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Mollica A, Ng E, Burke MJ, Nestor SM, Lee H, Rabin JS, Hamani C, Lipsman N, Giacobbe P. Treatment expectations and clinical outcomes following repetitive transcranial magnetic stimulation for treatment-resistant depression. Brain Stimul 2024; 17:752-759. [PMID: 38901565 DOI: 10.1016/j.brs.2024.06.006] [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: 12/20/2023] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Patient expectations, including both positive (placebo) and negative (nocebo) effects, influence treatment outcomes, yet their impact on acute repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant depression (TRD) is unclear. METHODS In this single-center retrospective chart review, 208 TRD patients completed the Stanford Expectation of Treatment Scale (SETS) before starting open-label rTMS treatment. Patients were offered two excitatory rTMS protocols (deep TMS or intermittent theta-burst stimulation), which stimulated the left dorsolateral prefrontal cortex. A minimum of 20 once daily treatments were provided, delivered over 4-6 weeks. Primary outcomes were 1) remission, measured by a post-treatment score of <8 on the Hamilton Depression Rating Scale (HAMD-17), and 2) premature discontinuation. The change in HAMD-17 scores over time was used as a secondary outcome. Physicians were blinded to SETS scores. Logistic and linear regression, adjusting for covariates, assessed SETS and HAMD-17 relationships. RESULTS Of 208 patients, 177 had baseline and covariate data available. The mean positivity bias score (positive expectancy minus negative expectancy subscale averages) was 0.48 ± 2.21, indicating the cohort was neutral regarding the expectations of their treatment on average. Higher positive expectancy scores were significantly associated with greater odds of remission (OR = 1.90, p = 0.003) and greater reduction in HAMD-17 scores (β = 1.30, p = 0.005) at the end of acute treatment, after adjusting for covariates. Negative expectancy was not associated with decreased odds of remission (p = 0.2) or treatment discontinuation (p = 0.8). CONCLUSIONS Higher pre-treatment positive expectations were associated with greater remission rates with open-label rTMS in a naturalistic cohort of patients with TRD.
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Affiliation(s)
- Adriano Mollica
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Enoch Ng
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Matthew J Burke
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sean M Nestor
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hyewon Lee
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Jennifer S Rabin
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; Rehabilitation Sciences Institute, University of Toronto, Canada
| | - Clement Hamani
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Nir Lipsman
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Peter Giacobbe
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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Ferraro MC, O'Connell NE, Sommer C, Goebel A, Bultitude JH, Cashin AG, Moseley GL, McAuley JH. Complex regional pain syndrome: advances in epidemiology, pathophysiology, diagnosis, and treatment. Lancet Neurol 2024; 23:522-533. [PMID: 38631768 DOI: 10.1016/s1474-4422(24)00076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 04/19/2024]
Abstract
Complex regional pain syndrome (CRPS) is a rare pain disorder that usually occurs in a limb after trauma. The features of this disorder include severe pain and sensory, autonomic, motor, and trophic abnormalities. Research from the past decade has offered new insights into CRPS epidemiology, pathophysiology, diagnosis, and treatment. Early identification of individuals at high risk of CRPS is improving, with several risk factors established and some others identified in prospective studies during the past 5 years. Better understanding of the pathophysiological mechanisms of CRPS has led to its classification as a chronic primary pain disorder, and subtypes of CRPS have been updated. Procedures for diagnosis have also been clarified. Although effective treatment of CRPS remains a challenge, evidence-based integrated management approaches provide new opportunities to improve patient care. Further advances in diagnosis and treatment of CRPS will require coordinated, international multicentre initiatives.
