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Huneke NTM, Amin J, Baldwin DS, Bellato A, Brandt V, Chamberlain SR, Correll CU, Eudave L, Garner M, Gosling CJ, Hill CM, Hou R, Howes OD, Ioannidis K, Köhler-Forsberg O, Marzulli L, Reed C, Sinclair JMA, Singh S, Solmi M, Cortese S. Placebo effects in randomized trials of pharmacological and neurostimulation interventions for mental disorders: An umbrella review. Mol Psychiatry 2024:10.1038/s41380-024-02638-x. [PMID: 38914807 DOI: 10.1038/s41380-024-02638-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 06/26/2024]
Abstract
There is a growing literature exploring the placebo response within specific mental disorders, but no overarching quantitative synthesis of this research has analyzed evidence across mental disorders. We carried out an umbrella review of meta-analyses of randomized controlled trials (RCTs) of biological treatments (pharmacotherapy or neurostimulation) for mental disorders. We explored whether placebo effect size differs across distinct disorders, and the correlates of increased placebo effects. Based on a pre-registered protocol, we searched Medline, PsycInfo, EMBASE, and Web of Knowledge up to 23.10.2022 for systematic reviews and/or meta-analyses reporting placebo effect sizes in psychopharmacological or neurostimulation RCTs. Twenty meta-analyses, summarising 1,691 RCTs involving 261,730 patients, were included. Placebo effect size varied, and was large in alcohol use disorder (g = 0.90, 95% CI [0.70, 1.09]), depression (g = 1.10, 95% CI [1.06, 1.15]), restless legs syndrome (g = 1.41, 95% CI [1.25, 1.56]), and generalized anxiety disorder (d = 1.85, 95% CI [1.61, 2.09]). Placebo effect size was small-to-medium in obsessive-compulsive disorder (d = 0.32, 95% CI [0.22, 0.41]), primary insomnia (g = 0.35, 95% CI [0.28, 0.42]), and schizophrenia spectrum disorders (standardized mean change = 0.33, 95% CI [0.22, 0.44]). Correlates of larger placebo response in multiple mental disorders included later publication year (opposite finding for ADHD), younger age, more trial sites, larger sample size, increased baseline severity, and larger active treatment effect size. Most (18 of 20) meta-analyses were judged 'low' quality as per AMSTAR-2. Placebo effect sizes varied substantially across mental disorders. Future research should explore the sources of this variation. We identified important gaps in the literature, with no eligible systematic reviews/meta-analyses of placebo response in stress-related disorders, eating disorders, behavioural addictions, or bipolar mania.
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Affiliation(s)
- Nathan T M Huneke
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
- Southern Health NHS Foundation Trust, Southampton, UK.
| | - Jay Amin
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | - David S Baldwin
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
- University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Alessio Bellato
- School of Psychology, University of Nottingham Malaysia, Semenyih, Malaysia
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Valerie Brandt
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hanover, Germany
| | - Samuel R Chamberlain
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Luis Eudave
- Faculty of Education and Psychology, University of Navarra, Pamplona, Spain
| | - Matthew Garner
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Corentin J Gosling
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Université Paris Nanterre, DysCo Lab, F-92000, Nanterre, France
- Université de Paris, Laboratoire de Psychopathologie et Processus de Santé, F-92100, Boulogne-Billancourt, France
| | - Catherine M Hill
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Sleep Medicine, Southampton Children's Hospital, Southampton, UK
| | - Ruihua Hou
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Oliver D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- H Lundbeck A/s, Iveco House, Watford, UK
- Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, London, UK
| | - Konstantinos Ioannidis
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | - Ole Köhler-Forsberg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Psychosis Research Unit, Aarhus University Hospital-Psychiatry, Aarhus, Denmark
| | - Lucia Marzulli
- Department of Translational Biomedicine and Neuroscience (DIBRAIN), University of Studies of Bari "Aldo Moro", Bari, Italy
| | - Claire Reed
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Julia M A Sinclair
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Satneet Singh
- Southern Health NHS Foundation Trust, Southampton, UK
| | - Marco Solmi
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Samuele Cortese
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- DiMePRe-J-Department of Precision and Regenerative Medicine-Jonic Area, University "Aldo Moro", Bari, Italy
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA
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Bonnet U. Ten years of maintenance treatment of severe melancholic depression in an adult woman including discontinuation experiences. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024. [PMID: 38901434 DOI: 10.1055/a-2332-6107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
BACKGROUND There are only few publications on long-term treatments for major depressive disorder (MDD) lasting 5 years or longer. Most clinical controlled trials lasted no longer than 2 years and some recent studies suggested an advantage of cognitive behavioral therapy (CBT) over antidepressants in relapse prevention of MDD. METHODS Exclusively outpatient "real world" treatment of severe melancholia, prospectively documented over 10 years with different serial treatment strategies, discontinuation phenomena and complications. METHODS Compared to CBT, agomelatine, mirtazapine, bupropion and high-dose milnacipran, high-dose venlafaxine (extended-release form, XR) was effective, even sustainably. Asymptomatic premature ventricular contractions (PVCs) were found at the beginning of the treatment of the MDD, which initially led to the discontinuation of high-dose venlafaxine (300 mg daily). Even the various treatment strategies mentioned above were unable to compensate for or prevent the subsequent severe deterioration in MDD (2 rebounds, 1 recurrence). Only the renewed use of high-dose venlafaxine was successful. PVC no longer occurred and the treatment was also well tolerated over the years, with venlafaxine serum levels at times exceeding 5 times the recommended upper therapeutic reference level (known bupropion-venlafaxine interaction, otherwise 2.5 to 3-fold increase with high-dose venlafaxine alone). During dose reduction or after gradual discontinuation of high-dose venlafaxine, rather mild withdrawal symptoms occurred, but as described above, also two severe rebounds and one severe recurrence happened. DISCUSSION This long-term observation supports critical reflections on the discontinuation of successful long-term treatment with antidepressants in severe MDD, even if it should be under "the protection" of CBT. The PVC seemed to be more related to the duration of the severe major depressive episode than to the venlafaxine treatment itself. A particular prospective observation of this longitudinal case study is that relapses (in the sense of rebounds) during or after previous venlafaxine tapering seemed to herald the recurrence after complete recovery. Remarkably, neither relapses nor recurrence could be prevented by CBT. CONCLUSION In this case, high-dose venlafaxine has a particular relapse-preventive (and "recurrence-preventive") effect with good long-term tolerability.
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Affiliation(s)
- Udo Bonnet
- Department of Mental Health, Evangelisches Krankenhaus Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg-Essen, D-44577 Castrop-Rauxel, Germany
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, D-45147 Essen, Germany
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3
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van Dellen E. Precision psychiatry: predicting predictability. Psychol Med 2024; 54:1500-1509. [PMID: 38497091 DOI: 10.1017/s0033291724000370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Precision psychiatry is an emerging field that aims to provide individualized approaches to mental health care. An important strategy to achieve this precision is to reduce uncertainty about prognosis and treatment response. Multivariate analysis and machine learning are used to create outcome prediction models based on clinical data such as demographics, symptom assessments, genetic information, and brain imaging. While much emphasis has been placed on technical innovation, the complex and varied nature of mental health presents significant challenges to the successful implementation of these models. From this perspective, I review ten challenges in the field of precision psychiatry, including the need for studies on real-world populations and realistic clinical outcome definitions, and consideration of treatment-related factors such as placebo effects and non-adherence to prescriptions. Fairness, prospective validation in comparison to current practice and implementation studies of prediction models are other key issues that are currently understudied. A shift is proposed from retrospective studies based on linear and static concepts of disease towards prospective research that considers the importance of contextual factors and the dynamic and complex nature of mental health.
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Affiliation(s)
- Edwin van Dellen
- Department of Psychiatry and University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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Wilhelm M, Hermann C, Rief W, Schedlowski M, Bingel U, Winkler A. Working with patients' treatment expectations - what we can learn from homeopathy. Front Psychol 2024; 15:1398865. [PMID: 38860049 PMCID: PMC11163137 DOI: 10.3389/fpsyg.2024.1398865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/13/2024] [Indexed: 06/12/2024] Open
Abstract
The usual homeopathic remedy, "globules," does not contain any pharmacologically active ingredient. However, many patients and practitioners report beneficial effects of homeopathic treatment on various health outcomes. Experimental and clinical research of the last two decades analyzing the underlying mechanisms of the placebo effect could explain this phenomenon, with patients' treatment expectations as the predominant mechanism. Treatment expectations can be optimized through various factors, such as prior information, communication, and treatment context. This narrative review analyses how homeopathy successfully utilizes these factors. Subsequently, it is discussed what evidence-based medicine could learn from homeopathic practice to optimize treatment expectations (e.g., using an empathic, patient-centered communication style, deliberately selecting objects in practice rooms, or using clear treatment rituals and salient contextual stimuli) and thereby treatment effectiveness. Homeopathic remedy does not work beyond the placebo effect but is recommended or prescribed as an active treatment by those who believe in it. Thus, practitioners need to understand the manner in which homeopathy (as an example of inert treatment) works and are advised to reintegrate its underlying effective placebo mechanisms into evidence-based medicine. This promises to increase treatment efficacy, tolerability, satisfaction, and compliance with evidence-based treatments, and addresses the desires patients are trying to satisfy in homeopathy in an ethical, fully informed way that is grounded in evidence-based medicine.
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Affiliation(s)
- Marcel Wilhelm
- Department of Clinical Psychology, Philipps-University Marburg, Marburg, Germany
| | - Christiane Hermann
- Department of Clinical Psychology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Winfried Rief
- Department of Clinical Psychology, Philipps-University Marburg, Marburg, Germany
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, University Clinic Essen, Essen, Germany
- Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro-and Behavioral Sciences, University Medicine Essen, Essen, Germany
- Translational Pain Research Unit, University Medicine Essen, Essen, Germany
| | - Alexander Winkler
- Department of Clinical Psychology, Justus-Liebig-University Giessen, Giessen, Germany
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Minozzi S, Ambrosi L, Saulle R, Uhm SS, Terplan M, Sinclair JM, Agabio R. Psychosocial and medication interventions to stop or reduce alcohol consumption during pregnancy. Cochrane Database Syst Rev 2024; 4:CD015042. [PMID: 38682758 PMCID: PMC11057221 DOI: 10.1002/14651858.cd015042.pub2] [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] [Indexed: 05/01/2024]
Abstract
BACKGROUND Despite the known harms, alcohol consumption is common in pregnancy. Rates vary between countries, and are estimated to be 10% globally, with up to 25% in Europe. OBJECTIVES To assess the efficacy of psychosocial interventions and medications to reduce or stop alcohol consumption during pregnancy. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO, from inception to 8 January 2024. We also searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). All searches included non-English language literature. We handsearched references of topic-related systematic reviews and included studies. SELECTION CRITERIA We included randomised controlled trials that compared medications or psychosocial interventions, or both, to placebo, no intervention, usual care, or other medications or psychosocial interventions used to reduce or stop alcohol use during pregnancy. Our primary outcomes of interest were abstinence from alcohol, reduction in alcohol consumption, retention in treatment, and women with any adverse event. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS We included eight studies (1369 participants) in which pregnant women received an intervention to stop or reduce alcohol use during pregnancy. In one study, almost half of participants had a current diagnosis of alcohol use disorder (AUD); in another study, 40% of participants had a lifetime diagnosis of AUD. Six studies took place in the USA, one in Spain, and one in the Netherlands. All included studies evaluated the efficacy of psychosocial interventions; we did not find any study that evaluated the efficacy of medications for the treatment of AUD during pregnancy. Psychosocial interventions were mainly brief interventions ranging from a single session of 10 to 60 minutes to five sessions of 10 minutes each. Pregnant women received the psychosocial intervention approximately at the end of the first trimester of pregnancy, and the outcome of alcohol use was reassessed 8 to 24 weeks after the psychosocial intervention. Women in the control group received treatment as usual (TAU) or similar treatments such as comprehensive assessment of alcohol use and advice to stop drinking during pregnancy. Globally, we found that, compared to TAU, psychosocial interventions may increase the rate of continuously abstinent participants (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.14 to 1.57; I2 =0%; 3 studies; 378 women; low certainty evidence). Psychosocial interventions may have little to no effect on the number of drinks per day, but the evidence is very uncertain (mean difference -0.42, 95% CI -1.13 to 0.28; I2 = 86%; 2 studies; 157 women; very low certainty evidence). Psychosocial interventions probably have little to no effect on the number of women who completed treatment (RR 0.98, 95% CI 0.94 to 1.02; I2 = 0%; 7 studies; 1283 women; moderate certainty evidence). None of the included studies assessed adverse events of treatments. We downgraded the certainty of the evidence due to risk of bias and imprecision of the estimates. AUTHORS' CONCLUSIONS Brief psychosocial interventions may increase the rate of continuous abstinence among pregnant women who report alcohol use during pregnancy. Further studies should be conducted to investigate the efficacy and safety of psychosocial interventions and other treatments (e.g. medications) for women with AUD. These studies should provide detailed information on alcohol use before and during pregnancy using consistent measures such as the number of drinks per drinking day. When heterogeneous populations are recruited, more detailed information on alcohol use during pregnancy should be provided to allow future systematic reviews to be conducted. Other important information that would enhance the usefulness of these studies would be the presence of other comorbid conditions such as anxiety, mood disorders, and the use of other psychoactive substances.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Ludovico Ambrosi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Rosella Saulle
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Seilin S Uhm
- School of Medicine, University of Southampton, Southampton, UK
| | - Mishka Terplan
- Friends Research Institute, Baltimore, USA
- Family and Community Medicine, University of California, San Francisco, San Francisco, USA
| | | | - Roberta Agabio
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
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Nasiri-Dehsorkhi H, Vaziri S, Esmaillzadeh A, Adibi P. Negative expectations (nocebo phenomenon) in clinical interventions: A scoping review. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2024; 13:106. [PMID: 38726093 PMCID: PMC11081451 DOI: 10.4103/jehp.jehp_269_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/06/2023] [Indexed: 05/12/2024]
Abstract
Unpredictable, undesirable, and confusing reactions in the face of psychological or medical interventions make the clinical presentation more complicated and may represent clinically unexplained symptoms and also disturbed the doctor-patients relationship and decrease patients' benefits of treatment. It seems that negative expectations from the treatment (nocebo phenomenon) can explain such reactions. The aim of the current study is a scoping review and investigate different aspects of the nocebo phenomenon (negative expectations) in clinical interventions. This paper follows a scoping review of the existence, importance, and multidimensions of the nocebo phenomenon in medical and psychological interventions. Data sources include literature databases (ProQuest, PubMed, Google Scholar, and Scopus) reviewed from inception dates to 2023, and the terms negative expectations, nocebo effect, placebo effect, negative placebo, and clinical interventions were searched. The review of the available articles showed that negative expectations play an important role in the process and effectiveness of clinical interventions. Negative expectations (here named nocebo effect) can significantly interfere with rapport and treatment processes. Some underlying components of the nocebo effect include negative expectancies, conditioning, social learning, memory, cognitive distortions, meaning, motivation, somatic focus, negative reinforcements, personality, anxiety, and neurophysiological factors such as CCK, dopamine, and cortisol are proposed for development and presence of nocebo phenomenon in clinical practice. Negative expectations with its biopsychosocial aspects play an important and amazing role in disorganizing medical and psychological interventions. Using appropriate methods to reduce nocebo effects in therapeutic interventions may increase treatment compliance and adherence and increase the effectiveness of interventions.
