How well do randomized controlled trial data generalize to 'real-world' clinical practice settings? A comparison of two generalized anxiety disorder studies

Fidelity in School-Based Positive Behavioral Interventions and Supports: Current Status of Compliance

OBJECTIVE

The current study identified and compared different treatment fidelity reporting methods.

METHOD

This paper includes 2 studies. In Study 1, the researchers compared and contrasted 3 sources of fidelity obtained in a study previously published by the authors; whereas, Study 2 did the same using a structured review of the literature.

RESULTS

Fidelity reporting methods included: self-reports, peer reports, observations, artifact review, and use of standardized procedures. Study 1: a statistically significant difference in fidelity results was identified between methods. Study 2: the most common method of reporting was no reporting (46%) followed by observations (25.6%), peer ratings (25.6%), and self-report (23.1%). When studies reported that fidelity was evaluated, 57% subsequently provided specific fidelity results.

CONCLUSIONS

Given that intervention fidelity is reported differently depending on the method used, then standard guidelines are needed for how this construct should be assessed and reported in practice and research.

Identification of major depressive disorder and prediction of treatment response using functional connectivity between the prefrontal cortices and subgenual anterior cingulate: A real-world study

BACKGROUND

Major depressive disorder (MDD) is associated with a heavy disease burden due to the difficulty in diagnosing the disorder and the uncertainty of treatment outcomes. Previous studies have demonstrated the value of functional connectivity (FC) between the dorsolateral prefrontal cortex (DLPFC) and the subgenual anterior cingulate cortex (sgACC) in the identification of MDD and the prediction of antidepressant efficacy. In the present study, we aimed to investigate whether FC is helpful in discriminating patients from healthy controls and in predicting treatment outcome.

METHODS

Seventy-six medication-free patients with MDD and 28 healthy controls were enrolled in the study. Magnetoencephalography (MEG) and the Hamilton Rating Score for Depression (HRSD-17) were administered at baseline. Then, the HRSD-17 was assessed weekly until each patient met the remission criteria, defined as a total HRSD-17 score ≤ 7. Time-dependent Cox regression analysis was used to evaluate the association between FC and the incidence of remission.

RESULTS

Healthy controls and MDD patients had opposite FC patterns; this may be helpful for identifying MDD (AUC = 0.8, p < 0.001, sensitivity 85.7%, specificity 67.9%). Alpha connectivity between the DLPFC and sgACC (HR 1.858, 95%CI 1.013-3.408, p = 0.045) was found to be an independent factor associated with better final antidepressant outcome.

LIMITATIONS

This study was conducted in a small sample of subjects. Further, the direction of regulation between the DLPFC and sgACC was not considered.

CONCLUSIONS

FC may help identify depression and may be related to the severity of depressive symptoms and predict the efficacy of antidepressant treatment.

Efficacy and effectiveness of valsartan/amlodipine and valsartan/amlodipine/hydrochlorothiazide in hypertension: randomized controlled versus observational studies

OBJECTIVE

The aim of this post-hoc analysis was to compare the results from randomized controlled trials (RCTs) and real-world evidence (RWE) studies of valsartan/amlodipine (Val/Aml) and valsartan/amlodipine/hydrochlorothiazide (Val/Aml/HCTZ) in patients with uncontrolled hypertension (>140/90 mmHg).

METHODS

Data was pooled from 15 RCTs (N = 5542) and 8 RWE studies (N = 1397) for Val/Aml; and 2 RCTs (N = 804) and 5 RWE studies (N = 9380) for Val/Aml/HCTZ. Patients who received Val/Aml (80/5, 160/5, 160/10, 320/5, or 320/10 mg), Val/Aml/HCTZ (160/5/12.5, 160/5/25, 160/10/12.5, 160/10/25, or 320/10/25 mg) or placebo were considered for this analysis. Only patients with both baseline and follow-up assessment within 60-90 days after baseline had been included in the analysis. Patients with missing values were excluded from the analysis. Using fitted linear mixed-effects model and random factors, treatment interactions and study design with mean sitting systolic blood pressure (msSBP), diastolic BP (msDBP) and pulse pressure (msPP) reductions from baseline to Week 8-12 of treatment were compared.

RESULTS

Baseline demographics and patient characteristics were comparable between RCT and RWE datasets and within Val/Aml and Val/Aml/HCTZ treatment groups. In both RCT and RWE studies, least-squares mean (LSM) reduction in msSBP/msDBP and msPP from baseline were significant (p < .05) across all dosages. The efficacy of Val/Aml in RCTs was statistically significantly greater than in RWE studies for msSBP/msDBP (-23.1/-13.8 vs. -17.9/-9.1 mmHg) but the difference was non-significant for msPP (-8.6 vs. -9.3 mmHg; p = .77). For Val/Aml/HCTZ, no direct comparison was available but a similar trend was observed. The difference observed for msSBP and msDBP may be due to routine practice setting, larger populations may have more confounders and different behaviors towards treatment adherence.