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Affiliation(s)
- Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Claudia Sommer
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Andreas Goebel
- Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Janet H Bultitude
- Centre for Pain Research, Department of Psychology, University of Bath, Bath, UK
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - G Lorimer Moseley
- IMPACT in Health, University of South Australia, Kaurna Country, Adelaide, SA, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
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Köhler-Forsberg O, Stiglbauer V, Brasanac J, Chae WR, Wagener F, Zimbalski K, Jefsen OH, Liu S, Seals MR, Gamradt S, Correll CU, Gold SM, Otte C. Efficacy and Safety of Antidepressants in Patients With Comorbid Depression and Medical Diseases: An Umbrella Systematic Review and Meta-Analysis. JAMA Psychiatry 2023; 80:1196-1207. [PMID: 37672261 PMCID: PMC10483387 DOI: 10.1001/jamapsychiatry.2023.2983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/21/2023] [Indexed: 09/07/2023]
Abstract
Importance Every third to sixth patient with medical diseases receives antidepressants, but regulatory trials typically exclude comorbid medical diseases. Meta-analyses of antidepressants have shown small to medium effect sizes, but generalizability to clinical settings is unclear, where medical comorbidity is highly prevalent. Objective To perform an umbrella systematic review of the meta-analytic evidence and meta-analysis of the efficacy and safety of antidepressant use in populations with medical diseases and comorbid depression. Data Sources PubMed and EMBASE were searched from inception until March 31, 2023, for systematic reviews with or without meta-analyses of randomized clinical trials (RCTs) examining the efficacy and safety of antidepressants for treatment or prevention of comorbid depression in any medical disease. Study Selection Meta-analyses of placebo- or active-controlled RCTs studying antidepressants for depression in individuals with medical diseases. Data Extraction and Synthesis Data extraction and quality assessment using A Measurement Tool for the Assessment of Multiple Systematic Reviews (AMSTAR-2 and AMSTAR-Content) were performed by pairs of independent reviewers following PRISMA guidelines. When several meta-analyses studied the same medical disease, the largest meta-analysis was included. Random-effects meta-analyses pooled data on the primary outcome (efficacy), key secondary outcomes (acceptability and tolerability), and additional secondary outcomes (response and remission). Main Outcomes and Measures Antidepressant efficacy presented as standardized mean differences (SMDs) and tolerability (discontinuation for adverse effects) and acceptability (all-cause discontinuation) presented as risk ratios (RRs). Results Of 6587 references, 176 systematic reviews were identified in 43 medical diseases. Altogether, 52 meta-analyses in 27 medical diseases were included in the evidence synthesis (mean [SD] AMSTAR-2 quality score, 9.3 [3.1], with a maximum possible of 16; mean [SD] AMSTAR-Content score, 2.4 [1.9], with a maximum possible of 9). Across medical diseases (23 meta-analyses), antidepressants improved depression vs placebo (SMD, 0.42 [95% CI, 0.30-0.54]; I2 = 76.5%), with the largest SMDs for myocardial infarction (SMD, 1.38 [95% CI, 0.82-1.93]), functional chest pain (SMD, 0.87 [95% CI, 0.08-1.67]), and coronary artery disease (SMD, 0.83 [95% CI, 0.32-1.33]) and the smallest for low back pain (SMD, 0.06 [95% CI, 0.17-0.39]) and traumatic brain injury (SMD, 0.08 [95% CI, -0.28 to 0.45]). Antidepressants showed worse acceptability (24 meta-analyses; RR, 1.17 [95% CI, 1.02-1.32]) and tolerability (18 meta-analyses; RR, 1.39 [95% CI, 1.13-1.64]) compared with placebo. Antidepressants led to higher rates of response (8 meta-analyses; RR, 1.54 [95% CI, 1.14-1.94]) and remission (6 meta-analyses; RR, 1.43 [95% CI, 1.25-1.61]) than placebo. Antidepressants more likely prevented depression than placebo (7 meta-analyses; RR, 0.43 [95% CI, 0.33-0.53]). Conclusions and Relevance The results of this umbrella systematic review of meta-analyses found that antidepressants are effective and safe in treating and preventing depression in patients with comorbid medical disease. However, few large, high-quality RCTs exist in most medical diseases.