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Affiliation(s)
- Hamid Nasiri-Dehsorkhi
- Department of Clinical Psychology, Roudehen Branch, Islamic Azad University, Roudehen, Iran
- Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahram Vaziri
- Department of Clinical Psychology, Roudehen Branch, Islamic Azad University, Roudehen, Iran
| | - Ahmad Esmaillzadeh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Peyman Adibi
- Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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7
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Poulios E, Pavlidou E, Papadopoulou SK, Rempetsioti K, Migdanis A, Mentzelou M, Chatzidimitriou M, Migdanis I, Androutsos O, Giaginis C. Probiotics Supplementation during Pregnancy: Can They Exert Potential Beneficial Effects against Adverse Pregnancy Outcomes beyond Gestational Diabetes Mellitus? BIOLOGY 2024; 13:158. [PMID: 38534428 DOI: 10.3390/biology13030158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Probiotics, as supplements or food ingredients, are considered to exert promising healthy effects when administered in adequate quantity. Probiotics' healthy effects are related with the prevention of many diseases, as well as decreasing symptom severity. Currently, the most available data concerning their potential health effects are associated with metabolic disorders, including gestational diabetes mellitus. There is also clinical evidence supporting that they may exert beneficial effects against diverse adverse pregnancy outcomes. The purpose of the current narrative study is to extensively review and analyze the current existing clinical studies concerning the probable positive impacts of probiotics supplementation during pregnancy as a protective agent against adverse pregnancy outcomes beyond gestational diabetes mellitus. METHODS a comprehensive and thorough literature search was conducted in the most precise scientific databases, such as PubMed, Scopus, and Web of Sciences, utilizing efficient, representative, and appropriate keywords. RESULTS in the last few years, recent research has been conducted concerning the potential beneficial effects against several adverse pregnancy outcomes such as lipid metabolism dysregulation, gestational hypertensive disorders, preterm birth, excessive gestational weight gain, caesarean risk section, vaginal microbiota impairment, mental health disturbances, and others. CONCLUSION up to the present day, there is only preliminary clinical data and not conclusive results for probiotics' healthy effects during pregnancy, and it remains questionable whether they could be used as supplementary treatment against adverse pregnancy outcomes beyond gestational diabetes mellitus.
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Affiliation(s)
- Efthymios Poulios
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Lemnos, Greece
| | - Eleni Pavlidou
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Lemnos, Greece
| | - Sousana K Papadopoulou
- Department of Nutritional Sciences and Dietetics, Faculty of Health Sciences, International Hellenic University, 57400 Thessaloniki, Greece
| | - Kalliopi Rempetsioti
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Lemnos, Greece
| | - Athanasios Migdanis
- Faculty of Medicine, University of Thessaly, 41500 Larissa, Greece
- Department of Nutrition and Dietetics, School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42132 Trikala, Greece
| | - Maria Mentzelou
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Lemnos, Greece
| | - Maria Chatzidimitriou
- Department of Biomedical Science, International Hellenic University, 57400 Thessaloniki, Greece
| | - Ioannis Migdanis
- Faculty of Medicine, University of Thessaly, 41500 Larissa, Greece
- Department of Nutrition and Dietetics, School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42132 Trikala, Greece
| | - Odysseas Androutsos
- Department of Nutrition and Dietetics, School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42132 Trikala, Greece
| | - Constantinos Giaginis
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Lemnos, Greece
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8
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Seymour J, Mathers N. Placebo stimulates neuroplasticity in depression: implications for clinical practice and research. Front Psychiatry 2024; 14:1301143. [PMID: 38268561 PMCID: PMC10806142 DOI: 10.3389/fpsyt.2023.1301143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024] Open
Abstract
Neither psychological nor neuroscientific investigations have been able to fully explain the paradox that placebo is designed to be inert in randomized controlled trials (RCTs), yet appears to be effective in evaluations of clinical interventions in all fields of medicine and alternative medicine. This article develops the Neuroplasticity Placebo Theory, which posits that neuroplasticity in fronto-limbic areas is the unifying factor in placebo response (seen in RCTs) and placebo effect (seen in clinical interventions) where it is not intended to be inert. Depression is the disorder that has the highest placebo response of any medical condition and has the greatest potential for understanding how placebos work: recent developments in understanding of the pathophysiology of depression suggest that fronto-limbic areas are sensitized in depression which is associated with a particularly strong placebo phenomenon. An innovative linkage is made between diverse areas of the psychology and the translational psychiatry literature to provide supportive evidence for the Neuroplasticity Placebo Theory. This is underpinned by neuro-radiological evidence of fronto-limbic change in the placebo arm of antidepressant trials. If placebo stimulates neuroplasticity in fronto-limbic areas in conditions other than depression - and results in a partially active treatment in other areas of medicine - there are far reaching consequences for the day-to-day use of placebo in clinical practice, the future design of RCTs in all clinical conditions, and existing unwarranted assertions about the efficacy of antidepressant medications. If fronto-limbic neuroplasticity is the common denominator in designating placebo as a partially active treatment, the terms placebo effect and placebo response should be replaced by the single term "placebo treatment."
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Affiliation(s)
- Jeremy Seymour
- Retired Consultant Psychiatrist, Rotherham Doncaster and South Humber NHS Trust, Rotherham, United Kingdom
| | - Nigel Mathers
- Emeritus Professor, Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
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Dercon Q, Mehrhof SZ, Sandhu TR, Hitchcock C, Lawson RP, Pizzagalli DA, Dalgleish T, Nord CL. A core component of psychological therapy causes adaptive changes in computational learning mechanisms. Psychol Med 2024; 54:327-337. [PMID: 37288530 DOI: 10.1017/s0033291723001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cognitive distancing is an emotion regulation strategy commonly used in psychological treatment of various mental health disorders, but its therapeutic mechanisms are unknown. METHODS 935 participants completed an online reinforcement learning task involving choices between pairs of symbols with differing reward contingencies. Half (49.1%) of the sample was randomised to a cognitive self-distancing intervention and were trained to regulate or 'take a step back' from their emotional response to feedback throughout. Established computational (Q-learning) models were then fit to individuals' choices to derive reinforcement learning parameters capturing clarity of choice values (inverse temperature) and their sensitivity to positive and negative feedback (learning rates). RESULTS Cognitive distancing improved task performance, including when participants were later tested on novel combinations of symbols without feedback. Group differences in computational model-derived parameters revealed that cognitive distancing resulted in clearer representations of option values (estimated 0.17 higher inverse temperatures). Simultaneously, distancing caused increased sensitivity to negative feedback (estimated 19% higher loss learning rates). Exploratory analyses suggested this resulted from an evolving shift in strategy by distanced participants: initially, choices were more determined by expected value differences between symbols, but as the task progressed, they became more sensitive to negative feedback, with evidence for a difference strongest by the end of training. CONCLUSIONS Adaptive effects on the computations that underlie learning from reward and loss may explain the therapeutic benefits of cognitive distancing. Over time and with practice, cognitive distancing may improve symptoms of mental health disorders by promoting more effective engagement with negative information.
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Affiliation(s)
- Quentin Dercon
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- UCL Institute of Mental Health, University College London, London, UK
| | - Sara Z Mehrhof
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Timothy R Sandhu
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - Caitlin Hitchcock
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | - Rebecca P Lawson
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - Diego A Pizzagalli
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, MA, USA
| | - Tim Dalgleish
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridgeshire, UK
| | - Camilla L Nord
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
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10
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Wathra RA, Mulsant BH, Reynolds CF, Lenze EJ, Karp JF, Daskalakis ZJ, Blumberger DM. Differential Placebo Responses for Pharmacotherapy and Neurostimulation in Late-Life Depression. Neuromodulation 2023; 26:1585-1591. [PMID: 35088720 DOI: 10.1016/j.neurom.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/21/2021] [Accepted: 10/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The magnitude of the placebo response depends on both the modality used as the "placebo" and the intervention with which it is compared, both of which can complicate the interpretation of randomized controlled trials (RCTs) for depression in late life. Given that neurostimulation and pharmacotherapy are among the most common interventions studied for late-life depression, comparing the relative placebo responses in studies of these interventions can aid interpretation of relative effect sizes. MATERIALS AND METHODS We analyzed data from two RCTs of adults aged ≥60 years in an episode of treatment-resistant major depression, one comparing aripiprazole and matching placebo pills and the other comparing deep repetitive transcranial magnetic stimulation (rTMS) and sham rTMS. In both RCTs, depression was assessed using the 17-item Hamilton Depression Rating Scale (HDRS-17). The primary comparison occurred after four weeks using analysis of covariance (ANCOVA) of HDRS-17 scores in participants who received placebo pills or sham rTMS. Relevant covariates included years of education, duration of depressive episode, and baseline HDRS-17 score. RESULTS Accounting for covariates, there was a larger reduction of HDRS-17 after four weeks in the sham rTMS group (estimated marginal mean ± SE: -5.90 ± 1.45; 95% CI: [-8.82, 2.98]) than in the placebo pills group (-1.07 ± 1.45; [-3.98, 1.85]). There were no significant differences between these groups in the binary outcome analysis of response and remission rates at four weeks or any outcome at trial end point comparison. CONCLUSIONS Sham rTMS may have a larger placebo response than placebo pills early in the treatment of older adults with treatment-resistant depression. Differential placebo responses should be considered in both the interpretation and design of RCTs.
