric disorders and impaired quality of life. Poorer prognosis of MDD in older adults might be explained by a lower perceived need of treatment, resulting in a lower rate of treatment-seeking behavior.
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Affiliation(s)
- Aude Manetti
- Assistance Publique-Hôpitaux de Paris, Service universitaire de Psychiatrie de l'adulte et du sujet âgé, Hôpitaux Universitaires Paris Ouest, Corentin Celton Hospital, Issy-les-Moulineaux, France.
| | - Nicolas Hoertel
- Assistance Publique-Hôpitaux de Paris, Service universitaire de Psychiatrie de l'adulte et du sujet âgé, Hôpitaux Universitaires Paris Ouest, Corentin Celton Hospital, Issy-les-Moulineaux, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France; INSERM U894, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Yann Le Strat
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France; INSERM U894, Centre de Psychiatrie et Neurosciences, Paris, France; Assistance Publique-Hôpitaux de Paris, Department of Psychiatry, Louis-Mourier Hospital, Colombes, France
| | - Jean-Pierre Schuster
- Assistance Publique-Hôpitaux de Paris, Service universitaire de Psychiatrie de l'adulte et du sujet âgé, Hôpitaux Universitaires Paris Ouest, Corentin Celton Hospital, Issy-les-Moulineaux, France
| | - Cédric Lemogne
- Assistance Publique-Hôpitaux de Paris, Service universitaire de Psychiatrie de l'adulte et du sujet âgé, Hôpitaux Universitaires Paris Ouest, Corentin Celton Hospital, Issy-les-Moulineaux, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France; INSERM U894, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Frédéric Limosin
- Assistance Publique-Hôpitaux de Paris, Service universitaire de Psychiatrie de l'adulte et du sujet âgé, Hôpitaux Universitaires Paris Ouest, Corentin Celton Hospital, Issy-les-Moulineaux, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France; INSERM U894, Centre de Psychiatrie et Neurosciences, Paris, France
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Chiappetta V, García-Rodríguez O, Jin CJ, Secades-Villa R, Blanco C. Predictors of quit attempts and successful quit attempts among individuals with alcohol use disorders in a nationally representative sample. Drug Alcohol Depend 2014; 141:138-44. [PMID: 24948080 DOI: 10.1016/j.drugalcdep.2014.05.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/21/2014] [Accepted: 05/22/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study sought to identify predictors of attempting to quit and of successfully quitting alcohol abuse or dependence in the general population. METHODS Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). RESULTS Approximately 10% of individuals with alcohol abuse and 18% of those with dependence attempted to quit over the three year follow-up period. Of those who tried, 38% of individuals with abuse and 30% of those with dependence successfully quit. Among individuals with alcohol abuse or dependence, being single, younger than 40 years old, having low income, a co-occurring psychiatric disorder and greater number of dependence symptoms increased the likelihood of attempting to quit. Among individuals with alcohol abuse, male gender and low educational attainment further increased the odds of quit attempts. However, greater severity of alcohol use disorder, having a co-occurring drug use disorder and greater number of psychiatric disorders decreased the odds of success among individuals with alcohol abuse, while female gender, being married and older than 40 years old increased the odds of success. Among individuals with alcohol dependence, having nicotine dependence, greater number of psychiatric disorders and personality disorders decreased the odds of success. CONCLUSIONS Predictors of attempts to quit are different and sometimes opposite from those leading to successful quitting probably indicating that some factors that increase motivation may decrease ability to quit. These findings may help in the development of more targeted and effective interventions for alcohol use disorders.
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Affiliation(s)
- Viviana Chiappetta
- New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA
| | - Olaya García-Rodríguez
- New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA; Department of Psychology, University of Oviedo, 33003 Oviedo, Spain
| | - Chelsea J Jin
- New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA
| | - Roberto Secades-Villa
- New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA; Department of Psychology, University of Oviedo, 33003 Oviedo, Spain
| | - Carlos Blanco
- New York State Psychiatric Institute, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA.