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital–Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Victoria Stiglbauer
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Jelena Brasanac
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Woo Ri Chae
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- BIH Charité Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Frederike Wagener
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Kim Zimbalski
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Oskar H. Jefsen
- Psychosis Research Unit, Aarhus University Hospital–Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Shuyan Liu
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Malik R. Seals
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Stefanie Gamradt
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph U. Correll
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, New York
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
| | - Stefan M. Gold
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- Department of Psychosomatic Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Institute of Neuroimmunology and Multiple Sclerosis, Universitätsklinikum Hamburg–Eppendorf, Hamburg, Germany
| | - Christian Otte
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
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Birkinshaw H, Friedrich CM, Cole P, Eccleston C, Serfaty M, Stewart G, White S, Moore RA, Phillippo D, Pincus T. Antidepressants for pain management in adults with chronic pain: a network meta-analysis. Cochrane Database Syst Rev 2023; 5:CD014682. [PMID: 37160297 PMCID: PMC10169288 DOI: 10.1002/14651858.cd014682.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well-being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients' global impression of change for certain chronic pain conditions. However, there has not been a network meta-analysis (NMA) examining all antidepressants across all chronic pain conditions. OBJECTIVES To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022. SELECTION CRITERIA We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double-blind. We included RCTs with active comparators that were unable to be double-blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow-up was less than two weeks and those with fewer than 10 participants in each arm. DATA COLLECTION AND ANALYSIS: Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta-analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta-Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB-MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal. MAIN RESULTS This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo-controlled (83), and parallel-armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short-term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest-ranked antidepressant with moderate- to high-certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain. Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate-certainty evidence) and continuous pain intensity (standardised mean difference (SMD) -0.31, 95% CI -0.39 to -0.24; 18 studies, 4959 participants; moderate-certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD -0.22, 95% CI -0.39 to 0.06; 4 studies, 1866 participants; moderate-certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD -0.5, 95% CI -0.78 to -0.22; 1 study, 406 participants; low-certainty evidence), while duloxetine showed a small effect (SMD -0.16, 95% CI -0.22 to -0.1; 26 studies, 7952 participants; moderate-certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest-ranked antidepressants with moderate-certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low-certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes. AUTHORS' CONCLUSIONS Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high-quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long-term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point.
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Affiliation(s)
- Hollie Birkinshaw
- Department of Psychology, University of Southampton, Southampton, UK
| | | | - Peter Cole
- Oxford Pain Relief Unit, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | | | | | - Simon White
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | | | | | - Tamar Pincus
- Department of Psychology, University of Southampton, Southampton, UK
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Jones AC, Robinson WD, Delbridge EJ, Brown BJ, McPhee DP. Psychopharmacology attitudes, beliefs, and practices among systemic family therapists and supervisors. JOURNAL OF MARITAL AND FAMILY THERAPY 2023. [PMID: 37036303 DOI: 10.1111/jmft.12639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 06/19/2023]
Abstract
Many aspects of systemic family therapist (SFT) training and competence play a vital role in effective treatment and professional satisfaction. One area that has been significantly overlooked by many SFTs is the role of psychotropic medication (PM) in conjunction with talk therapy for optimal mental health outcomes. This study explores the current status of PM in SFT training and clinical practice. Our findings highlight the continued struggle of SFTs in their comfort level with addressing the PM needs of their clients. We identified a perceived inadequacy of SFT training and supervision regarding PM use. SFTs around the world need to find educational opportunities to improve their competence in working with their clients and their prescribed medications. Additional studies need to be conducted on strategies and mechanisms to improve client care. If SFTs are ignorant of PM, their treatment of clients-who often use PM-will be compromised.
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Affiliation(s)
- Adam C Jones
- Department of Human Development, Family Studies, and Counseling, Texas Woman's University, Denton, Texas, USA
| | - W David Robinson
- Human Development and Family Studies Department, Utah State University, Logan, Utah, USA
| | - Emilee J Delbridge
- Department of Family Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Braden J Brown
- Department of Family Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Douglas P McPhee
- Department of Marriage and Family Therapy, Mount Mercy University, Cedar Rapids, Iowa, USA
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Sakurai H, Uribe S, Cirillo P, Fuertes-Saiz A, Camprodon JA, Barbour T. Residual symptoms after achieving remission with repetitive transcranial magnetic stimulation in depression. J Affect Disord 2022; 301:154-161. [PMID: 34998805 DOI: 10.1016/j.jad.2021.12.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 12/08/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Hitoshi Sakurai
- Department of Neuropsychiatry, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Sofia Uribe
- Department of Psychiatry, Laboratory for Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, 149 13th Street, 2nd floor, Boston, MA, United States
| | - Patricia Cirillo
- Department of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alejandro Fuertes-Saiz
- Transcranial Magnetic Stimulation Unit, Hospital La Salud, Valencia, Spain; Department of Medicine and Surgery, TXP Research Group, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain
| | - Joan A Camprodon
- Department of Psychiatry, Laboratory for Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, 149 13th Street, 2nd floor, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, MA, United States
| | - Tracy Barbour
- Department of Psychiatry, Laboratory for Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, 149 13th Street, 2nd floor, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, MA, United States.