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Affiliation(s)
- Rafae A Wathra
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benoit H Mulsant
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Charles F Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Arizona College of Medicine - Tucson, Tucson, AZ, USA
| | - Zafiris J Daskalakis
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Daniel M Blumberger
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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11
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Borgogna NC, Owen T, Aita SL. The absurdity of the latent disease model in mental health: 10,130,814 ways to have a DSM-5-TR psychological disorder. J Ment Health 2023:1-9. [PMID: 37947129 DOI: 10.1080/09638237.2023.2278107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Latent disease classification is currently the accepted approach to mental illness diagnosis. In the United States, this takes the form of the Diagnostic and Statistical Manual of Mental Disorders-5-Text Revision (DSM-5-TR). Latent disease classification has been criticized for reliability and validity problems, particularly regarding diagnostic heterogeneity. No authors have calculated the scope of the heterogeneity problem of the entire DSM-5-TR. AIMS We addressed this issue by calculating the unique diagnostic profiles that exist for every DSM-5-TR diagnosis. METHODS We did this by applying formulas previously used in smaller heterogeneity analyses to all diagnoses within the DSM-5-TR. RESULTS We found that there are 10,130,814 ways to be diagnosed with a mental illness using DSM-5-TR criteria. When specifiers are considered, this number balloons to over 161 septillion unique diagnostic presentations (driven mainly by bipolar II disorder). Additionally, there are 1,951,065 ways to present with psychiatric symptoms, yet not meet diagnostic criteria. CONCLUSIONS Latent disease classification leads to considerable heterogeneity in possible presentations. We provide examples of how latent disease classification harms research and treatment programs. We echo recommendations for the dismissal of latent disease classification as a mental illness diagnostic program.
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Affiliation(s)
- Nicholas C Borgogna
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | - Tyler Owen
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | - Stephen L Aita
- Department of Psychology, University of Maine, Orono, ME, USA
- Department of Mental Health, VA Maine Healthcare System, Augusta, ME, USA
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12
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Viglione V, Boffa A, Previtali D, Vannini F, Faldini C, Filardo G. The 'placebo effect' in the conservative treatment of plantar fasciitis: a systematic review and meta-analyses. EFORT Open Rev 2023; 8:719-730. [PMID: 37787480 PMCID: PMC10562949 DOI: 10.1530/eor-23-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Purpose The study of the placebo effect is key to elucidate the 'real effect' of conservative interventions for plantar fasciitis. The aim of this meta-analysis was to quantify the impact of placebo in the different conservative treatments of plantar fasciitis. Methods A systematic literature review was performed on double-blind placebo-controlled trials (RCTs) according to PRISMA guidelines on PubMed, Embase, and Web of Science. The meta-analysis primary outcome was the 0-10 pain variation after placebo treatments analyzed at 1 week, 1, 3, 6, and 12 months. The risk of bias was assessed using the RoB 2.0 tool, while the overall quality of evidence was graded according to the GRADE guidelines. Results The placebo effect for conservative treatments was studied in 42 double-blind RCTs on 1724 patients. The meta-analysis of VAS pain showed a statistically significant improvement after placebo administration of 2.13/10 points (P < 0.001), being highest at 12 months with 2.79/10 points (P < 0.001). The improvement of the placebo groups was higher in the extracorporeal shock wave therapy studies compared to the injection studies (2.59 vs 1.78; P = 0.05). Eight studies had a low risk of bias, 23 studies had 'some concerns,' and 4 studies had a high risk of bias. The GRADE evaluation showed an overall high quality of evidence. Conclusion This systematic review and meta-analysis demonstrated that the placebo effect represents an important component of all conservative approaches to treat plantar fasciitis. This effect is statistically and clinically significant, increases over time, and depends on the type of conservative treatment applied to address plantar fasciitis.
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Affiliation(s)
- Valentina Viglione
- Clinica Ortopedica e Traumatologica 1 IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Angelo Boffa
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Previtali
- Department of Surgery, EOC, Service of Orthopaedics and Traumatology, Lugano, Switzerland
| | - Francesca Vannini
- Clinica Ortopedica e Traumatologica 1 IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cesare Faldini
- Clinica Ortopedica e Traumatologica 1 IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Department of Surgery, EOC, Service of Orthopaedics and Traumatology, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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13
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Hird EJ, Diederen K, Leucht S, Jensen KB, McGuire P. The Placebo Effect in Psychosis: Why It Matters and How to Measure It. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2023; 3:605-613. [PMID: 37881581 PMCID: PMC10593894 DOI: 10.1016/j.bpsgos.2023.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 12/04/2022] [Accepted: 02/20/2023] [Indexed: 03/07/2023] Open
Abstract
Psychosis is characterized by unusual percepts and beliefs in the form of hallucinations and delusions. Antipsychotic medication, the primary treatment for psychosis, is often ineffective and accompanied by severe side effects, but research has not identified an effective alternative in several decades. One reason that clinical trials fail is that patients with psychosis tend to show a significant therapeutic response to inert control treatments, known as the placebo effect, which makes it difficult to distinguish drug effects from placebo effects. Conversely, in clinical practice, a strong placebo effect may be useful because it could enhance the overall treatment response. Identifying factors that predict large placebo effects could improve the future outlook of psychosis treatment. Biomarkers of the placebo effect have already been suggested in pain and depression, but not in psychosis. Quantifying markers of the placebo effect would have the potential to predict placebo effects in psychosis clinical trials. Furthermore, the placebo effect and psychosis may represent a shared neurocognitive mechanism in which prior beliefs are weighted against new sensory information to make inferences about reality. Examining this overlap could reveal new insights into the mechanisms underlying psychosis and indicate novel treatment targets. We provide a narrative review of the importance of the placebo effect in psychosis and propose a novel method to assess it.
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Affiliation(s)
- Emily J. Hird
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England
| | - Kelly Diederen
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Munich, Germany
| | - Karin B. Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Philip McGuire
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England
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14
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Curie A, Oberlander TF, Jensen KB. Placebo effects in children with autism spectrum disorder. Dev Med Child Neurol 2023; 65:1316-1320. [PMID: 36917698 DOI: 10.1111/dmcn.15574] [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: 09/14/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 03/16/2023]
Abstract
Placebo responses are frequently observed in research studies and clinical contexts, yet there is limited knowledge about the placebo effect among children with neurodevelopmental disorders. Here, we review the placebo effect in autism spectrum disorder (ASD). Placebo responses are widely evident in ASD clinical trials and could partly operate via so-called placebo-by-proxy, whereby caregivers or clinicians indirectly shape patient outcomes. Understanding the role of placebo effects in ASD may help discern genuine treatment effects from contextual factors in clinical trials. The much less studied nocebo effect, or negative placebo, might contribute to the experience of side effects in ASD treatments but empirical data is missing. Better knowledge about placebo and nocebo mechanisms may contribute to the development of more effective research designs, such as three-armed designs that account for natural history, and improved treatments for ASD symptoms. At a clinical level, deeper knowledge about placebo and nocebo effects may optimize the delivery of care for individuals with ASD in the future. WHAT THIS PAPER ADDS: Placebo responses are evident in autism spectrum disorder (ASD) clinical trials. Placebo responses in ASD are likely dependent on a placebo-by-proxy mechanism.
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Affiliation(s)
- Aurore Curie
- Reference Center for Intellectual Disability from Rare Causes, Department of Child Neurology, Woman Mother and Child Hospital, Hospices Civils de Lyon, Bron, France
| | - Tim F Oberlander
- Department of Pediatrics and School of Population and Public Health, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Karin B Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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15
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Mohamadi S, Ahmadzad-Asl M, Nejadghaderi SA, Jabbarinejad R, Mirbehbahani SH, Sinyor M, Richter MA, Davoudi F. Systematic Review and Meta-Analysis of the Placebo Effect and its Correlates in Obsessive Compulsive Disorder. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2023; 68:479-494. [PMID: 35876317 PMCID: PMC10408559 DOI: 10.1177/07067437221115029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is a major mental health condition with a lifetime prevalence rate of 1.3% among adults. While placebo effects are well described for conditions such as depressive and anxiety disorders, they have not been systematically characterized in OCD. OBJECTIVES We aimed to determine the impact of placebos in improving different symptom domains in patients with OCD. METHODS We systematically searched PubMed, EMBASE, Scopus, Web of Science, Ovid, the Cochrane Library, and Google Scholar databases/search engine from inception to January 2021 for randomized controlled trials of treatments for OCD with a placebo arm. A modified Cohen's effect size (ES) was calculated using change in baseline to endpoint scores for different measurement scales within placebo arms to estimate placebo effects and to investigate their correlates by random-effects model meta-analyses. RESULTS Forty-nine clinical trials (placebo group n = 1993), reporting 80 OCD specific (153 measures in general) were included in the analysis. Overall placebo ES (95% confidence interval [CI]) was 0.32 (0.22-0.41) on OCD symptoms, with substantial heterogeneity (I-square = 96.1%). Among secondary outcomes, general scales, ES: 0.27 (95%CI: 0.14-0.41), demonstrated higher ES than anxiety and depression scales, ES: 0.14 (95%CI: -0.4 to 0.32) and 0.05 (95%CI: -0.05 to 0.14), respectively. Clinician-rated scales, ES: 0.27(95%CI: 0.20-0.34), had a higher ES than self-reported scales, ES: 0.07 (95%CI: -0.08 to 0.22). More recent publication year, larger placebo group sample size, shorter follow-up duration, and younger age of participants were all associated with larger placebo ES. Egger's test reflected possible small-study effect publication bias (P = 0.029). CONCLUSION Placebo effects are modest in OCD trials and are larger in clinician ratings, for younger patients, and early in the treatment course. These findings underscore the need for clinicians and scientists to be mindful of placebo effects when formulating treatments or research trials for OCD. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019125979.
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Affiliation(s)
- Safoura Mohamadi
- Mental Health Research Center, School of Behavioural Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Ahmadzad-Asl
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Roxana Jabbarinejad
- Cognitive Neuroscience Laboratory, Brain Injury Research, Think + Speak lab, Shirley Ryan Ability Lab, Northwestern University, Chicago, IL, USA
| | | | - Mark Sinyor
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Margaret A. Richter
- Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Farnoush Davoudi
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Community and Family Medicine Department, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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16
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Aran A, Harel M, Ovadia A, Shalgy S, Cayam-Rand D. Mediators of Placebo Response to Cannabinoid Treatment in Children with Autism Spectrum Disorder. J Clin Med 2023; 12:jcm12093098. [PMID: 37176538 PMCID: PMC10179251 DOI: 10.3390/jcm12093098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
The placebo response has a substantial impact on treatment outcome. However, data regarding mediators of the placebo response in children with autism spectrum disorder (ASD) are sparse. This retrospective study investigated possible mediators of the placebo response among participants of a placebo-controlled trial of cannabinoid treatment for behavioral problems in children with ASD (CBA trial, age 5-21 years). We used a specifically designed questionnaire to explore possible mediators of the placebo response in 88 participants of the CBA trial who received a placebo and had valid outcome scores. The parents of 67 participants completed the questionnaire. The placebo response was positively associated with the child's comprehension of the treatment purpose (p = 0.037). There was also a trend for participants who had a relative aggravation of symptoms before treatment onset to improve following placebo treatment (p = 0.053). No other domains, including parental expectations, previous positive experience with similar treatments (behavioral conditioning), parental locus of control, quality of the patient-physician relationships, and adherence to study medications were associated with placebo-response. This finding suggests that efforts to explain the treatment purpose to children with disabilities may enhance treatment efficacy in clinical practice and decrease differences in the placebo response between study arms. Contrary to our hypothesis, parental expectations regarding cannabinoid treatment were not associated with the placebo response.
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Affiliation(s)
- Adi Aran
- Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Moria Harel
- Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Aminadav Ovadia
- Psychology Department, Yezreel Valley College, Yezreel Valley 1930600, Israel
| | - Shulamit Shalgy
- Psychology Department, Yezreel Valley College, Yezreel Valley 1930600, Israel
| | - Dalit Cayam-Rand
- Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
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17
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Tobe R, Zhu Y, Gleissl T, Rossomanno S, Veenstra-VanderWeele J, Smith J, Hollander E. Predictors of placebo response in three large clinical trials of the V1a receptor antagonist balovaptan in autism spectrum disorder. Neuropsychopharmacology 2023:10.1038/s41386-023-01573-9. [PMID: 37045991 PMCID: PMC10267133 DOI: 10.1038/s41386-023-01573-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023]
Abstract
High rates of placebo response are increasingly implicated in failed autism spectrum disorder (ASD) clinical trials. Despite this, there are limited investigations of placebo response in ASD. We sought to identify baseline predictors of placebo response and quantify their influence on clinical scales of interest for three harmonized randomized clinical trials of balovaptan, a V1a receptor antagonist. We employed a two-step approach to identify predictors of placebo response on the Vineland-II two-domain composite (2DC) (primary outcome and a caregiver measure) and Clinical Global Impression (CGI) scale (secondary outcome and a clinician measure). The initial candidate predictor set of variables pertained to participant-level, site-specific, and protocol-related factors. Step 1 aimed to identify influential predictors of placebo response using Least Absolute Shrinkage and Selection Operator (LASSO) regression, while Step 2 quantified the influence of predictors via linear regression. Results were validated through statistical bootstrapping approaches with 500 replications of the analysis dataset. The pooled participant-level dataset included individuals with ASD aged 5 to 62 years (mean age 21 [SD 10]), among which 263 and 172 participants received placebo at Weeks 12 and 24, respectively. Although no influential predictors were identified for CGI, findings for Vineland-II 2DC are robust and informative. Decreased placebo response was predicted by higher baseline Vineland-II 2DC (i.e., more advanced adaptive function), longer trial duration, and European (vs United States) sites, while increased placebo response was predicted by commercial (vs academic) sites, attention deficit hyperactivity disorder and depression. Identification of these factors may be useful in anticipating and mitigating placebo response in drug development efforts in ASD and across developmental and psychiatric conditions.
