Psychotherapy in controlled psychopharmacology trials. Does it matter if we ignore it?

A double-blind, placebo-controlled treatment trial of citalopram for major depressive disorder in older patients with heart failure: the relevance of the placebo effect and psychological symptoms

BACKGROUND

Little is known about the treatment of depression in older patients with heart failure. This study was developed to investigate the effectiveness of antidepressant treatment for major depressive disorder (MDD) in the elderly with heart failure.

METHODS

We enrolled 72 older outpatients with ejection fraction <50 and diagnosed with MDD by the structured clinical interview for DSM-IV. Thirty-seven patients, 19 on citalopram and 18 on placebo, initiated an 8-week double-blind treatment phase. Measurements were performed with the 31-item Hamilton Rating Scale for Depression (Ham-D-31), the Montgomery-Asberg rating scale (MADRS) and the Systematic Assessment for Treatment Emergent Effects (SAFTEE). A psychiatrist followed up the patients weekly, performing a consultation for about 20 min to field complaints after the measurements.

RESULTS

A trend toward superiority of citalopram over placebo in reducing depression was observed in MADRS scores (15.05+9.74 vs 9.44+9.25, P=.082) but not on HAM-D scores. The depressive symptomatology significantly decreased in both groups (P < .001). The high rate of placebo response during the double-blind phase (56.3%) led us to conclude the study at the interim analysis with 37 patients.

CONCLUSION

Citalopram treatment of MDD in older patients with heart failure is well-tolerated with low rates of side effects, but was not significantly more effective than placebo in the treatment of depression. Weekly psychiatric follow-up including counseling may contribute to the improvement of depression in this population. Scales weighted on psychological symptoms such as the MADRS are possibly better suited to measure depression severity and improvement in patients with heart failure.

Assessing performance of a randomized versus a non-randomized study design

INTRODUCTION

Randomization is the most optimal design for evaluating program-effectiveness. In practice, however, conducting a randomized controlled trial is not always feasible. For a non-randomized study into the effect of a parent management training, predefined intervention and control groups of families were matched on six key characteristics. The quality of this match was then compared with the quality which is to be expected from a randomized study.

METHODS

The performance of matching intervention and control families for predefined and randomized groups was evaluated by simulating new hypothetical intervention and control groups. The Mahalanobis metric was used to assess the distance between families in the intervention and the control groups and pairwise matching was performed. The global distance between these groups was used as measure of the balance of covariates in all matched pairs, with a smaller distance indicating a higher match quality.

RESULTS

In the ideal situation, when predefined groups are actually equal to randomized groups, the expected probability of a more equal balance of characteristics in the former groups than in the latter groups is 0.50. Using the data obtained in our study, and our predefined groups, this expected probability was 0.34.

CONCLUSION

Even when randomized groups are more balanced than predefined groups, using the latter groups for analyses might still be acceptable when the differences in group means are small. Findings suggest that matching can be a viable alternative to randomization for situations in which randomization is not feasible due to pragmatic constraints. However, a more accurate judgment on the value of the results obtained in this study requires results from similar analyses performed in other studies for comparison.

Bias in psychopathology research

PURPOSE OF REVIEW

Biases are frequently invoked in psychopathology research, either as core features of particular forms of psychopathology or as errors and distortions that affect psychiatric assessment, diagnosis, treatment, and research methodology. This review provides an overview of recent research on the forms of bias that are commonly examined in the field.

RECENT FINDINGS

Recent research has made a number of advances in the analysis of cognitive and affective biases underpinning psychopathology: the effect of rating and other biases on psychiatric assessment and diagnosis; the role of race and gender in psychiatric practice; financial and institutional influences on psychiatric services; and several biases affecting research methodology, study design, and statistical inference.

SUMMARY

Bias has several distinct meanings, and encompasses a disparate set of phenomena, so no over-arching conclusion about the place of bias in psychopathology research can be drawn. Recent work, however, makes solid progress toward a better understanding of systematic distortions and how they can be recognized and reduced.