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Kearns B, Cooper K, Orr M, Essat M, Hamilton J, Cantrell A. The Incidence and Costs of Adverse Events Associated with Antidepressants: Results from a Systematic Review, Network Meta-Analysis and Multi-Country Economic Model. Neuropsychiatr Dis Treat 2022; 18:1133-1143. [PMID: 35698594 PMCID: PMC9188369 DOI: 10.2147/ndt.s356414] [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: 12/30/2021] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE There is variation in the safety profile of antidepressants. Rates of adverse events along with the costs of treating them can be an important factor influencing the choice of depression treatment. This study sought to estimate the comparative safety of commonly prescribed antidepressants, and how the costs of treating these varied across European countries. METHODS A systematic literature review was conducted (in Medline, Embase, PsycINFO and CENTRAL) to identify placebo-controlled trials reporting rates of at least one type of sexual dysfunction, weight change, insomnia, anxiety, and anhedonia. Eight antidepressants were considered: duloxetine, escitalopram, fluoxetine, paroxetine, sertraline, trazodone, venlafaxine, and vortioxetine. This evidence was synthesised via Bayesian random effects network meta-analyses to provide comparative estimates of safety. A systematic search identified country-specific costs of managing depression and adverse events of antidepressants. Evidence on costs and safety was combined in an economic model to provide country-specific costs for Bulgaria, the Czech Republic, Greece, Hungary, Italy, Romania, Slovakia, Portugal, and Poland. RESULTS Trazodone had the lowest rates of both insomnia (odds ratio 0.66, 95% credible interval 0.31 to 1.38) and anxiety (0.13, <0.01 to 1.80). All antidepressants were associated with increased rates of sexual dysfunction relative to placebo. Weight change was largest for fluoxetine (kg change -1.01, -1.40 to -0.60) and sertraline (-1.00, -1.36 to -0.65), although heterogeneity was extreme for this outcome. No evidence was identified for anhedonia. Total costs were lowest for trazodone in all nine of the countries evaluated. This was primarily due to reduced rates of treatment discontinuation. CONCLUSION Trazodone generally had the best safety profile of the antidepressants evaluated. This led to healthcare costs being lowest for trazodone in all nine European countries, emphasising the importance of considering rates of adverse events when choosing a pharmacological treatment to treat symptoms of depression.
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Affiliation(s)
- Benjamin Kearns
- School of Health and Related Research (SCHARR), the University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research (SCHARR), the University of Sheffield, Sheffield, UK
| | - Martin Orr
- School of Health and Related Research (SCHARR), the University of Sheffield, Sheffield, UK
| | - Munira Essat
- School of Health and Related Research (SCHARR), the University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (SCHARR), the University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (SCHARR), the University of Sheffield, Sheffield, UK
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8
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Trinchieri M, Perletti G, Magri V, Stamatiou K, Montanari E, Trinchieri A. Urinary side effects of psychotropic drugs: A systematic review and metanalysis. Neurourol Urodyn 2021; 40:1333-1348. [PMID: 34004020 DOI: 10.1002/nau.24695] [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] [Received: 03/01/2021] [Revised: 04/11/2021] [Accepted: 04/16/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the effects of psychotropic drugs on bladder function. MATERIALS AND METHODS A systematic review was carried out by searching PubMed and Embase databases for randomized controlled trials enrolling patients treated with psychotropic drugs with available information on treatment-related urinary disorders. RESULTS A total of 52 studies was selected. In antidepressant therapy, bladder voiding symptoms, rather than storage symptoms, were more frequently observed. Pooled analysis demonstrated a higher odds ratio (OR) of voiding disorders in comparison with placebo (OR: 3.30; confidence interval [CI]: 1.90-5.72; 7856 participants; p < 0.001). Odds for voiding dysfunction was higher for tricyclic antidepressants and for Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) when compared to Selective Serotonin Reuptake Inhibitors (SSRIs). Treatment with antipsychotics was associated with heterogeneous urinary disorders including emptying and storage disorders. OR for incontinence in patients with dementia taking antipsychotics was higher than placebo (OR: 4.09; CI: 1.71-9.79, p = 0.002) with no difference between different atypical antipsychotics. Rate of voiding disorders was not different between conventional and atypical antipsychotics (OR: 1.64; CI: 0.79-3.39, p = 0.19), although quetiapine showed higher odds to cause voiding dysfunction than other atypical antipsychotics (OR: 2.14; CI: 1.41-3.26; p > 0.001). CONCLUSIONS In patients taking tricyclic antidepressants or SNRIs, bladder voiding disorders, could be the side effects of therapy rather than symptoms of a urological disease. Patients treated with these drugs should be actively monitored for the appearance of urinary symptoms. Antipsychotic treatment is associated with various urinary side effects requiring a tailored approach.