CONCLUSION

These findings demonstrate that the efficacy of Val/Aml and Val/Aml/HCTZ in RCTs was more pronounced compared with their effectiveness in RWE studies in different ethnic populations although the overall benefit was not different.

Efficacy and tolerability of trazodone retard monotherapy: results of the Serbian non-interventional study

OBJECTIVE

Trazodone is an effective antidepressant. The present study was designed as a non-interventional open-label, multi-centre, post-marketing study. The aim of the study was to evaluate the therapeutic effectiveness and tolerability of trazodone retard formulation (Trittico(®) retard) in everyday clinical practice.

METHODS

Two hundred and forty-two patients with depressive disorder from 19 different centres were included in the study. The antidepressant and anxyolitic effects were assessed using Hamilton anxiety rating scale 14 items version, Hamilton depression rating scale 14 items version and Clinical Global Impression Severity scale.

RESULTS

After only two weeks of therapy, a statistically significant improvement in the HAM-D score, was observed. This observation was maintained over the whole study period, up to the day 56.

CONCLUSIONS

Our study points toward clinical effectiveness of the prolonged-release formulation of trazodone in the treatment of unselected depressed patients in real-world practice.

Pharmacotherapy of anxiety disorders in German-speaking countries: current status and changes between 1994 and 2011

Over the past years, international treatment guidelines have been established for the treatment of anxiety disorders. Nevertheless, little is known as to whether the actual inpatient treatment follows these guidelines. The main goal of this study was to answer the question whether patients with anxiety disorder are treated according to treatment guidelines. A total of 2,573 psychiatric inpatients with the diagnosis of anxiety disorder (920 men, 1,653 women) were identified on the basis of the data of the international drug safety programme in psychiatry AMSP. Of these patients, 25.3% presented with phobia, 26.6% with panic disorder, 18.7% with generalized anxiety disorder (GAD), and 29.4% with other diagnoses of anxiety. In all of the patients, 12.7% did not receive any psychotropic medication and 22.9% were not treated with antidepressants. Only 59.3% of patients with GAD, 73.9% of patients with panic disorder, and 52.1% of patients with phobia were treated according to diagnostic guidelines. The majority (60.3%) of all patients received one or two psychotropic drugs, and only 3.7% received five or more psychotropic drugs. In two groups of patients (one group with phobia and one with panic disorder), the annual prescription rate of antidepressants significantly increased over time. The prescription rate for anticonvulsants in patients with GAD increased from 0% in 1997 to 41.7% in 2011, and for antipsychotics, from 40.7% in 1997 to 47.2% in 2011. In particular, patients with GAD were commonly treated with antipsychotics.

Pregabalin: a review of its use in adults with generalized anxiety disorder

Pregabalin (Lyrica(®)), a well established anxiolytic agent, has been approved in the EU for the treatment of generalized anxiety disorder (GAD) in adults. It has a distinct mechanism of action relative to other anti-anxiety agents (α2δ binding at presynaptic voltage dependent calcium channels leading to inhibition of excitatory neurotransmission), a rapid onset of effect (typically ≤1 week) and broad spectrum activity against both the psychic and somatic symptoms of GAD. In long-term studies, pregabalin maintained improvements in anxiety symptoms that occurred in response to short-term treatment and delayed the time to relapse of GAD compared with placebo. Common comorbidities of GAD, such as insomnia, gastrointestinal symptoms and subsyndromal depression, have no effect on the anxiolytic efficacy of, and moreover are specifically improved by, pregabalin. Treatment with pregabalin is generally well tolerated; the drug has an adverse event profile that includes dizziness, somnolence and weight gain. The potential for abuse of pregabalin is low; the risk of withdrawal symptoms is generally low when the drug is discontinued gradually (over 1 week). Alongside selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs), pregabalin is considered a first-line agent for the long-term treatment of GAD by the World Federation of Societies of Biological Psychiatry. It should be stressed, however, that definitive head-to-head studies comparing pregabalin with SSRI/SNRIs, including in patients with GAD and co-morbid major depressive disorder, are currently lacking. Recently, a study of SSRI/SNRI augmentation with pregabalin yielded positive results, while another study of switching from long-term benzodiazepine therapy to pregabalin was inconclusive; further investigations on these topics are warranted.