Deception in clinical trials and its impact on recruitment and adherence of study participants

A proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist for PTSD: Design, methods, and recruitment

Background

Almost eight million Americans suffer from Posttraumatic Stress Disorder (PTSD). Current PTSD drug therapies rely on repurposed antidepressants and anxiolytics, which produce undesirable side effects and have recognized compliance issues. Vasopressin represents a promising and novel target for pharmacological intervention. Logistical issues implementing a clinical trial for a novel PTSD pharmaceutical are relatively uncharted territory as trials concerning a new agent have not been published in the past several decades. All published trials have repurposed FDA-approved psychoactive medications with known risk profiles. Our recruitment challenges are discussed in this context.

Methods

An 18-week proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist (SRX246) for PTSD was conducted. All participants received SRX246 for 8 weeks, the placebo for 8 weeks, and the drug vs. placebo arms were compared. Participants were assessed every 2 weeks for PTSD symptoms as well as other medication effects. Results were expected to provide an initial demonstration of safety and tolerability in this clinical population and potentially clinical efficacy in SRX246-treated patients measured by Clinician Administered PTSD Scale (CAPS) score changes, clinical impression, and other indices compared to placebo. The primary hypothesis was that SRX246 would result in a clinically meaningful 10-point reduction in mean CAPS score compared to placebo.

Discussion

This study is the first to investigate an oral vasopressin 1a receptor antagonist for PTSD. As a wave of PTSD clinical trials with new pharmaceutical compounds are beginning now, lessons learned from our recruitment challenges may be invaluable to these endeavors.

The ethical anatomy of payment for research participants

In contrast to most publications on the ethics of paying research subjects, which start by identifying and analyzing major ethical concerns raised by the practice (in particular, risks of undue inducement and exploitation) and end with a set of—more or less well-justified—ethical recommendations for using payment schemes immune to these problems, this paper offers a systematic, principle-based ethical analysis of the practice. It argues that researchers have a prima facie moral obligation to offer payment to research subjects, which stems from the principle of social beneficence. This principle constitutes an ethical “spine” of the practice. Other ethical principles of research ethics (respect for autonomy, individual beneficence, and justice/fairness) make up an ethical “skeleton” of morally sound payment schemes by providing additional moral reasons for offering participants (1) recompense for reasonable expenses; and (2a) remuneration conceptualized as a reward for their valuable contribution, provided (i) it meets standards of equality, adequacy and non-exploitation, and (ii) it is not overly attractive (i.e., it does not constitute undue inducement for participation or retention, and does not encourage deceptive behaviors); or (2b) remuneration conceptualized as a market-driven price, provided (i) it is necessary and designed to help the study achieve its social and scientific goals, (ii) it does not reinforce wider social injustices and inequalities; (iii) it meets the requirement of non-exploitation; and (iv) it is not overly attractive. The principle of justice provides a strong ethical reason for not offering recompenses for lost wages (or loss of other reasonably expected profits).

Correlates of high phosphatidylethanol (PEth) levels and their concordance with self-reported heavy alcohol consumption among men who have sex with men who binge drink alcohol

BACKGROUND

Heavy alcohol use, including binge drinking, is associated with high morbidity and mortality among men who have sex with men (MSM). Self-reported alcohol measures may lead to inaccurate estimates due to recall and social desirability biases. Objective alcohol biomarkers like phosphatidylethanol (PEth) can be used to corroborate self-report and could help to inform treatment approaches and research strategies for alcohol using MSM.

METHODS

From 2015 to 2020, alcohol using MSM ≥18 years were enrolled in a randomized controlled trial evaluating the efficacy of naltrexone in reducing binge drinking. Using this trial's baseline data, we applied multivariable logistic regression to identify the correlates of high PEth levels (i.e., ≥87 ng/ml) and concordance between PEth levels and self-reported heavy drinking.