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Affiliation(s)
| | - Gianpaolo Perletti
- Section of Medical and Surgical Sciences, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Human Structure and Repair, Faculty of Medicine and Medical Sciences, Ghent University, Ghent, Belgium
| | | | | | - Emanuele Montanari
- Department of Urology, IRCCS Ca' Granda Ospedale Maggiore Policlinico-University of Milan, Milan, Italy
| | - Alberto Trinchieri
- Department of Urology, IRCCS Ca' Granda Ospedale Maggiore Policlinico-University of Milan, Milan, Italy
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Abstract
Transcranial direct current stimulation (tDCS) is a novel treatment option for major depression which could be provided as a first-line treatment. tDCS is a non-invasive form of transcranial stimulation which changes cortical tissue excitability by applying a weak (0.5-2 mA) direct current via scalp electrodes. Anodal and cathodal stimulation leads to depolarisation and hyperpolarisation, respectively, and cumulative effects are observed with repeated sessions. The montage in depression most often involves anodal stimulation to the left dorsolateral prefrontal cortex. Rates of clinical response, remission, and improvements in depressive symptoms following a course of active tDCS are greater in comparison to a course of placebo sham-controlled tDCS. In particular, the largest treatment effects are evident in first episode and recurrent major depression, while minimal effects have been observed in treatment-resistant depression. The proposed mechanism is neuroplasticity at the cellular and molecular level. Alterations in neural responses have been found at the stimulation site as well as subcortically in prefrontal-amygdala connectivity. A possible mediating effect could be cognitive control in emotion dysregulation. Additional beneficial effects on cognitive impairments have been reported, which would address an important unmet need. The tDCS device is portable and can be used at home. Clinical trials are required to establish the efficacy, feasibility and acceptability of home-based tDCS treatment and mechanisms.
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Affiliation(s)
- Rachel Woodham
- School of Psychology, University of East London, London, UK
| | | | - Julian Mutz
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Cynthia H Y Fu
- School of Psychology, University of East London, London, UK.,Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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10
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Roughan WH, Campos AI, García-Marín LM, Cuéllar-Partida G, Lupton MK, Hickie IB, Medland SE, Wray NR, Byrne EM, Ngo TT, Martin NG, Rentería ME. Comorbid Chronic Pain and Depression: Shared Risk Factors and Differential Antidepressant Effectiveness. Front Psychiatry 2021; 12:643609. [PMID: 33912086 PMCID: PMC8072020 DOI: 10.3389/fpsyt.2021.643609] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
The bidirectional relationship between depression and chronic pain is well-recognized, but their clinical management remains challenging. Here we characterize the shared risk factors and outcomes for their comorbidity in the Australian Genetics of Depression cohort study (N = 13,839). Participants completed online questionnaires about chronic pain, psychiatric symptoms, comorbidities, treatment response and general health. Logistic regression models were used to examine the relationship between chronic pain and clinical and demographic factors. Cumulative linked logistic regressions assessed the effect of chronic pain on treatment response for 10 different antidepressants. Chronic pain was associated with an increased risk of depression (OR = 1.86 [1.37-2.54]), recent suicide attempt (OR = 1.88 [1.14-3.09]), higher use of tobacco (OR = 1.05 [1.02-1.09]) and misuse of painkillers (e.g., opioids; OR = 1.31 [1.06-1.62]). Participants with comorbid chronic pain and depression reported fewer functional benefits from antidepressant use and lower benefits from sertraline (OR = 0.75 [0.68-0.83]), escitalopram (OR = 0.75 [0.67-0.85]) and venlafaxine (OR = 0.78 [0.68-0.88]) when compared to participants without chronic pain. Furthermore, participants taking sertraline (OR = 0.45 [0.30-0.67]), escitalopram (OR = 0.45 [0.27-0.74]) and citalopram (OR = 0.32 [0.15-0.67]) specifically for chronic pain (among other indications) reported lower benefits compared to other participants taking these same medications but not for chronic pain. These findings reveal novel insights into the complex relationship between chronic pain and depression. Treatment response analyses indicate differential effectiveness between particular antidepressants and poorer functional outcomes for these comorbid conditions. Further examination is warranted in targeted interventional clinical trials, which also include neuroimaging genetics and pharmacogenomics protocols. This work will advance the delineation of disease risk indicators and novel aetiological pathways for therapeutic intervention in comorbid pain and depression as well as other psychiatric comorbidities.