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Affiliation(s)
- Russell Tobe
- Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY, USA.
| | - Yajing Zhu
- F. Hoffmann-La Roche Ltd., Welwyn Garden City, UK
| | | | | | - Jeremy Veenstra-VanderWeele
- Department of Psychiatry, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Janice Smith
- F. Hoffmann-La Roche Ltd., Welwyn Garden City, UK
| | - Eric Hollander
- Department of Psychiatry and Behavioral Sciences and Albert Einstein College of Medicine, New York, NY, USA
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18
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Homma G, Daimon T. Usefulness of the placebo lead-in design for clinical trials with binary outcomes. Clin Trials 2023; 20:145-152. [PMID: 36627841 DOI: 10.1177/17407745221140048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND In placebo-controlled clinical trials to develop new drugs for the treatment of psychiatric or neurological disorders, a high and sometimes greater-than-expected placebo response makes it difficult to show the superiority of an investigational drug over a corresponding placebo. To avoid such difficulty, a placebo lead-in design has been presented, but its usefulness has been open to discussion. Although the statistical properties of the placebo lead-in design are investigated in the context of continuous outcomes, whether these properties can be generalized for binary or ordinal cases remains unclear. METHODS We investigate whether the placebo lead-in design is useful in clinical trials with binary outcomes through mathematical formulae and a numerical investigation. Specifically, we compare the proportion of placebo responders, the drug-placebo difference, and the effect size between two populations: one enriched for placebo nonresponders and the other comprising the all-comers. RESULTS Under positive correlation of the data between the lead-in stage and the randomized stage for both treatment groups, we mathematically show that the proportion of responders in the population enriched for placebo nonresponders is less than that in the all-comers population, and whether the placebo lead-in design increases the drug-placebo difference depends on the variances of outcomes in both treatment groups as well as the correlations of the outcomes between two stages. Further, through a numerical investigation, we show that whether the placebo lead-in design increases the effect size strongly depends on the magnitude of the correlations and their difference. CONCLUSION If the correlation of the placebo-placebo group is much higher than that of the placebo-drug group, the placebo lead-in design is advantageous in most cases but has an impact on an estimand in placebo nonresponders. Therefore, we do not recommend using the placebo lead-in design for clinical trials with binary outcomes.
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Affiliation(s)
- Gosuke Homma
- Biostatistics & Data Science, Boehringer-Ingelheim Co., Ltd, Tokyo, Japan
| | - Takashi Daimon
- Department of Biostatistics, Hyogo Medical University, Nishinomiya, Japan
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19
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Kang H, Miksche MS, Ellingsen DM. Association between personality traits and placebo effects: a preregistered systematic review and meta-analysis. Pain 2023; 164:494-508. [PMID: 35947877 DOI: 10.1097/j.pain.0000000000002753] [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: 03/15/2022] [Accepted: 08/02/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Placebo effects are ubiquitous yet highly variable between individuals and therefore strongly affect clinical trial outcomes such as pain relief. It is unclear whether dispositional psychological traits influence responsiveness to placebo. This preregistered meta-analysis and systematic review synthesized the literature investigating the association between personality traits and placebo effects. Based on 21 studies with 798 participants, we performed formal meta-analyses for 10 different personality traits, including behavioral inhibition, fun seeking, goal-drive persistence, reward responsiveness, empathic concern, empathic fantasy, perspective-taking, personal distress, optimism, and anxiety. We did not find evidence of associations between any of these traits and magnitude of placebo effects, which was supported by equivalence tests. Furthermore, we did not find evidence for moderating factors such as placebo manipulation type (conditioning or nonconditioning) or condition (pain or nonpain). These findings challenge the notion that personality influences responsiveness to placebos and contradict its utility for identifying placebo "responders" and "nonresponders."
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Affiliation(s)
- Heemin Kang
- Department of Psychology, University of Oslo, Norway
- Norwegian Centre for Mental Disorders Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | | | - Dan-Mikael Ellingsen
- Department of Psychology, University of Oslo, Norway
- Division of Radiology and Nuclear Medicine, Department of Physics and Computational Radiology, Oslo University Hospital, Oslo, Norway
- School of Health Sciences, Kristiania University College, Oslo, Norway
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20
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Bosman M, Smeets F, Elsenbruch S, Tack J, Simrén M, Talley N, Winkens B, Masclee A, Keszthelyi D. Placebo response in pharmacological trials in patients with functional dyspepsia-A systematic review and meta-analysis. Neurogastroenterol Motil 2023; 35:e14474. [PMID: 36168188 PMCID: PMC10078497 DOI: 10.1111/nmo.14474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/18/2022] [Accepted: 09/12/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pharmacological trials in functional dyspepsia (FD) are associated with high placebo response rates. We aimed to identify the magnitude and contributing factors to the placebo response. METHODS We conducted a systematic review and meta-analysis including randomized controlled trials (RCTs) with a dichotomous outcome in adult patients with FD that compared an active pharmacotherapeutic treatment with placebo. Our main outcome was identification of the magnitude of the pooled placebo response rate for the following endpoints: symptom responder, symptom-free responder, adequate relief responder, and combined endpoint responder (i.e., the primary endpoint of each specific trial regarding treatment response). Several putative moderators (i.e., patient, disease, and trial characteristics) were examined. KEY RESULTS We included 26 RCTs in our analysis. The pooled placebo response rate was 39.6% (95% CI 30.1-50.0) using the symptom responder definition, 20.5% (12.8-31.0) using the symptom-free responder definition, 38.5% (33.8-43.6) using the adequate relief responder definition, and 35.5% (31.6-39.7) using the combined endpoint responder definition. A lower overall baseline symptom score was significantly associated with a higher placebo response rate. No other moderators were found to significantly impact the placebo response rate. Due to the lack of data, no analyses could be performed according to individual FD subtypes or symptoms. CONCLUSIONS AND INFERENCES The pooled placebo response rate in pharmacological trials in FD is about 39%, depending on which responder definitions is used. Future trials should consider applying an entry criterion based on minimal level of symptom severity to decrease the placebo response. We also suggest separate reporting of core FD symptoms pending more concrete harmonization efforts in FD trials.
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Affiliation(s)
- Michelle Bosman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Fabiënne Smeets
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sigrid Elsenbruch
- Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr University Bochum, Bochum, Germany.,Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium.,Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nicholas Talley
- NHMRC Center of research Excellence in Digestive Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Ad Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center, Maastricht, The Netherlands
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21
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Correll CU, Solmi M, Cortese S, Fava M, Højlund M, Kraemer HC, McIntyre RS, Pine DS, Schneider LS, Kane JM. The future of psychopharmacology: a critical appraisal of ongoing phase 2/3 trials, and of some current trends aiming to de-risk trial programmes of novel agents. World Psychiatry 2023; 22:48-74. [PMID: 36640403 PMCID: PMC9840514 DOI: 10.1002/wps.21056] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 01/15/2023] Open
Abstract
Despite considerable progress in pharmacotherapy over the past seven decades, many mental disorders remain insufficiently treated. This situation is in part due to the limited knowledge of the pathophysiology of these disorders and the lack of biological markers to stratify and individualize patient selection, but also to a still restricted number of mechanisms of action being targeted in monotherapy or combination/augmentation treatment, as well as to a variety of challenges threatening the successful development and testing of new drugs. In this paper, we first provide an overview of the most promising drugs with innovative mechanisms of action that are undergoing phase 2 or 3 testing for schizophrenia, bipolar disorder, major depressive disorder, anxiety and trauma-related disorders, substance use disorders, and dementia. Promising repurposing of established medications for new psychiatric indications, as well as variations in the modulation of dopamine, noradrenaline and serotonin receptor functioning, are also considered. We then critically discuss the clinical trial parameters that need to be considered in depth when developing and testing new pharmacological agents for the treatment of mental disorders. Hurdles and perils threatening success of new drug development and testing include inadequacy and imprecision of inclusion/exclusion criteria and ratings, sub-optimally suited clinical trial participants, multiple factors contributing to a large/increasing placebo effect, and problems with statistical analyses. This information should be considered in order to de-risk trial programmes of novel agents or known agents for novel psychiatric indications, increasing their chances of success.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Marco Solmi
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA
| | - Maurizio Fava
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikkel Højlund
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
- Mental Health Services in the Region of Southern Denmark, Department of Psychiatry Aabenraa, Aabenraa, Denmark
| | - Helena C Kraemer
- Department of Psychiatry and Behavioral Sciences, Stanford University, Cupertino, CA, USA
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Daniel S Pine
- Section on Developmental Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA
| | - Lon S Schneider
- Department of Psychiatry and Behavioral Sciences, and Department of Neurology, Keck School of Medicine, and L. Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - John M Kane
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
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22
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The effect of oxytocin nasal spray on social interaction in young children with autism: a randomized clinical trial. Mol Psychiatry 2023; 28:834-842. [PMID: 36302965 PMCID: PMC9607840 DOI: 10.1038/s41380-022-01845-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
Early supports to enhance social development in children with autism are widely promoted. While oxytocin has a crucial role in mammalian social development, its potential role as a medication to enhance social development in humans remains unclear. We investigated the efficacy, tolerability, and safety of intranasal oxytocin in young children with autism using a double-blind, randomized, placebo-controlled, clinical trial, following a placebo lead-in phase. A total of 87 children (aged between 3 and 12 years) with autism received 16 International Units (IU) of oxytocin (n = 45) or placebo (n = 42) nasal spray, morning and night (32 IU per day) for twelve weeks, following a 3-week placebo lead-in phase. Overall, there was no effect of oxytocin treatment over time on the caregiver-rated Social Responsiveness Scale (SRS-2) (p = 0.686). However, a significant interaction with age (p = 0.028) showed that for younger children, aged 3-5 years, there was some indication of a treatment effect. Younger children who received oxytocin showed improvement on caregiver-rated social responsiveness ( SRS-2). There was no other evidence of benefit in the sample as a whole, or in the younger age group, on the clinician-rated Clinical Global Improvement Scale (CGI-S), or any secondary measure. Importantly, placebo effects in the lead-in phase were evident and there was support for washout of the placebo response in the randomised phase. Oxytocin was well tolerated, with more adverse side effects reported in the placebo group. This study suggests the need for further clinical trials to test the benefits of oxytocin treatment in younger populations with autism.Trial registration www.anzctr.org.au (ACTRN12617000441314).
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23
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Goyal RK, Kalaria SN, McElroy SL, Gopalakrishnan M. An exploratory machine learning approach to identify placebo responders in pharmacological binge eating disorder trials. Clin Transl Sci 2022; 15:2878-2887. [PMID: 36126231 PMCID: PMC9747128 DOI: 10.1111/cts.13406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 01/26/2023] Open
Abstract
Randomized, placebo-controlled trials for binge eating disorder (BED) have revealed highly variable, and often marked, rates of short-term placebo response. Several quantitative based analyses in patients with BED have inconsistently demonstrated which patient factors attribute to an increase in placebo response. The objective of this study is to utilize machine learning (ML) algorithms to identify moderators of placebo response in patients with BED. Data were pooled from 12 randomized placebo-controlled trials evaluating different treatment options for BED. The final dataset consisted of 189 adults receiving placebo with complete information of baseline variables. Placebo responders were defined as patients experiencing ≥75% reduction in binge eating frequency (BEF) at study end point. Nine patient prerandomization variables were included as predictors. Patients were divided into training and testing subsets according to an 75%:25% distribution while preserving the proportion of placebo responders. All analysis was performed in the software Pumas 2.0. Gaussian Naïve Bayes algorithm showed the best cross-validation accuracy (~64%) and was chosen as the final algorithm. Shapley analysis suggested that patients with low baseline BEF and anxiety status were strong moderators of placebo response. Upon applying the final algorithm on the test dataset, the resulting sensitivity was 88% and prediction accuracy was 72%. This is the first application of ML to identify moderators of placebo response in BED. The results of this analysis confirm previous findings of lesser baseline disease severity and adds that patients with no anxiety are more susceptible to placebo response.