RESULTS

Of 118 MSM, 64% had PEth levels ≥87 ng/ml and 72% had PEth levels that were concordant with self-reported heavy alcohol use. Factors significantly associated in separate models with elevated PEth levels were income ≥$60,000 (adjusted odds ratio [aOR] = 4.09; 95% CI = 1.13 to 14.82), being employed (aOR = 4.04; 95% CI = 1.45 to 11.32), episodic cannabis use (aOR = 4.63; 95% CI = 1.27 to 16.92), and any alcohol/substance use prior to or during anal intercourse (aOR = 2.52; 95% CI = 1.08 to 5.90). Living with HIV was associated with significantly lower odds of elevated PEth levels (aOR = 0.23; 95% CI = 0.09 to 0.61). Factors associated with significantly higher concordance between PEth levels and self-reported heavy alcohol use included at least weekly use of poppers (aOR = 6.41; 95% CI = 1.27 to 32.28) and polysubstance use (aOR = 2.53; 95% CI = 1.02 to 6.27). Living with HIV was associated with lower odds of concordance (aOR = 0.36; 95% CI = 0.14 to 0.97).

CONCLUSIONS

PEth may enhance the detection of heavy drinking among MSM, including the identification of subpopulations that may benefit from targeted alcohol reduction interventions. However, PEth values for MSM living with HIV showed modest concordance with self-reported alcohol use and may need to be supplemented with additional biomarkers or evaluated against a different cutoff.

Can the use of deception be justified in medical education research? A point/counterpoint and case study

Deception is a common feature of behavioral research design, although not commonly employed in the medical literature. It can promote scientific validity but is ethically controversial because it compromises subject autonomy and incurs additional costs.  In this Point/Counterpoint monograph, we review the nature of deception in research and present arguments for and against its ethical use as a research methodology in behavioral studies.  We describe the necessary guidelines, safeguards, and oversight, when deceptive methodology is considered, and report our experiences and lessons learned from conducting a multi-institutional audit study that relied upon deception of academic radiology faculty.

Ethical considerations around volunteer payments in a malaria human infection study in Kenya: an embedded empirical ethics study

Human Infection Studies (HIS) have emerged as an important research approach with the potential to fast track the global development of vaccines and treatments for infectious diseases, including in low resource settings. Given the high level of burdens involved in many HIS, particularly prolonged residency and biological sampling requirements, it can be challenging to identify levels of study payments that provide adequate compensation but avoid 'undue' levels of inducement to participate. Through this embedded ethics study, involving 97 healthy volunteers and other research stakeholders in a malaria HIS programme in Kenya, and using in-depth interviews, focus group discussions and observations during and after a malaria HIS, we give a grounded account of ethical issues emerging in relation to study payments in this setting. While careful community, national, international scientific and ethics review processes meant that risks of serious harm were highly unlikely, the levels of motivation to join HIS seen could raise concerns about study payments being too high. Particular value was placed on the reliability, rather than level, of study payment in this setting, where subsistence livelihoods are common. Study volunteers were generally clear about the study aims at the point of recruitment, and this knowledge was retained over a year later, although most reported experiencing more burdens than anticipated at enrolment. Strict study screening procedures, regular clinical and laboratory monitoring of volunteers, with prompt treatment with antimalarial at predetermined endpoints suggested that the risks of serious harm were highly unlikely. Ethical concerns emerged in relation to volunteers' attempts to conceal symptoms, hoping to prolong residency periods and increase study payments; and volunteers making decisions that compromised important family relationships and personal values. Our findings support an interpretation that, although study volunteers were keen to join the study to access cash payments, they also paid attention to other features of the study and the general clinical research landscape, including levels of risk associated with study participation. Overall, our analysis shows that the ethical concerns emerging from the study payments can be addressed through practical measures, hinged on reducing burdens and strengthening communication, raising important issues for research policy and planning.

Point-of-Care Test for Assessing Tenofovir Adherence: Feasibility and Recommendations from Women in an Oral PrEP Program in Kenya and Their Healthcare Providers

Oral pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention modality when taken as recommended. Women in sub-Saharan Africa may have adherence challenges that remain undisclosed to providers. Real-time measures that identify non-adherence can allow for immediate exploration of adherence challenges, counseling and interventions. We conducted a formative qualitative study in Kenya to explore oral PrEP experiences and reactions to a point-of-care urine test (UT) identifying recent (past 4 days) non-adherence to tenofovir-based PrEP among female PrEP users (25 in-depth interviews; 4 focus groups) and health care provider (10 key informant interviews). Findings indicate that use of the UT would be highly feasible in the context of regular PrEP care, largely acceptable to clients and providers, and could improve adherence. Clients emphasized the need for transparent client-centered strategies in delivering results. This formative study informs the development of tools to implement this point-of-care UT in future interventional studies and clinical settings.