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Enduring effects of evidence-based psychotherapies in acute depression and anxiety disorders versus treatment as usual at follow-up — A longitudinal meta-analysis. Clin Psychol Rev 2014; 34:367-75. [DOI: 10.1016/j.cpr.2014.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 05/05/2014] [Accepted: 05/08/2014] [Indexed: 11/19/2022]
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Humphreys K. A review of the impact of exclusion criteria on the generalizability of schizophrenia treatment research. ACTA ACUST UNITED AC 2014. [DOI: 10.3371/csrp.kh.061314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Habibi R, Lexchin J. Quality and quantity of information in summary basis of decision documents issued by health Canada. PLoS One 2014; 9:e92038. [PMID: 24651766 PMCID: PMC3961288 DOI: 10.1371/journal.pone.0092038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 02/19/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Health Canada's Summary Basis of Decision (SBD) documents outline the clinical trial information that was considered in approving a new drug. We examined the ability of SBDs to inform clinician decision-making. We asked if SBDs answered three questions that clinicians might have prior to prescribing a new drug: 1) Do the characteristics of patients enrolled in trials match those of patients in their practice? 2) What are the details concerning the drug's risks and benefits? 3) What are the basic characteristics of trials? METHODS 14 items of clinical trial information were identified from all SBDs published on or before April 2012. Each item received a score of 2 (present), 1 (unclear) or 0 (absent). The unit of analysis was the individual SBD, and an overall SBD score was derived based on the sum of points for each item. Scores were expressed as a percentage of the maximum possible points, and then classified into five descriptive categories based on that score. Additionally, three overall 'component' scores were tallied for each SBD: "patient characteristics", "benefit/risk information" and "basic trial characteristics". RESULTS 161 documents, spanning 456 trials, were analyzed. The majority (126/161) were rated as having information sometimes present (score of >33 to 66%). No SBDs had either no information on any item, or 100% of the information. Items in the patient characteristics component scored poorest (mean component score of 40.4%), while items corresponding to basic trial information were most frequently provided (mean component score of 71%). CONCLUSION The significant omissions in the level of clinical trial information in SBDs provide little to aid clinicians in their decision-making. Clinicians' preferred source of information is scientific knowledge, but in Canada, access to such information is limited. Consequently, we believe that clinicians are being denied crucial tools for decision-making.
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Affiliation(s)
- Roojin Habibi
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Joel Lexchin
- School of Health Policy and Management, York University, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Hoertel N, Limosin F, Leleu H. Poor longitudinal continuity of care is associated with an increased mortality rate among patients with mental disorders: results from the French National Health Insurance Reimbursement Database. Eur Psychiatry 2014; 29:358-64. [PMID: 24439514 DOI: 10.1016/j.eurpsy.2013.12.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 12/03/2013] [Accepted: 12/11/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Research on the impact of the continuity of care (COC) on health outcomes in patients with mental illness is limited. This observational study examined whether the longitudinal COC is associated with a decreased likelihood of death among patients with mental disorders in the French general population. METHOD Data were derived from the French National Health Insurance (NHI) reimbursement database. Patients with any mental disorder who visited a psychiatrist at least twice within 6 months were included. The primary endpoint was death by all causes. We measured longitudinal COC with a psychiatrist twice a year between 2007 and 2010, using the COC index developed by Bice and Boxerman. The COC index was analysed as a time-dependent variable in a survival analysis after adjustments for age, gender and stratifying on comorbidities and social status. RESULTS Among 14,515 patients visiting a psychiatrist at least twice in 6 months and tracked over 3 years, likelihood of death was significantly lower in patients with higher continuity of care (hazard ratio for an increase in 0.1 of continuity, adjusted for age, sex, and stratified on comorbidities and social status: 0.83 [0.83-0.83]), particularly in those with bipolar disorder, major depressive disorder and schizophrenia. CONCLUSION Improving longitudinal continuity of care in mental health care may contribute to substantially decrease mortality.
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Affiliation(s)
- N Hoertel
- Department of Psychiatry, assistance publique-hôpitaux de Paris (AP-HP), Corentin-Celton Hospital, 4, parvis Corentin-Celton, 92130 Issy-les-Moulineaux, France; Inserm UMR 894, Psychiatry and Neurosciences Center, Paris, France; Paris Descartes University, PRES Sorbonne Paris-Cité, Paris, France.