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Affiliation(s)
- William H. Roughan
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Adrián I. Campos
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Luis M. García-Marín
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Gabriel Cuéllar-Partida
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- UQ Diamantina Institute, The University of Queensland and Translational Research Institute, Brisbane, QLD, Australia
| | - Michelle K. Lupton
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Ian B. Hickie
- Brain and Mind Centre, University of Sydney, Camperdown, NSW, Australia
| | - Sarah E. Medland
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Naomi R. Wray
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
- Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Enda M. Byrne
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Trung Thanh Ngo
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- UQ Diamantina Institute, The University of Queensland and Translational Research Institute, Brisbane, QLD, Australia
| | - Nicholas G. Martin
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Miguel E. Rentería
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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11
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Birkinshaw H, Friedrich C, Cole P, Eccleston C, Serfaty M, Stewart G, White S, Moore RA, Pincus T. Antidepressants for pain management in adults with chronic pain: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Peter Cole
- Oxford Pain Relief Unit; Churchill Hospital, Oxford University Hospitals NHS Trust; Oxford UK
| | | | | | | | - Simon White
- School of Pharmacy and Bioengineering; Keele University; Keele UK
| | | | - Tamar Pincus
- Department of Psychology; Royal Holloway University of London; Egham UK
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12
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Zanardi R, Prestifilippo D, Fabbri C, Colombo C, Maron E, Serretti A. Precision psychiatry in clinical practice. Int J Psychiatry Clin Pract 2021; 25:19-27. [PMID: 32852246 DOI: 10.1080/13651501.2020.1809680] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The treatment of depression represents a major challenge for healthcare systems and choosing among the many available drugs without objective guidance criteria is an error-prone process. Recently, pharmacogenetic biomarkers entered in prescribing guidelines, giving clinicians the possibility to use this additional tool to guide prescription and improve therapeutic outcomes. This marked an important step towards precision psychiatry, which aim is to integrate biological and environmental information to personalise treatments. Only genetic variants in cytochrome enzymes are endorsed by prescribing guidelines, but in the future polygenic predictors of treatment outcomes may be translated into the clinic. The integration of genetics with other relevant information (e.g., concomitant diseases and treatments, drug plasma levels) could be managed in a standardised way through ad hoc software. The overcoming of the current obstacles (e.g., staff training, genotyping and informatics facilities) can lead to a broad implementation of precision psychiatry and represent a revolution for psychiatric care.Key pointsPrecision psychiatry aims to integrate biological and environmental information to personalise treatments and complement clinical judgementPharmacogenetic biomarkers in cytochrome genes were included in prescribing guidelines and represented an important step towards precision psychiatryTherapeutic drug monitoring is an important and cost-effective tool which should be integrated with genetic testing and clinical evaluation in order to optimise pharmacotherapyOther individual factors relevant to pharmacotherapy response (e.g., individual's symptom profile, concomitant diseases) can be integrated with genetic information through artificial intelligence to provide treatment recommendationsThe creation of pharmacogenetic services within healthcare systems is a challenging and multi-step process, education of health professionals, promotion by institutions and regulatory bodies, economic and ethical barriers are the main issues.
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Affiliation(s)
- Raffaella Zanardi
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Dario Prestifilippo
- Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Chiara Fabbri
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Cristina Colombo
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Eduard Maron
- Department of Psychiatry, University of Tartu, Tartu, Estonia.,Division of Brain Sciences, Department of Medicine, Faculty of Medicine, Centre for Neuropsychopharmacology, Imperial College London, London, UK.,Documental Ltd, Tallinn, Estonia
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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