Audio-digital recordings to assess ratings reliability in clinical trials of schizophrenia

We examined ratings reliability in 5 clinical trials of subjects with schizophrenia experiencing an acute exacerbation of psychosis. Audio-digital recordings of site-based interviews of the Positive and Negative Syndrome Scale (PANSS) or Brief Psychiatric Rating Scale (BPRS) were used to obtain blinded, site-independent scores to evaluate paired scoring concordance. High intraclass correlations were noted between 1810 paired site-based and site-independent PANSS scores (r = 0.801) and 1837 paired BPRS scores (r = 0.897) with high limits of agreement such that 93.9% of paired scores were within the calculated 95% confidence intervals. In 2 studies where sufficient PANSS data was available at baseline and endpoint, blinded site-independent ratings yielded a predictive value of 84.2% for replicating site-based response/nonresponse treatment outcomes. There was a significant positive correlation between site-based scores and paired scoring deviations (PANSS: r = 0.246; p < 0.0001; BPRS: r = 0.176; p < 0.0001). The magnitude (symptom severity) of PANSS or BPRS scores affected the directionality of paired scoring deviations in each study. Site-based raters scored the most symptomatic subjects higher and less symptomatic subjects lower than the paired site-independent raters on either instrument. This analysis affirms the utility of paired audio-digital scoring of site-based interviews as a surveillance strategy for schizophrenia studies. We noted a high predictive value of blinded site-independent raters to replicate site-based treatment outcomes. The bi-directionality of paired scoring deviations observed for both the PANSS and BPRS is consistent with findings found for depression rating instruments.

Use of a Novel Couples' Verification Tool in a Male Partner Treatment Study of Women With Recurrent Bacterial Vaginosis

Verification of relationship status beyond self-report is an important aspect in sexually transmitted infection research, including partner treatment studies where primary sexual partners are targeted for enrollment. This exploratory study describes the use of a novel couples' verification tool in a male partner treatment study of women with recurrent bacterial vaginosis.

Remote Methods for Conducting Tobacco-Focused Clinical Trials

Most tobacco-focused clinical trials are based on locally conducted studies that face significant challenges to implementation and successful execution. These challenges include the need for large, diverse, yet still representative study samples. This often means a protracted, costly, and inefficient recruitment process. Multisite clinical trials can overcome some of these hurdles but incur their own unique challenges. With recent advances in mobile health and digital technologies, there is now a promising alternative: Remote Trials. These trials are led and coordinated by a local investigative team, but are based remotely, within a given community, state, or even nation. The remote approach affords many of the benefits of multisite trials (more efficient recruitment of larger study samples) without the same barriers (cost, multisite management, and regulatory hurdles). The Coronavirus Disease 2019 (COVID-19) global health pandemic has resulted in rapid requirements to shift ongoing clinical trials to remote delivery and assessment platforms, making methods for the conduct of remote trials even more timely. The purpose of the present review is to provide an overview of available methods for the conduct of remote tobacco-focused clinical trials as well as illustrative examples of how these methods have been implemented across recently completed and ongoing tobacco studies. We focus on key aspects of the clinical trial pipeline including remote: (1) study recruitment and screening, (2) informed consent, (3) assessment, (4) biomarker collection, and (5) medication adherence monitoring. Implications With recent advances in mobile health and digital technologies, remote trials now offer a promising alternative to traditional in-person clinical trials. Remote trials afford expedient recruitment of large, demographically representative study samples, without undo burden to a research team. The present review provides an overview of available methods for the conduct of remote tobacco-focused clinical trials across key aspects of the clinical trial pipeline.

Assessing the Scope and Predictors of Intentional Dose Non-adherence in Clinical Trials

BACKGROUND

Although there is broad agreement that the accurate estimation of non-adherence rates in clinical trials is essential to determining the dose-response relationship, treatment safety and efficacy effects, no accurate estimates have ever been produced.

METHODS

This study used a novel platform combining artificial intelligence and virtual patient monitoring to identify and quantify the scope of unreported intentional non-adherence in clinical trials of new medical therapies. Nearly 260,000 observations were drawn from a convenience sample of 2976 study volunteers participating in 23 clinical trials of psychiatric, neurological and neuromuscular diseases.

RESULTS

The results indicate that 4% of all confirmed doses were intentionally non-adherent, 48% of all study volunteers had at least one intentionally non-adherent dose and 5% of study volunteers were intentionally non-adherent for more than one-third of all doses required.