| | - F Limosin
- Department of Psychiatry, assistance publique-hôpitaux de Paris (AP-HP), Corentin-Celton Hospital, 4, parvis Corentin-Celton, 92130 Issy-les-Moulineaux, France; Inserm UMR 894, Psychiatry and Neurosciences Center, Paris, France; Paris Descartes University, PRES Sorbonne Paris-Cité, Paris, France
| | - H Leleu
- COMPAQ-HPST, INSERM U988, institut Gustave-Roussy, Villejuif, France
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Emmelkamp PM, David D, Beckers T, Muris P, Cuijpers P, Lutz W, Andersson G, Araya R, Banos Rivera RM, Barkham M, Berking M, Berger T, Botella C, Carlbring P, Colom F, Essau C, Hermans D, Hofmann SG, Knappe S, Ollendick TH, Raes F, Rief W, Riper H, Van Der Oord S, Vervliet B. Advancing psychotherapy and evidence-based psychological interventions. Int J Methods Psychiatr Res 2014; 23 Suppl 1:58-91. [PMID: 24375536 PMCID: PMC6878277 DOI: 10.1002/mpr.1411] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Psychological models of mental disorders guide research into psychological and environmental factors that elicit and maintain mental disorders as well as interventions to reduce them. This paper addresses four areas. (1) Psychological models of mental disorders have become increasingly transdiagnostic, focusing on core cognitive endophenotypes of psychopathology from an integrative cognitive psychology perspective rather than offering explanations for unitary mental disorders. It is argued that psychological interventions for mental disorders will increasingly target specific cognitive dysfunctions rather than symptom-based mental disorders as a result. (2) Psychotherapy research still lacks a comprehensive conceptual framework that brings together the wide variety of findings, models and perspectives. Analysing the state-of-the-art in psychotherapy treatment research, "component analyses" aiming at an optimal identification of core ingredients and the mechanisms of change is highlighted as the core need towards improved efficacy and effectiveness of psychotherapy, and improved translation to routine care. (3) In order to provide more effective psychological interventions to children and adolescents, there is a need to develop new and/or improved psychotherapeutic interventions on the basis of developmental psychopathology research taking into account knowledge of mediators and moderators. Developmental neuroscience research might be instrumental to uncover associated aberrant brain processes in children and adolescents with mental health problems and to better examine mechanisms of their correction by means of psychotherapy and psychological interventions. (4) Psychotherapy research needs to broaden in terms of adoption of large-scale public health strategies and treatments that can be applied to more patients in a simpler and cost-effective way. Increased research on efficacy and moderators of Internet-based treatments and e-mental health tools (e.g. to support "real time" clinical decision-making to prevent treatment failure or relapse) might be one promising way forward.
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Affiliation(s)
- Paul M.G. Emmelkamp
- Department of Clinical PsychologyUniversity of AmsterdamAmsterdamThe Netherlands
- King Abdulaziz UniversityJeddahSaudi Arabia
| | - Daniel David
- Department of Clinical Psychology and PsychotherapyBabes‐Bolyai UniversityCluj‐NapocaRomania
- Mount Sinai School of Medicine, Department of Oncological SciencesNew YorkUSA
| | - Tom Beckers
- KU Leuven, LeuvenBelgium and University of AmsterdamAmsterdamThe Netherlands
| | - Peter Muris
- Maastricht UniversityMaastrichtThe Netherlands
| | - Pim Cuijpers
- Department of Clinical PsychologyVU University AmsterdamAmsterdamThe Netherlands
- EMGO Institute for Health and Care ResearchVU University and VU University Medical CentreAmsterdamThe Netherlands
- Leuphana UniversityLüneburgGermany
| | - Wolfgang Lutz
- Department of PsychologyUniversity of TrierTrierGermany
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability ResearchLinköping UniversityLinköpingSweden
- Department of Clinical Neuroscience, Psychiatry SectionKarolinska InstitutetStockholmSweden
| | - Ricardo Araya
- Academic Unit of Psychiatry, School of Social and Community MedicineUniversity of BristolBristolUK
| | | | - Michael Barkham
- Centre for Psychological Services Research, Department of PsychologyUniversity of SheffieldSheffieldUK
| | - Matthias Berking
- Leuphana UniversityLüneburgGermany
- Institute of Clinical Psychology and PsychotherapyUniversity of Marburg, Marburg and Philipps‐University MarburgMarburgGermany
| | - Thomas Berger
- Department of Clinical Psychology and PsychotherapyUniversity of BernBernSwitzerland
| | | | - Per Carlbring
- Department of PsychologyStockholm UniversityStockholmSweden
| | - Francesc Colom
- Psychoeducation and Psychological Treatments Area, Barcelona Bipolar Disorders Unit, IDIBAPS‐CIBERSAMInstitute of Neurosciences, Hospital ClinicBarcelonaSpain
| | | | | | | | - Susanne Knappe
- Institute of Clinical Psychology and PsychotherapyTechnische Universität DresdenDresdenGermany
| | | | | | - Winfried Rief
- Institute of Clinical Psychology and PsychotherapyUniversity of Marburg, Marburg and Philipps‐University MarburgMarburgGermany
| | - Heleen Riper
- Department of Clinical PsychologyVU University AmsterdamAmsterdamThe Netherlands
- EMGO Institute for Health and Care ResearchVU University and VU University Medical CentreAmsterdamThe Netherlands
- Department of PsychiatryVU University Medical CentreAmsterdamThe Netherlands
| | - Saskia Van Der Oord
- KU Leuven, LeuvenBelgium and University of AmsterdamAmsterdamThe Netherlands