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Affiliation(s)
- Rahul K. Goyal
- Center for Translational MedicineSchool of Pharmacy, University of MarylandBaltimoreMarylandUSA
| | - Shamir N. Kalaria
- Center for Translational MedicineSchool of Pharmacy, University of MarylandBaltimoreMarylandUSA
| | - Susan L. McElroy
- Department of Psychiatry and Behavioral NeuroscienceUniversity of Cincinnati, College of MedicineMasonOhioUSA
| | - Mathangi Gopalakrishnan
- Center for Translational MedicineSchool of Pharmacy, University of MarylandBaltimoreMarylandUSA
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24
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Bloomfield-Clagett B, Ballard ED, Greenstein DK, Wilkinson ST, Grunebaum MF, Murrough JW, Mathew SJ, Phillips JL, Fava M, Sanacora G, Zarate CA. A Participant-Level Integrative Data Analysis of Differential Placebo Response for Suicidal Ideation and Nonsuicidal Depressive Symptoms in Clinical Trials of Intravenous Racemic Ketamine. Int J Neuropsychopharmacol 2022; 25:827-838. [PMID: 35994774 PMCID: PMC9593215 DOI: 10.1093/ijnp/pyac055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/03/2022] [Accepted: 08/22/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clinical trials of intravenous (IV) racemic (R,S)-ketamine (hereafter referred to as IV ketamine) have consistently reported rapid and substantial reductions in overall depressive symptoms compared with saline (inactive placebo) or midazolam (active placebo). The evidence for IV ketamine's specific effects on suicidal ideation is less clear, however. This study sought to examine whether differential placebo (saline or midazolam) response to overall depressive symptoms vs suicidal ideation may help explain these divergent findings. METHODS Data for this participant-level integrative data analysis were drawn from 151 participants across 10 studies, and linear regression was used to examine the relationship between placebo response for suicidal ideation vs other depressive symptoms indexed from standard rating scales-specifically, depressed mood, anhedonia, anxiety, and guilt-over time. RESULTS For participants receiving saline placebo (n = 46), greater placebo response was observed for suicidal ideation compared with other symptoms indexed from standard depression rating scales, except for anxiety. For those receiving midazolam placebo (n = 105), greater placebo response was observed for suicidal ideation compared with depressed mood or anhedonia, and no significant differences were observed when comparing suicidal ideation with anxiety or guilt. CONCLUSIONS Taken together, the results provide preliminary evidence of a differential placebo response for suicidal ideation vs other depressive symptoms, while anxiety and suicidal ideation appear to produce similar placebo response profiles. These findings may help explain the more modest findings in clinical IV ketamine trials for suicidal ideation than overall depression.
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Affiliation(s)
- Bartholt Bloomfield-Clagett
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth D Ballard
- Correspondence: Elizabeth D. Ballard, PhD, Building 10, CRC Room 7-5341, 10 Center Drive, MSC 1282, Bethesda, MD 20892 ()
| | - Deanna K Greenstein
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | | | - Michael F Grunebaum
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, New York, USA
| | - James W Murrough
- Depression and Anxiety Center for Discovery and Treatment, Departments of Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sanjay J Mathew
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer L Phillips
- University of Ottawa Institute of Mental Health Research and Department of Psychiatry, Ottawa, ON, Canada
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA
| | - Gerard Sanacora
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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25
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Can placebos reduce intrusive memories? Behav Res Ther 2022; 158:104197. [PMID: 36122440 DOI: 10.1016/j.brat.2022.104197] [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: 03/22/2022] [Revised: 07/29/2022] [Accepted: 09/02/2022] [Indexed: 11/23/2022]
Abstract
After traumatic experiences, intrusive memories can flash back and evoke significant distress. Here, we investigated whether the frequency and severity of intrusions can be reduced by the provision of placebo. After the (online) exposure to the trauma-film paradigm, healthy participants (N = 112) received deceptive placebo (DP), open-label placebo (OLP), or no treatment. In the DP group, participants were led to believe to receive a dopamine-modulating drug, which was supposed to disrupt the consolidation of traumatic memories, although they in fact received the same placebo tablets as the OLP group for one week. The results show that the groups did not differ in the frequency of intrusive memories after one week. However, participants receiving OLP reported a significantly reduced intensity of intrusions as compared to DP. Across groups, negative expectations about the intensity and controllability of intrusions were associated with a higher frequency of intrusions, higher distress, higher burden, and more negative appraisal. The results suggest that expectations play an important role in the emergence of intrusive memories and that some of the disabling aspects of intrusive memories can be reduced by placebo. This may carry clinical potential because placebos are an accessible, cost-effective intervention to reduce the risk of intrusive memories.
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26
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Parong J, Seitz AR, Jaeggi SM, Green CS. Expectation effects in working memory training. Proc Natl Acad Sci U S A 2022; 119:e2209308119. [PMID: 36067292 PMCID: PMC9477404 DOI: 10.1073/pnas.2209308119] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022] Open
Abstract
There is a growing body of research focused on developing and evaluating behavioral training paradigms meant to induce enhancements in cognitive function. It has recently been proposed that one mechanism through which such performance gains could be induced involves participants' expectations of improvement. However, no work to date has evaluated whether it is possible to cause changes in cognitive function in a long-term behavioral training study by manipulating expectations. In this study, positive or negative expectations about cognitive training were both explicitly and associatively induced before either a working memory training intervention or a control intervention. Consistent with previous work, a main effect of the training condition was found, with individuals trained on the working memory task showing larger gains in cognitive function than those trained on the control task. Interestingly, a main effect of expectation was also found, with individuals given positive expectations showing larger cognitive gains than those who were given negative expectations (regardless of training condition). No interaction effect between training and expectations was found. Exploratory analyses suggest that certain individual characteristics (e.g., personality, motivation) moderate the size of the expectation effect. These results highlight aspects of methodology that can inform future behavioral interventions and suggest that participant expectations could be capitalized on to maximize training outcomes.
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Affiliation(s)
- Jocelyn Parong
- Department of Psychology, University of Wisconsin–Madison, Madison, WI 53706
| | - Aaron R. Seitz
- Department of Psychology, University of California, Riverside, CA 92521
| | | | - C. Shawn Green
- Department of Psychology, University of Wisconsin–Madison, Madison, WI 53706
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27
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Pardo-Cabello AJ, Manzano-Gamero V, Puche-Cañas E. Placebo: a brief updated review. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:1343-1356. [PMID: 35943515 PMCID: PMC9361274 DOI: 10.1007/s00210-022-02280-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/03/2022] [Indexed: 11/04/2022]
Abstract
Our aims were to provide updated information on placebo/nocebo effect and the potential use of placebo in clinical practice. This article can only provide a rough overview on the placebo and nocebo effect and is intended to serve as a starting point for the reader to go deeper into the corresponding literature. The placebo effect has been observed in multiple medical conditions, after oral administration, with manual therapies as well as with surgery and invasive procedures. The use of placebo in clinical trials is fundamental, although the ethics of its use is under discussion. The placebo may behave like a drug from the pharmacokinetic and pharmacodynamic point of view and can also be associated with adverse events (nocebo effect). Placebo can modify treatment by increasing or decreasing the effects of drugs. The factors associated with the occurrence of placebo effect are multiple, but in addition to those that depend on the placebo itself, the doctor-patient relationship would be the most important. As a result of findings that were published in the last two decades, the psycho-neurobiological basis of placebo is becoming better understood, although further studies are needed. In conclusion, the placebo effect in the clinic exhibits weak to moderate intensity. Placebo, in addition to its use in the clinical trial, should be considered another therapeutic remedy either as stand alone or in association with treatment, and could be useful in certain circumstances. The use of placebo should be regulated by the European health authorities through a guide in clinical practice that will improve patient care.
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Affiliation(s)
- Alfredo Jose Pardo-Cabello
- Department of Internal Medicine, Hospital Universitario San Cecilio, Avda. de La Innovación, s/n, 18016, Granada, Spain.
| | - Victoria Manzano-Gamero
- Department of Internal Medicine, Hospital Universitario Virgen de Las Nieves, Granada, Spain
| | - Emilio Puche-Cañas
- Department of Pharmacology, School of Medicine, University of Granada, Granada, Spain
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28
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Richter LE, Machleit-Ebner A, Scherbaum N, Bonnet U. How Effective is a Web-Based Mental Health Intervention (Deprexis) in the Treatment of Moderate and Major Depressive Disorders when started during Routine Psychiatric Inpatient Treatment as an Adjunct Therapy? A Pragmatic Parallel-Group Randomized Controlled Trial. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2022. [PMID: 35882364 DOI: 10.1055/a-1826-2888] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Internet-based self-help-programs like deprexis have been increasingly shown to reduce depressive symptoms if added to distinct, primarily outpatient-treatment-settings. There is limited information about the effectiveness of deprexis if started at routine psychiatric hospital inpatient treatment of moderate-to-severe major depressive disorder (MDD). SUBJECTS AND METHODS To examine, sixty-nine adult MDD-inpatients were randomly assigned to a 12-week-period of treatment-as-usual (TAU, N=33) or TAU plus guided deprexis (TAU-PLUS, N=36). The study was planned as a pragmatic approach considering psychiatric routine conditions, particularly, offering an instant and flexible discharge management when the patients felt stabilized enough for primary/secondary care. Therefore, there was no fixed time frame for the inpatient treatment duration. Post-discharge, patients were followed by structured telephone interviews up to study-endpoint, i. e., 12 weeks after deprexis-initiation. Primary (Beck-Depression-Inventory-II, BDI-II) and secondary outcome-measures (Hamilton-Depression-Scale, Clinical-Global-Impression-Severity, WHO-Well-Being-Index, Helping-Alliance-Questionnaire) were carried out at study entry and every 2 weeks. Furthermore, the working alliance with deprexis as well as the inpatient treatment duration, the daily activity and the utilization of post-hospital care after discharge were determined. RESULTS At week 12, modified ITT-analyses showed significant between-group differences of BDI-II scores in favor of the TAU-PLUS-patients (p=.03) corresponding to a medium effect size (d=-.73, 95% CI -1.4 to .06). TAU-PLUS-patients showed greater daily activity (p=.04, d=.70, 95% CI -.03 to 1.38) and had been discharged significantly earlier from inpatient treatment (p=.003). Post-discharge, the TAU-PLUS-group reported a lower rate of post-hospital care (p=.01) and re-admissions (p=.04). Secondary outcome-measures including the alliance with the therapists were not significantly different between the groups at study-endpoint. The patients´ working-alliance with deprexis significantly predicted MDD-improvement and wellbeing. Both groups (TAU and TAU plus deprexis) were comparable with regard to the prescribed antidepressant medication. Unfortunately, detailed data on the amount and actual duration of the psychotherapeutic and special therapeutic individual and group settings of the TAU were not collected CONCLUSION: TAU plus deprexis was superior to TAU in improving subjective depression-severity (BDI-II) and daily activity in patients having sought psychiatric inpatient MDD-treatment before. This beneficial effect appeared 12 weeks after inpatient deprexis-initiation, i. e. when the vast majority of patients were back in primary/secondary care. Adjunctive deprexis was associated with earlier discharges and a significant advantage for post-hospital stabilization. In this regard, it could be promising to include deprexis into inpatient treatment conditions, thereby also preparing its continuing outpatient use. We found no evidence that deprexis interfered negatively with the alliance between the patients and their therapists.
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Affiliation(s)
- Lisa Emily Richter
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Evangelisches Krankenhaus Castrop-Rauxel, Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg-Essen, Germany
| | - Annika Machleit-Ebner
- Medical Study Center of the Evangelische. Krankenhausgemeinschaft Herne
- Castrop-Rauxel gGmbH, Herne, Germany
| | - Norbert Scherbaum
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Udo Bonnet
- Department of Psychiatry, Psychotherapy, and Psychosomatic Medicine, Evangelisches Krankenhaus Castrop-Rauxel, Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg-Essen, Germany.,LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
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Daily mother-infant skin-to-skin contact and maternal mental health and postpartum healing: a randomized controlled trial. Sci Rep 2022; 12:10225. [PMID: 35715486 PMCID: PMC9205929 DOI: 10.1038/s41598-022-14148-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 06/02/2022] [Indexed: 11/09/2022] Open
Abstract
This randomized controlled trial examined the effects of a daily hour of mother-infant skin-to-skin contact (SSC) during the first five postnatal weeks, compared to care-as-usual, on maternal depressive (primary outcome), anxiety, stress, fatigue, pain, and delivery-related post-traumatic stress symptoms (PTSS). Prenatal symptom severity and touch discomfort were examined as moderators. Mothers and full-term infants were randomly allocated to SSC or care-as-usual conditions and followed during the first postnatal year. For the total group (intention-to-treat analyses), care-as-usual mothers showed an increase of anxiety symptoms from week 2 to 12, while SSC mothers displayed a stability of anxiety symptoms. Also, care-as-usual mothers showed an initial decrease in fatigue followed by an increase, while SSC mothers showed a decrease from week 2 to 12. In per-protocol analyses, including only the SSC dyads who adhered to SSC guidelines, findings on anxiety, but not fatigue, were replicated. No SSC effects were found for depressive, stress, and pain symptoms. No moderator, dose-response, or 52-week follow-up effects were found. PTSS were low with little variation; consequently, analyses were discontinued. Daily SSC in healthy mother-infant dyads may reduce anxiety and fatigue symptoms, but not depressive, stress, and pain symptoms, during the early postpartum period. Replication studies are recommended.