CONCLUSIONS

Several factors were associated with, and predictive of, unreported intentional non-adherence including clinical trial phase; clinical trial duration; geographic location where the study was conducted; and investigative site enrollment volume. The findings also show that although the overall rate of intentional non-adherence does not change over the course of a clinical trial, study volunteers who deliberately chose not to take their first dose had a mean intentional non-adherence rate five times higher than that observed among those who were first dose adherent. Implications of the study results are discussed.

Vulnerability and Clinical Research: Mapping the Challenges for Stakeholders

Beyond what are characterized as Special Populations in U.S. FDA regulatory considerations is vulnerability of patient populations in a broader context of international guidance. Such a review suggests a rich appreciation for the diversity of patients. Vulnerable patients' status and the associated patient protections are of growing interest in the clinical research environment. To participate in the current developments and reflections, we selected 12 international & recognized core documents that are discussing human research protections and identify all references to them pertinent to Vulnerables. This allows the identification of 15 different categories of Vulnerability, that we group in five kinds of challenges. We then map significant regulatory and ethical interpretations and their implications toward applying what Vulnerability constitutes for the stakeholder ecosystem and its evolving direction as part of the overall protection for patients, defined as a "chain of protection." Different levels of understanding are proposed: Who are vulnerable (a 'macro'-mapping), what is Vulnerability (a 'meso'-mapping) leading to applications with practical questions (a 'micro'-mapping). We offer this analysis and mapping for practical benefit to a range of stakeholders with staffs whose functional responsibilities indirectly or directly essentially touch the broad spectrum of involvement with patients. The practical application is for multi-stakeholder consideration of patients-as-subjects in research, especially for Sites and Ethics Committees/IRBs, given the extended efforts of "patient-centricity"-the 'how's' and 'what's' of including patients in the clinical research process from discovery to RWE and its implications. Also considered is the value of education and training purposes on the true diversity of patients so that sensitivity to such matters from protocol development through informed consent and privacy protections are taken into account in the era of "new science," technological advances, and expansion of clinical research investigators, patient populations, and types of non-traditional research sites.

Utilizing content-knowledge questionnaires to assess study eligibility and detect deceptive responding

Background: Deceptive responding during eligibility screening presents a significant concern for assessing inclusion/exclusion criteria. This problem is compounded in settings for which biomarkers or other objective verification (e.g., urinalysis) are not feasible.Objectives: Introduce and describe content-knowledge questionnaires as an objective method for collaterally assessing study eligibility.Methods: Participants (N = 3772; 66.1% female) recruited using the crowdsourcing resource Amazon Mechanical Turk (mTurk) completed a Cannabis Knowledge Questionnaire (CKQ). The CKQ contained four-items indexing knowledge of typical cannabis costs, weights, and terminology. Self-reported cannabis use history was collected and compared to individual item and total scale scores. A separate in-laboratory assessment evaluated participants during in-person screening for cannabis, alcohol, and cocaine research protocols (N = 43).Results: Good internal consistency (α = .74) was observed. The most common correctly answered question was about dabbing (41.4%) followed by cannabis cost (37.6%), hybrid strains (36.6%), and estimated weight (29.7%). Current cannabis use was associated with large effect size increases in the rate of correct responses (RR = 3.64) as well as odds of a correct response on individual items (OR = 5.88-21.48). In the laboratory study, participants with a positive urine drug test for cannabis or those reporting lifetime regular cannabis use scored higher than those without this history (RR = 1.89-2.61).Conclusion: These findings highlight the efficiency and efficacy of including content-knowledge questionnaires for collateral assessment of study eligibility, especially when biomarkers are not possible. Future studies will be useful for extending this initial demonstration to alternative settings and substances.

Are Payments to Human Research Subjects Ethically Suspect?

Bioethicists and institutional review boards often worry that paying human subjects too much money for research participation might compromise informed consent by coercing or unduly influencing individuals to enroll in studies against their better judgment. However, empirical research does not support the hypothesis that payments adversely impact judgment and decision-making concerning research participation, and the opposite problem - underpayment - also raises significant ethical concerns, such as exploitation, and under-enrollment. In this article, I argue that our ethical qualms about the negative impact of money on decisions concerning research participation are largely unfounded and reflect more general concerns about the need to avoid repeating abuses of human subjects that occurred in the past. I shall also argue that the best way to promote the rights and welfare of human research subjects is to treat them as competent adults who have the capacity to make wise choices involving money. What this argument means in practice is that offering human subjects money for their participation should not be regarded as ethically suspect, absent substantial evidence to the contrary.