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Schat A, van Noorden MS, Noom MJ, Giltay EJ, van der Wee NJA, Vermeiren RRJM, Zitman FG. Predictors of outcome in outpatients with anxiety disorders: the Leiden routine outcome monitoring study. J Psychiatr Res 2013; 47:1876-85. [PMID: 24074517 DOI: 10.1016/j.jpsychires.2013.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 09/04/2013] [Accepted: 09/09/2013] [Indexed: 12/01/2022]
Abstract
Little is known about the predictors of outcome in anxiety disorders in naturalistic outpatient settings. We analyzed 2-year follow-up data collected through Routine Outcome Monitoring (ROM) in a naturalistic sample of 917 outpatients in psychiatric specialty care in order to identify factors predicting outcome. We included patients with panic disorder with or without agoraphobia, agoraphobia without panic, social phobia, or generalized anxiety disorder. Main findings from Cox regression analyses demonstrated that several socio-demographic variables (having a non-Dutch ethnicity [HR = 0.71)], not having a daily occupation [HR = 0.76]) and clinical factors (having a diagnosis of agoraphobia [HR = 0.67], high affective lability [HR = 0.80] and behavior problems [HR = 0.84]) decreased chances of response (defined as 50% reduction of anxiety severity) over the period of two years. Living with family had a protective predictive value [HR = 1.41]. These results may imply that factors that could be thought to limit societal participation, are associated with elevated risk of poor outcome. A comprehensive ROM screening process at intake may aid clinicians in the identification of patients at risk of chronicity.
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Affiliation(s)
- A Schat
- Leiden University Medical Centre, Department of Psychiatry, P.O. Box 7500, 2300 RC Leiden, The Netherlands.
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Why does the lifetime prevalence of major depressive disorder in the elderly appear to be lower than in younger adults? Results from a national representative sample. J Affect Disord 2013; 149:160-5. [PMID: 23434051 DOI: 10.1016/j.jad.2013.01.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 01/20/2013] [Accepted: 01/21/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND The explanation of the lower lifetime prevalence rate of major depressive disorder (MDD) in older adults compared to younger people in community surveys is debated. This study examines the hypothesis that the decrease of the lifetime prevalence of MDD in older adults may be due to an age-related difference in the lifetime prevalence of subthreshold hypomania and, to a lesser extent, to the increased rate of medical induced-depression. METHODS Data were derived from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a national representative sample of 43,093 adults of the United States population. We examined lifetime prevalence rates of pure MDD and MDD plus subthreshold hypomania (D(m)) by age, assuming that the lifetime prevalence of pure MDD in older adults would be similar to that in the youngest cohort, consequent to an inverse age-D(m) relationship. We further considered non-hierarchical MDD (i.e., general medical condition depressive disorders were not ruled out) with the same method. RESULTS The lifetime prevalence of D(m) among depressed adults aged 65 years and over was substantially lower compared to the youngest group. When considering non-hierarchical MDD, the odds ratio of the lifetime prevalence estimates of non-hierarchical pure MDD in older adults compared to the youngest group appeared not significantly different from 1. CONCLUSIONS Findings indicate that the decrease of lifetime prevalence of MDD in older adults may be due to an age-related difference in the lifetime prevalence of subthreshold hypomania and, to a lesser extent, to the increased rate of medical induced-depression.
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Hoertel N, de Maricourt P, Gorwood P. Novel routes to bipolar disorder drug discovery. Expert Opin Drug Discov 2013; 8:907-18. [PMID: 23706065 DOI: 10.1517/17460441.2013.804057] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Bipolar disorder (BD) is a severe and chronic medical condition typified by episodic recurrent mania (or hypomania) in addition to major depression. BD is associated with a number of negative outcomes including premature death, reduced quality of life and can also lead to other complications including impaired cognitive function. Unfortunately, the currently available pharmacological treatments for BD are insufficient for many with the condition. AREAS COVERED This review focuses on known therapeutic targets of mood stabilizing drugs including: the glycogen synthase kinase-3 (GSK-3), the phosphoinositide pathway and protein kinase C (PKC), the brain-derived neurotrophic factor (BDNF), and histone deacetylases (HDACs). This article also presents new promising therapeutic targets including: the glutamatergic pathway, mitochondrial modulators, neuropeptide-converting endopeptidases, the insulin transduction pathway, the purinergic system and the melatoninergic system. EXPERT OPINION Challenges in improving methods and tools to generate, integrate and analyze high-dimensional data are required to allow opening novel routes to BD drug discovery. Through the application of systems biology approaches and the use of bioinformatical tools to integrate all omics data, it will be possible in the near future to gain deeper insights into pathophysiology of BD. This will in turn lead to the identification and exploitation of new potential therapeutic approaches.