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Faltinsen E, Todorovac A, Staxen Bruun L, Hróbjartsson A, Gluud C, Kongerslev MT, Simonsen E, Storebø OJ. Control interventions in randomised trials among people with mental health disorders. Cochrane Database Syst Rev 2022; 4:MR000050. [PMID: 35377466 PMCID: PMC8979177 DOI: 10.1002/14651858.mr000050.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated. OBJECTIVES To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait-list versus no-treatment, (ii) usual care versus wait-list or no-treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait-list or no-treatment. Wait-list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no-treatment participants are not offered the experimental intervention by the researchers. SEARCH METHODS In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers. SELECTION CRITERIA We included randomised trials assessing patients with a mental health disorder that compared wait-list, usual care, or placebo interventions with wait-list or no-treatment . DATA COLLECTION AND ANALYSIS Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane's risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre-planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random-effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed-effect model). MAIN RESULTS We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep-wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait-list versus no-treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait-list or no-treatment and found a SMD -0.33 (95% CI -0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait-list or no-treatment was SMD -0.37 (95% CI -0.49 to -0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger's test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD -0.49 (95% CI -0.64 to -0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait-list or no-treatment on benefits was SMD -0.14 (95% CI -0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD -0.21 (95% CI -0.35 to -0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep-wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed-effect model in a sensitivity analysis on the comparison for usual care versus wait-list and no-treatment, the results were significant with an SMD of -0.46 (95 % CI -0.64 to -0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains. AUTHORS' CONCLUSIONS We found marked variations in effects between placebo versus no-treatment and wait-list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait-list or no-treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research.
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Affiliation(s)
- Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | | | - Asbjørn Hróbjartsson
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
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31
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Quan H, Chen X, Luo J, Chen X. A generalized weighted combination test of treatment effect for clinical trials with a sequential parallel comparison design and binary endpoint. Stat Med 2022; 41:2725-2744. [PMID: 35347756 DOI: 10.1002/sim.9381] [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: 08/23/2021] [Revised: 02/04/2022] [Accepted: 03/05/2022] [Indexed: 11/10/2022]
Abstract
To address the issue of a large placebo effect in certain therapeutic areas, rather than the application of the traditional gold standard parallel group placebo-controlled design, different versions of the sequential parallel comparison design have been advocated. In general, the design consists of two consecutive stages and three treatment groups. Stage 1 placebo nonresponders potentially form a prespecified patient subgroup for formal between-treatment comparison at the final analysis. In this research, a version of the design is considered for a binary endpoint. To fully utilize all available data, a generalized weighted combination test is proposed in case placebo has a relatively small effect for some of the study endpoints. The weighted combination of the test based on stage 1 data and the test based on stage 2 data of stage 1 placebo nonresponders suggested in the literature uses only a part of the study data and is a special case of this generalized weighted combination test. A multiple imputation approach is outlined for handling missing not at random data. Simulation is conducted to evaluate the performances of the methods and a data example is employed to illustrate the applications of the methods.
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Affiliation(s)
- Hui Quan
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
| | - Xiaofei Chen
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
| | - Junxiang Luo
- Biostatistics and Programming, Moderna, Cambridge, Massachusetts, USA
| | - Xun Chen
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
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32
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Burke MJ, Romanella SM, Mencarelli L, Greben R, Fox MD, Kaptchuk TJ, Pascual-Leone A, Santarnecchi E. Placebo effects and neuromodulation for depression: a meta-analysis and evaluation of shared mechanisms. Mol Psychiatry 2022; 27:1658-1666. [PMID: 34903861 DOI: 10.1038/s41380-021-01397-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/31/2021] [Accepted: 11/23/2021] [Indexed: 12/20/2022]
Abstract
There is growing evidence that placebo effects can meaningfully modulate the brain. However, there has been little consideration of whether these changes may overlap with regions/circuits targeted by depression treatments and what the implications of this overlap would be on measuring efficacy in placebo-controlled clinical trials. In this systematic review and meta-analysis, we searched PubMed/Medline and Google Scholar for functional MRI and PET neuroimaging studies of placebo effects. Studies recruiting both healthy subjects and patient populations were included. Neuroimaging coordinates were extracted and included for Activation Likelihood Estimation (ALE) meta-analysis. We then searched for interventional studies of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS) for depression and extracted target coordinates for comparative spatial analysis with the placebo effects maps. Of 1169 articles identified, 34 neuroimaging studies of placebo effects were included. There were three significant clusters of activation: left dorsolateral prefrontal cortex (DLPFC) (x = -41, y = 16, z = 34), left sub-genual anterior cingulate cortex (sgACC)/ventral striatum (x = -8, y = 18, z = -15) and the right rostral anterior cingulate cortex (rACC) (x = 4, y = 42, z = 10). There were two significant deactivation clusters: right basal ganglia (x = 20, y = 2, z = 7) and right dorsal anterior cingulate cortex (dACC) (x = 1, y = -5, z = 45). TMS and DBS targets for depression treatment overlapped with the left DLPFC cluster and sgACC cluster, respectively. Our findings identify a common set of brain regions implicated in placebo effects across healthy individuals and patient populations, and provide evidence that these regions overlap with depression treatment targets. We model the statistical impacts of this overlap and demonstrate critical implications on measurements of clinical trial efficacy for this field.
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Affiliation(s)
- Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. .,Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada. .,Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Sara M Romanella
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Siena Brain Investigation & Neuromodulation Lab (Si-BIN Lab), Department of Medicine, Surgery and Neuroscience, Neurology and Clinical Neurophysiology Section, University of Siena, Siena, Italy
| | - Lucia Mencarelli
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Siena Brain Investigation & Neuromodulation Lab (Si-BIN Lab), Department of Medicine, Surgery and Neuroscience, Neurology and Clinical Neurophysiology Section, University of Siena, Siena, Italy
| | - Rachel Greben
- Harquail Centre for Neuromodulation and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Michael D Fox
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Center for Brain Circuit Therapeutics, Departments of Neurology, Psychiatry, and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Athinoula A. Martinos Centre for Biomedical Imaging, Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Ted J Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alvaro Pascual-Leone
- Department of Neurology, Harvard Medical School, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research and Center for Memory Health, Hebrew SeniorLife, Boston, MA, USA.,Guttmann Brain Health Institut, Guttmann Institut, Universitat Autonoma, Barcelona, Spain
| | - Emiliano Santarnecchi
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. .,Precision Neuroscience & Neuromodulation Program, Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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33
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Wollmer MA, Neumann I, Jung S, Bechinie A, Herrmann J, Müller A, Wohlmuth P, Fournier-Kaiser L, Sperling C, Peters L, Kneer J, Engel J, Jürgensen F, Schulze J, Nagel M, Prager W, Sinke C, Kahl KG, Karst M, Dulz B, Kruger THC. Clinical effects of glabellar botulinum toxin injections on borderline personality disorder: A randomized controlled trial. J Psychopharmacol 2022; 36:159-169. [PMID: 35102782 DOI: 10.1177/02698811211069108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Inhibition of frowning via injections of botulinum toxin A (BTX) into the glabellar region has shown beneficial effects in the treatment of major depression. Preliminary research suggests that improvements in the affective domain are not depression-specific, but may also translate to other psychiatric disorders. AIM This 16-week, single-blind, two-center randomized controlled trial investigated the influence of BTX on clinical symptoms of borderline personality disorder (BPD). METHODS Fifty-four patients with BPD were randomly assigned to treatment with BTX (n = 27) or a minimal acupuncture (ACU) control condition (n = 27). Clinical outcomes were followed at 2, 4, 6, 8, 12, and 16 weeks. Primary endpoint was the relative score change on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) 8 weeks after baseline relative to the control group and adjusted for treatment center. Secondary and additional outcome variables were self-rated borderline symptoms, comorbid symptoms of depression, psychological distress, and clinical global impression. RESULTS Participants showed significant improvements at the primary efficacy endpoint in both treatment groups (BTX: M = -0.39, SD = 0.39; ACU: M = -0.35, SD = 0.42), but no superior effect of the BTX condition in comparison with the control intervention was found-F(1,5323) = 0.017, p = 0.68). None of the secondary or additional outcomes yielded significant group differences. Side effects were mild and included headache, transient skin or muscle irritations, and dizziness. CONCLUSION Evidence regarding the efficacy of BTX for BDP remains limited, and the design of adequate control conditions presents an opportunity for further research.ClinicalTrials.gov registry: Botulinum Toxin A for Emotional Stabilization in Borderline Personality Disorder (BPD), NCT02728778, https://clinicaltrials.gov/ct2/show/NCT02728778.
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Affiliation(s)
- M Axel Wollmer
- Asklepios Clinic North - Ochsenzoll, Asklepios Campus Hamburg, Medical Faculty, Semmelweis University, Germany
| | - Insa Neumann
- Asklepios Clinic North - Ochsenzoll, Asklepios Campus Hamburg, Medical Faculty, Semmelweis University, Germany
| | - Stefanie Jung
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Agnès Bechinie
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Julian Herrmann
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Antje Müller
- Asklepios Clinic North - Ochsenzoll, Asklepios Campus Hamburg, Medical Faculty, Semmelweis University, Germany
| | | | - Larissa Fournier-Kaiser
- Asklepios Clinic North - Ochsenzoll, Asklepios Campus Hamburg, Medical Faculty, Semmelweis University, Germany
| | - Christian Sperling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Liza Peters
- Asklepios Clinic North - Ochsenzoll, Asklepios Campus Hamburg, Medical Faculty, Semmelweis University, Germany
| | - Jonas Kneer
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Jannis Engel
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Frank Jürgensen
- Asklepios Clinic North - Ochsenzoll, Asklepios Campus Hamburg, Medical Faculty, Semmelweis University, Germany
| | - Jara Schulze
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Matthias Nagel
- Department of Psychiatry and Psychotherapy, Asklepios Clinic North - Wandsbek, Hamburg, Germany.,Clinic for Psychiatry and Psychotherapy, University of Lübeck, Luebeck, Germany
| | - Welf Prager
- Dermatologische Praxis, Prager & Partner, Hamburg, Germany
| | - Christopher Sinke
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany
| | - Kai G Kahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Matthias Karst
- Department of Anesthesiology and Intensive Care Medicine, Pain Clinic, Hannover Medical School, Hannover, Germany
| | - Birger Dulz
- Asklepios Clinic North - Ochsenzoll, Asklepios Campus Hamburg, Medical Faculty, Semmelweis University, Germany
| | - Tillmann H C Kruger
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
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34
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Gorantla S, Gopireddy MMR, Bhat A, Ayyasamy L, Jaishankar SKJ, Kherallah B, Nersesyan H. Placebo response with subcutaneous injections in calcitonin gene-related peptide receptor monoclonal antibody migraine preventative trials – A systematic review and meta-analysis. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221120103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The majority of CGRP monoclonal antibodies for migraine prevention are administered subcutaneously. Therefore, we attempted to calculate the pooled placebo response with subcutaneous placebo injections in this systematic review and meta-analysis. Methods: We identified 16 randomized controlled trials that met our inclusion and exclusion criteria through a comprehensive search in five electronic databases (PubMed Central, EMBASE, MEDLINE, Cochrane library and clinicaltrials.gov ). The risk of bias was assessed for all included studies. Random effects model was used to calculate pooled mean monthly migraine days and 50% response rates. Results: A total of 4240 subjects were included from 16 studies in this meta-analysis. The pooled mean monthly migraine day reduction with subcutaneous placebo injections was 2.15 (95% CI: 1.60–2.69). The pooled proportion of patients achieving a 50% reduction in mean monthly headache days was 26% (95% CI: 20%–31%). Placebo response accounted for more than 50% of therapeutic gain in our study. Conclusion: A substantial placebo response was noted with subcutaneous injections in migraine CGRP monoclonal antibody clinical trials. This meta-analysis may serve as a reference point to calculate sample size in clinical trials using subcutaneous interventions for migraine prevention. We registered our study at PROSPERO (CRD42020185300).