Audio-digital recordings for surveillance in clinical trials of major depressive disorder

Ratings surveillance is used in clinical trials to assure ratings reliability of site-based scores. One surveillance method employs audio-digital recordings of site-based clinician interviews to obtain remote, site-independent scores for assessment of paired scoring concordance and interview quality. We examined the utility of this surveillance strategy using paired site-independent scores derived from recorded site-based Montgomery-Asberg depression rating scale (MADRS) interviews obtained from patients with major depressive disorder (MDD) participating in 5 clinical trials.

High correlations were noted between the 3736 paired site-based and site-independent scores across all visits. Some rater “outliers” were identified whose ratings performance improved following remediation. In 3 studies with available outcome data, the blinded remote ratings yielded a high predictive value (91.2%) for replicating treatment response rates.

The magnitude of the total MADRS scores affected the directionality of paired scoring deviations in each of the 5 studies. Across all visits, site-based raters scored the more severe MADRS scores (≥30) higher than site-independent raters and the less severe MADRS scores (<20) lower than site-independent raters. Individual MADRS items were similarly affected by the directionality of symptom severity.

This analysis affirms the utility of audio-digital recording of site-based interviews as a surveillance strategy for quality assurance (monitoring and remediation). In addition, the high predictive value of blinded remote ratings to replicate site-based treatment outcomes may be useful to affirm primary site-based results when there is a potential of functional unblinding. The use of remote ratings as a primary measure beyond its utility for quality assurance needs further exploration.

Association Between Financial Incentives and Participant Deception About Study Eligibility

IMPORTANCE

Offers of payment for research participation are ubiquitous but may lead prospective participants to deceive about eligibility, jeopardizing study integrity and participant protection. To date, neither the rate of payment-induced deception nor the influence of payment amount has been systematically studied in a nationally representative randomized survey experiment.

OBJECTIVES

To estimate payment-associated deception about eligibility for an online survey and to assess whether there is an association between payment amount and deception frequency.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, 7-group survey experiment. Data were collected in March 2018 and analyzed from March to August 2018. The setting was a nationally representative online survey among US adults drawn from the GfK KnowledgePanel.

INTERVENTIONS

Varying payment amounts for participation ($5, $10, or $20 cash equivalent) and direction of eligibility criterion (having received or not having received an influenza vaccination in the past 6 months).

MAIN OUTCOMES AND MEASURES

Proportion of respondents reporting recent influenza vaccination.

RESULTS

In total, 2275 individuals participated in the survey, a 59.4% (2275 of 3829) response rate; 51.8% (1108) were female, and 21.1% of respondents (399) were aged 18 to 29 years, 24.9% (532) were aged 30 to 44 years, 26.0% (601) were aged 45 to 59 years, and 28.0% (738) were 60 years or older. For participants offered a $5 incentive, the reported frequency of recent influenza vaccination was 16.6% higher (95% CI, 9.1%-24.1%) among those told that eligibility (and thus payment) required recent vaccination than among those told that eligibility required no recent vaccination. The corresponding differences were 21.0% (95% CI, 13.5%-28.5%) among those offered $10 and 15.4% (95% CI, 7.8%-23.0%) among those offered $20. Estimated proportions of ineligible individuals who responded deceptively regarding eligibility ranged from 10.5% to 22.8% across study groups. There was no evidence that higher payment was associated with higher frequency of deception.

CONCLUSIONS AND RELEVANCE

In a nationally representative randomized survey experiment to evaluate whether and to what extent payment is associated with participants misleading investigators about their research eligibility, this study found evidence of significant deception. However, no association was observed between payment amount and frequency of deception. Further research is needed to extend these findings to clinical research. These data suggest that, when possible, investigators should rely on objective tests of eligibility rather than self-report.

The Extraordinary Importance of Sleep: The Detrimental Effects of Inadequate Sleep on Health and Public Safety Drive an Explosion of Sleep Research

New sleep deprivation studies confirm the relationship between inadequate sleep and a wide range of disorders, such as hypertension, obesity and type-2 diabetes, cardiovascular disease, impaired immune functioning, and more.