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Affiliation(s)
- Nicolas Hoertel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de psychiatrie, Issy-les-Moulineaux, Paris, France
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Are subjects in treatment trials of panic disorder representative of patients in routine clinical practice? Results from a national sample. J Affect Disord 2013; 146:383-9. [PMID: 23084184 DOI: 10.1016/j.jad.2012.09.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 09/25/2012] [Accepted: 09/25/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Research on the generalizability of clinical trials in panic disorder is limited. The present study sought to quantify the generalizability of clinical trials' results of individuals with DSM-IV panic disorder (PD) to a large community sample. METHODS Data were derived from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a large national representative sample of 43,093 adults of the United States population. We applied a standard set of eligibility criteria representative of PD clinical trials to all adults with past 12 months PD (n=907), and then to a subgroup of participants seeking treatment (n=105). Our aim was to determine the proportion of participants with PD who would have been excluded by typical eligibility criteria. RESULTS We found that more than 8 out of ten participants (80.52%; 95% CI=77.13-83.52%) with PD were excluded by at least one criterion. In the subgroup of participants who sought treatment, the exclusion rate by at least one criterion was higher (92.40%; 95% CI=84.60-96.42%). For the full sample and the treatment-seeking subsample, having currently a depression and a diagnosis of alcohol or drug abuse/dependence were the criteria excluding the highest percentage of participants. Having a lifetime history of bipolar disorder and a current significant medical condition also excluded a substantial proportion of individuals in both samples. Exclusion rates were similar when considering panic disorder with and without agoraphobia. CONCLUSIONS Clinical trials, that exclude a majority of adults with panic disorder, should carefully consider the impact of eligibility criteria on the generalizability of their results. As required by CONSORT guidelines, reporting exclusion rate estimate and reasons of eligibility should be mandatory in both clinical trials and meta-analyses.
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Hoertel N, Le Strat Y, Limosin F, Dubertret C, Gorwood P. Prevalence of subthreshold hypomania and impact on internal validity of RCTs for major depressive disorder: results from a national epidemiological sample. PLoS One 2013; 8:e55448. [PMID: 23405152 PMCID: PMC3566200 DOI: 10.1371/journal.pone.0055448] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 01/02/2013] [Indexed: 11/25/2022] Open
Abstract
Background Growing evidence supports the validity of distinguishing major depressive disorder (MDD) plus a lifetime history of subthreshold hypomania (D(m)) from pure MDD in psychiatric classifications. The present study sought to estimate the proportion of individuals with D(m) that would have been included in RCTs for MDD using typical eligibility criteria, and examine the potential impact of including these participants on internal validity. Methods Data were derived from the 2001–2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a national representative sample of 43,093 adults of the United States population. We examined the proportion of participants with a current diagnosis of pure MDD and D(m) that would have been eligible in clinical trials for MDD with a traditional set of eligibility criteria, and compared it with that of participants with bipolar 2 disorder if the same set of eligibility criteria was applied. We considered 4 models including different definitions of subthreshold hypomania. Results We found that more than 7 out of ten participants with pure MDD and with D(m) would have been excluded by at least one classical eligibility criterion. Prevalence rate of individuals with D(m) in RCTs for MDD with traditional eligibility criteria would have ranged from 7.98% to 22.59%. Overall exclusion rate of individuals with MDD plus at least 4 lifetime concomitant hypomanic probes significantly differ from those with pure MDD, whereas it was not significantly different in those with at least 2 lifetime concomitant hypomanic probes compared to those with bipolar 2 disorder. Conclusions The current design of clinical trials for MDD may suffer from impaired external validity and potential impaired internal validity, due to the inclusion of a substantial proportion of individuals with subthreshold hypomania presenting with similar pattern of exclusion rates to those with bipolar 2 disorder, possibly resulting in a selection bias.
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Affiliation(s)
- Nicolas Hoertel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France.
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