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Affiliation(s)
- Sasikanth Gorantla
- University of Illinois College of Medicine at Peoria and Illinois Neurological Institute, OSF Healthcare, Peoria, IL, USA
| | | | - Archana Bhat
- Evidencian Research Associates, Bangalore, India
| | | | | | - Bassil Kherallah
- University of Illinois College of Medicine at Peoria and Illinois Neurological Institute, OSF Healthcare, Peoria, IL, USA
| | - Hrachya Nersesyan
- University of Illinois College of Medicine at Peoria and Illinois Neurological Institute, OSF Healthcare, Peoria, IL, USA
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35
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Smith EA, Horan WP, Demolle D, Schueler P, Fu DJ, Anderson AE, Geraci J, Butlen-Ducuing F, Link J, Khin NA, Morlock R, Alphs LD. Using Artificial Intelligence-based Methods to Address the Placebo Response in Clinical Trials. INNOVATIONS IN CLINICAL NEUROSCIENCE 2022; 19:60-70. [PMID: 35382067 PMCID: PMC8970233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The placebo response is a highly complex psychosocial-biological phenomenon that has challenged drug development for decades, particularly in neurological and psychiatric disease. While decades of research have aimed to understand clinical trial factors that contribute to the placebo response, a comprehensive solution to manage the placebo response in drug development has yet to emerge. Advanced data analytic techniques, such as artificial intelligence (AI), might be needed to take the next leap forward in mitigating the negative consequences of high placebo-response rates. The objective of this review was to explore the use of techniques such as AI and the sub-discipline of machine learning (ML) to address placebo response in practical ways that can positively impact drug development. This examination focused on the critical factors that should be considered in applying AI and ML to the placebo response issue, examples of how these techniques can be used, and the regulatory considerations for integrating these approaches into clinical trials.
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Affiliation(s)
- Erica A Smith
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - William P Horan
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Dominique Demolle
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Peter Schueler
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Dong-Jing Fu
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Ariana E Anderson
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Joseph Geraci
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Florence Butlen-Ducuing
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Jasmine Link
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Ni A Khin
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Robert Morlock
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
| | - Larry D Alphs
- Drs. Smith and Demolle are with Cognivia in Mont St. Guibert, Belgium
- Dr. Horan is with VeraSci in Durham, North Carolina
- Drs. Horan and Anderson are with the University of California at Los Angeles in Los Angeles, California
- Dr. Schueler is with ICON Clinical Research in Langen, Germany
- Dr. Fu is with Janssen Reasearch and Development, LLC, in Titusville, New Jersey
- Dr. Geraci is with Nurosene Health, Inc. in Toronto, Ontario; Queen's University in Kingston, Ontario; and the Center for Biotechnology and Genomics Medicine, Medical College of Georgia, in Augusta, Georgia
- Dr. Butlen-Ducuing is with European Medicines Agency in Amsterdam, Netherlands
- Ms. Link is with Boehringer Ingelheim Pharma GmbH and Company KG in Baden Württenberg, Germany
- Dr. Khin is with Neurocrine Biosciences, Inc. in San Diego, California
- Dr. Morlock is with YourCareChoice in Ann Arbor, Michigan
- Dr. Alphs is with Denovo Biopharma, LLC in San Diego, California (at the time of writing, he was with Newron Pharmaceuticals in Morriston, New Jersey)
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Wunram HL, Hamacher S, Oberste M, Neufang S, Belke L, Jänicke F, Graf C, Schönau E, Bender S, Fricke O. Influence of motivational placebo-related factors on the effects of exercise treatment in depressive adolescents. Eur Child Adolesc Psychiatry 2022; 31:1-14. [PMID: 33709258 PMCID: PMC9343287 DOI: 10.1007/s00787-021-01742-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/08/2021] [Indexed: 11/26/2022]
Abstract
Recent meta-analyses reveal a moderate effect of physical activity (PA) in the treatment of adolescent depression. However, not only the underlying neurobiological mechanisms, also the influences of placebo-related motivational factors (beliefs and expectancies in sporting, enjoyment and prior sports experiences), are still unclear. Based on the data of our prior study "Mood Vibes", we hypothesized that placebo-inherent factors like positive prior sports experiences and motivational factors, (positive beliefs, expectancies, and enjoyment related to PA), would increase the effects of an add-on exercise-therapy in juvenile depression. From 64 included depressed adolescents, 41 underwent an intensive add-on PA-therapy. Motivational factors were assessed using sport-specific scales. The changes in depression scores under treatment were rated by self-rating scale (German "Childhood Depression Inventory", (DIKJ)). A mixed model for repeated measures (MMRM) was used to analyze the effects of the different motivational variates on DIKJ. While prior sports experiences had no impact, motivational factors showed a significant effect on PA-induced changes in DIKJ scores (p = 0.002). The demotivated participants improved less, whereas it was sufficient to be neutral towards sporting to benefit significantly more. Motivational placebo-related factors (beliefs, expectancies and enjoyment regarding PA) affected the outcomes of an exercise treatment in depressed adolescents. Yet, a neutral mindset was sufficient to profit more from PA. Prior sporting in the sense of positive conditioning and as a protective factor did not play a role. Knowledge about these influences could in a second step help to develop tailored therapies.
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Affiliation(s)
- Heidrun Lioba Wunram
- Department of Child and Adolescent Psychiatry Psychosomatic and Psychotherapy, University Hospital of Cologne, Cologne, Germany
| | - Stefanie Hamacher
- Department of Medical Statistics, Informatics and Epidemiology (IMSIE), University of Cologne, Cologne, Germany
| | - Max Oberste
- Department of Medical Statistics, Informatics and Epidemiology (IMSIE), University of Cologne, Cologne, Germany
- Department for Molecular and Cellular Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Susanne Neufang
- Department of Psychiatry and Psychotherapy, Medical Faculty Heinrich-Heine University, Düsseldorf, Germany
| | - Luisa Belke
- Children’s Hospital Amsterdam Street, Cologne, Germany
| | | | - Christine Graf
- Institute of Movement and Neuroscience, German Sport University Cologne, Cologne, Germany
| | - Eckhard Schönau
- Children’s Hospital, University Hospital of Cologne and UniReha®, University Hospital of Cologne, Cologne, Germany
| | - Stephan Bender
- Department of Child and Adolescent Psychiatry Psychosomatic and Psychotherapy, University Hospital of Cologne, Cologne, Germany
| | - Oliver Fricke
- Department of Child and Adolescent Psychiatry, Psychotherapy and Child Neurology, Gemeinschaftskrankenhaus Herdecke and Chairs of Child and Adolescent Psychiatry, Witten/Herdecke University, Witten, Germany
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Basavaraju R, Ithal D, Thanki MV, Ramalingaiah AH, Thirthalli J, Reddy RP, Brady RO, Halko MA, Bolo NR, Keshavan MS, Pascual-Leone A, Mehta UM, Kesavan M. Intermittent theta burst stimulation of cerebellar vermis enhances fronto-cerebellar resting state functional connectivity in schizophrenia with predominant negative symptoms: A randomized controlled trial. Schizophr Res 2021; 238:108-120. [PMID: 34653740 PMCID: PMC8662658 DOI: 10.1016/j.schres.2021.10.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Negative symptoms of schizophrenia are substantially disabling and treatment resistant. Novel treatments like repetitive transcranial magnetic stimulation (TMS) need to be examined for the same using the experimental medicine approach that incorporates tests of mechanism of action in addition to clinical efficacy in trials. METHODS Study was a double-blind, parallel, randomized, sham-controlled trial recruiting schizophrenia with at least a moderate severity of negative symptoms. Participants were randomized to real or sham intermittent theta burst stimulation (iTBS) under MRI-guided neuro-navigation, targeting the cerebellar vermis area VII-B, at a stimulus intensity of 100% active motor threshold, two sessions/day for five days (total = 6000 pulses). Assessments were conducted at baseline (T0), day-6 (T1) and week-6 (T2) after initiation of intervention. Main outcomes were, a) Scale for the Assessment of Negative Symptoms (SANS) score (T0, T1, T2), b) fronto-cerebellar resting state functional connectivity (RSFC) (T0, T1). RESULTS Thirty participants were recruited in each arm. Negative symptoms improved in both arms (p < 0.001) but was not significantly different between the two arms (p = 0.602). RSFC significantly increased between the cerebellar vermis and the right inferior frontal gyrus (pcluster-FWER = 0.033), right pallidum (pcluster-FWER = 0.042) and right frontal pole (pcluster-FWER = 0.047) in the real arm with no change in the sham arm. CONCLUSION Cerebellar vermal iTBS engaged a target belonging to the class of cerebello-subcortical-cortical networks, implicated in negative symptoms of schizophrenia. However, this did not translate to a superior clinical efficacy. Future trials should employ enhanced midline cerebellar TMS stimulation parameters for longer durations that can potentiate and translate biological changes into clinical effects.
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Affiliation(s)
- Rakshathi Basavaraju
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Dhruva Ithal
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Milind Vijay Thanki
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Arvinda Hanumanthapura Ramalingaiah
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Rajakumari P. Reddy
- Department of Clinical Psychology, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Roscoe O. Brady
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Mark A. Halko
- Department of Psychiatry, McLean Hospital and Harvard Medical School, Belmont, MA, USA
| | - Nicolas R. Bolo
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Matcheri S. Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research and Center for Memory Health, Hebrew Senior Life, Boston, MA, USA; Department of Neurology, Harvard Medical School, Boston, MA, USA; Guttmann Brain Health Institut, Institut Guttmann, Universitat Autonoma Barcelona, Spain.
| | - Urvakhsh Meherwan Mehta
- Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore 560029, Karnataka, India.
| | - Muralidharan Kesavan
- Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore 560029, Karnataka, India.
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Differential power of placebo across major psychiatric disorders: a preliminary meta-analysis and machine learning study. Sci Rep 2021; 11:21301. [PMID: 34716400 PMCID: PMC8556377 DOI: 10.1038/s41598-021-99534-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/09/2021] [Indexed: 11/09/2022] Open
Abstract
The placebo effect across psychiatric disorders is still not well understood. In the present study, we conducted meta-analyses including meta-regression, and machine learning analyses to investigate whether the power of placebo effect depends on the types of psychiatric disorders. We included 108 clinical trials (32,035 participants) investigating pharmacological intervention effects on major depressive disorder (MDD), bipolar disorder (BD) and schizophrenia (SCZ). We developed measures based on clinical rating scales and Clinical Global Impression scores to compare placebo effects across these disorders. We performed meta-analysis including meta-regression using sample-size weighted bootstrapping techniques, and machine learning analysis to identify the disorder type included in a trial based on the placebo response. Consistently through multiple measures and analyses, we found differential placebo effects across the three disorders, and found lower placebo effect in SCZ compared to mood disorders. The differential placebo effects could also distinguish the condition involved in each trial between SCZ and mood disorders with machine learning. Our study indicates differential placebo effect across MDD, BD, and SCZ, which is important for future neurobiological studies of placebo effects across psychiatric disorders and may lead to potential therapeutic applications of placebo on disorders more responsive to placebo compared to other conditions.
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Sprengers JJ, van Andel DM, Bruining H. Dr. Sprengers et al. Reply. J Am Acad Child Adolesc Psychiatry 2021; 60:938-939. [PMID: 33450401 DOI: 10.1016/j.jaac.2020.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
Before we elaborate on the postulated discrepancies between our trial and previous bumetanide in autism spectrum disorder (ASD) trials, we would like to acknowledge the crucial pioneering work on the γ-aminobutyric acid (GABA) developmental sequence by Dr. Ben-Ari and colleagues. Chloride dysregulation and altered GABA polarity have been implicated in neurological and neurodevelopmental disorders, including some forms of ASD. Etiologies underlying ASD are profoundly heterogeneous, and an important challenge is to link the optimal treatment to individual patients. Indeed, ASD animal models indicate reversed GABA polarity as a treatment target in some,1,2 but not all, studies.3 The aim of the Bumetanide in Autism Medication and Biomarker (BAMBI) trial was to replicate previous trial findings and to develop stratification biomarkers that may help to understand expected variability in treatment response.
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Affiliation(s)
- Jan J Sprengers
- UMC Utrecht Brain Centre, University Medical Centre Utrecht, The Netherlands
| | - Dorinde M van Andel
- UMC Utrecht Brain Centre, University Medical Centre Utrecht, The Netherlands
| | - Hilgo Bruining
- UMC Utrecht Brain Centre, University Medical Centre Utrecht, The Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, N=You centre, Amsterdam Neuroscience, Amsterdam Reproduction and Development, The Netherlands.
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Peerdeman KJ, Geers AL, Della Porta D, Veldhuijzen DS, Kirsch I. Underpredicting pain: an experimental investigation into the benefits and risks. Pain 2021; 162:2024-2035. [PMID: 33470747 DOI: 10.1097/j.pain.0000000000002199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
ABSTRACT Expectancies can shape pain and other experiences. Generally, experiences change in the direction of what is expected (ie, assimilation effects), as seen with placebo effects. However, in case of large expectation-experience discrepancies, experiences might change away from what is expected (ie, contrast effects). Previous research has demonstrated contrast effects on various outcomes, but not pain. We investigated the effects of strong underpredictions of pain on experienced pain intensity. In addition, we assessed related outcomes including (certainty of) expectations, fear of pain, pain unpleasantness, autonomic responses, and trust. Healthy participants (study 1: n = 81 and study 2: n = 123) received verbal suggestions that subsequent heat stimuli would be moderately or highly painful (correct prediction), mildly painful (medium underprediction; study 2 only), or nonpainful (strong underprediction). Both studies showed that participants experienced less intense pain upon strong underprediction than upon correct prediction (ie, assimilation). Expected pain, fear of pain, and pain unpleasantness were generally also lowered. However, strong underprediction simultaneously lowered certainty of expectations and trust in the experimenter. Study 2 indicated that the effects of strong underprediction vs medium underprediction generally did not differ. Moreover, study 2 provided some indications for reduced heart rate and skin conductance levels but increased skin conductance responses upon strong underprediction. In conclusion, even strong underpredictions of pain can reduce pain (ie, cause assimilation), although not significantly more than medium underpredictions. However, strong underpredictions can cause uncertainty and undermine trust. These findings suggest that healthcare providers may wish to be cautious with providing overly positive information about painful medical procedures.
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Affiliation(s)
- Kaya J Peerdeman
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands
| | - Andrew L Geers
- Department of Psychology, University of Toledo, Toledo, OH, United States
| | - Delia Della Porta
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - Dieuwke S Veldhuijzen
- Unit Health, Medical and Neuropsychology, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden, the Netherlands
| | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, MA, United States
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Zhou Y, Wade TD. The impact of COVID-19 on body-dissatisfied female university students. Int J Eat Disord 2021; 54:1283-1288. [PMID: 33851442 PMCID: PMC8250175 DOI: 10.1002/eat.23521] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This study investigated the impact of COVID-19 on young women's disordered eating and their responses to online interventions to reduce disordered eating. METHOD University students at risk of developing an eating disorder (N = 100) were randomly assigned to either receiving an online intervention to reduce disordered eating or not. Forty-one participants entered the study from September 2019 to March 2020 (pre-COVID) and 59 after physical distancing was introduced due to COVID pandemic (during COVID). Online assessments were conducted at baseline and 1-week follow up. RESULTS There was a significant increase in weight concerns, disordered eating, and negative affect among participants entering the trial during COVID compared to pre-COVID. The increases in the first two variables remained when adjusting for baseline negative affect. No significant interactions between time, condition and COVID status were observed. DISCUSSION Young women experienced increased levels of disordered eating after the onset of COVID. While no interactions with COVID were detected, changes to within-group effect sizes for disordered eating more than doubled for both online interventions and assessment from pre-COVID to during COVID, suggesting any attention to issues related to disordered eating in the context of reduced social contact may be beneficial.
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Affiliation(s)
- Yuan Zhou
- College of Education Psychology & Social Work, Flinders UniversityAdelaideSouth AustraliaAustralia
| | - Tracey D. Wade
- College of Education Psychology & Social Work, Flinders UniversityAdelaideSouth AustraliaAustralia
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Rotem A, Ben-Sheetrit J, Newcorn J, Danieli Y, Peskin M, Golubchik P, Ben-Hayun R, Weizman A, Manor I. The Placebo Response in Adult ADHD as Objectively Assessed by the TOVA Continuous Performance Test. J Atten Disord 2021; 25:1311-1320. [PMID: 31965885 DOI: 10.1177/1087054719897819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: We compared the placebo response (PR) as measured by the Test of Variables of Attention (TOVA) and the Conners' Adult ADHD Rating Scale (CAARS) scores. Method: A retrospective data analysis from a double-blind placebo-controlled study of metadoxine-ER in adults with ADHD. An additional database was used for comparison to TOVA response after methylphenidate challenge (TOVA-MPH-R). Results: PR was highest when calculated from the TOVA-Attention Composite Score (ACS). The PR showed significantly fewer variables improving concomitantly compared with MPH-R. The most prominent correlation between the CAARS-PR and the TOVA-PR was in the Omissions score (p = .032), which was age-dependent (b = .0007, p <.001). Discussion: TOVA-PR has an index-specific profile compared with CAARS-PR and TOVA-MPH-R. The partial correlation of TOVA-PR with CAARS-PR suggests that a composite score of TOVA specific indices and CAARS could have a synergic impact to improve the reliability of the response assessment in adult ADHD.
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Affiliation(s)
- Ann Rotem
- Geha Mental Health Center, Petah Tikva, Israel
| | | | | | | | - Miriam Peskin
- Geha Mental Health Center, Petah Tikva, Israel.,Tel Aviv University, Israel
| | - Pavel Golubchik
- Geha Mental Health Center, Petah Tikva, Israel.,Tel Aviv University, Israel
| | - Rachel Ben-Hayun
- Rambam Health Care Campus, Haifa, Israel.,Bar-Ilan University, Ramat Gan, Israel
| | - Abraham Weizman
- Geha Mental Health Center, Petah Tikva, Israel.,Tel Aviv University, Israel.,The Felsenstein Medical Research Center, Petah Tikva, Israel
| | - Iris Manor
- Geha Mental Health Center, Petah Tikva, Israel.,Tel Aviv University, Israel
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Bosman M, Elsenbruch S, Corsetti M, Tack J, Simrén M, Winkens B, Boumans T, Masclee A, Keszthelyi D. The placebo response rate in pharmacological trials in patients with irritable bowel syndrome: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:459-473. [PMID: 33765447 DOI: 10.1016/s2468-1253(21)00023-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinical trials in irritable bowel syndrome are associated with high placebo response rates. We aimed to identify the magnitude of the placebo response and the contributing factors to this occurrence. METHODS We did a systematic review and meta-analysis with a search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials between April 1, 1959, and April 30, 2020. We included all randomised controlled trials that compared an active pharmacotherapeutic agent with placebo and had a dichotomous outcome of response to therapy (in terms of global improvement or improvement in abdominal pain) in adults (aged ≥18 years) with irritable bowel syndrome. Exclusion criteria were trials reporting on treatment satisfaction as a dichotomous outcome of response to therapy or clinician-reported outcomes and a treatment duration of less than 4 weeks. Our main outcome was identification of the magnitude of the pooled placebo response rate for the following endpoints: global improvement, abdominal pain, and US Food and Drug Administration (FDA) endpoints. We extracted information from published reports and pooled proportions through meta-analysis with random effects. The study was registered with PROSPERO, CRD42020170908. FINDINGS Of the 6863 publications identified, 70 articles describing 73 randomised controlled trials were included in our analysis. The pooled placebo response rate was 27·3% (95% CI 24·3-30·9) using the global improvement endpoint, 34·4% (31·2-37·8) using the abdominal pain endpoint, and 17·9% (15·2-21·0) using the composite FDA endpoint responder definition, all with substantial heterogeneity between the trials. Studies published before 2006, and those done in Europe, with a parallel design, a run-in period of 2 weeks or less, a dose schedule of three times a day or more, or a smaller sample size of the control group were significantly associated with an increased pooled placebo response rate. INTERPRETATION More than a quarter of patients with irritable bowel syndrome had a placebo response in terms of global improvement, with multiple associated moderators. We recommend future trials apply a run-in period of at least 2 weeks and dose once or twice a day to minimise the placebo response rate. FUNDING None.
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Affiliation(s)
- Michelle Bosman
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, Netherlands.
| | - Sigrid Elsenbruch
- Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr University Bochum, Bochum, Germany; Department of Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; University of Nottingham and Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, Catholic University of Leuven, Leuven, Belgium; Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Thimo Boumans
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, Netherlands
| | - Ad Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, Netherlands
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González-Blanch C, Muñoz-Navarro R, Medrano LA, Moriana JA, Ruiz-Rodríguez P, Cano-Vindel A. Moderators and predictors of treatment outcome in transdiagnostic group cognitive-behavioral therapy for primary care patients with emotional disorders. Depress Anxiety 2021; 38:757-767. [PMID: 34043853 DOI: 10.1002/da.23164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/06/2021] [Accepted: 04/17/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Transdiagnostic group cognitive behavior therapy (TD-GCBT) has shown to be efficacious in the treatment of emotional disorders in primary care. However, little is known about possible moderators or predictors of treatment outcome. We aimed to explore the potential predictors and moderators of outcome in a large multicentre randomized controlled trial comparing TD-GCBT plus treatment as usual (TAU) to TAU alone. METHOD Putative demographic and baseline clinical variables were examined using the PROCESS macro as potential predictors/moderators of depressive and anxiety symptoms at posttreatment and 1-year follow-up. RESULTS Analyses were based on a study completer sample of 1061 participants randomized to TD-CBT + TAU (n = 527) or TAU alone (n = 534), with 631 participants assessed at the posttreatment evaluation and 388 at the 1-year follow-up. Individuals working or with a partner among sociodemographic variables, and higher baseline comorbidities and more severity of symptoms among clinical variables obtained more benefits from adding TDCBT to TAU. Those taking medication before treatment obtained less benefits from the TD-GCBT than those without prescribed antidepressant medications, after controlling for baseline severity of symptoms. Overall, the moderating effect of clinical (but not sociodemographic) variables remained at 1-year follow-up. CONCLUSION Findings support largely the generalization of the TD-GCBT for emotional disorders in primary care to a variety of sociodemographic and clinical groups. However, TD-GCBT seems to work to a greater extent for those individuals with a more severe clinical profile. Providing TD-GCBT before prescribing antidepressant medication and while people are still working may enhance the effects of adding this psychological treatment to TAU in primary care.
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Affiliation(s)
- César González-Blanch
- Mental Health Centre, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Roger Muñoz-Navarro
- Department of Psychology and Sociology, Faculty of Social and Human Sciences University of Zaragoza, Zaragoza, Spain
| | - Leonardo Adrián Medrano
- Research Secretariat, Faculty of Psychology, Universidad Empresarial Siglo 21, Córdoba, Argentina
| | - Juan Antonio Moriana
- Department of Psychology, Maimónides Institute for Research in Biomedicine of Cordoba-IMIBIC, Reina Sofía University Hospital, University of Córdoba, Córdoba, Spain
| | | | - Antonio Cano-Vindel
- Department of Experimental Psychology, Cognitive Processes and Speech Therapy, Faculty of Psychology, Complutense University of Madrid, Madrid, Spain
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Mellem MS, Kollada M, Tiller J, Lauritzen T. Explainable AI enables clinical trial patient selection to retrospectively improve treatment effects in schizophrenia. BMC Med Inform Decis Mak 2021; 21:162. [PMID: 34016112 PMCID: PMC8135147 DOI: 10.1186/s12911-021-01510-0] [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: 12/29/2020] [Accepted: 04/29/2021] [Indexed: 12/04/2022] Open
Abstract
Background Heterogeneity among patients’ responses to treatment is prevalent in psychiatric disorders. Personalized medicine approaches—which involve parsing patients into subgroups better indicated for a particular treatment—could therefore improve patient outcomes and serve as a powerful tool in patient selection within clinical trials. Machine learning approaches can identify patient subgroups but are often not “explainable” due to the use of complex algorithms that do not mirror clinicians’ natural decision-making processes. Methods Here we combine two analytical approaches—Personalized Advantage Index and Bayesian Rule Lists—to identify paliperidone-indicated schizophrenia patients in a way that emphasizes model explainability. We apply these approaches retrospectively to randomized, placebo-controlled clinical trial data to identify a paliperidone-indicated subgroup of schizophrenia patients who demonstrate a larger treatment effect (outcome on treatment superior than on placebo) than that of the full randomized sample as assessed with Cohen’s d. For this study, the outcome corresponded to a reduction in the Positive and Negative Syndrome Scale (PANSS) total score which measures positive (e.g., hallucinations, delusions), negative (e.g., blunted affect, emotional withdrawal), and general psychopathological (e.g., disturbance of volition, uncooperativeness) symptoms in schizophrenia. Results Using our combined explainable AI approach to identify a subgroup more responsive to paliperidone than placebo, the treatment effect increased significantly over that of the full sample (p < 0.0001 for a one-sample t-test comparing the full sample Cohen’s d = 0.82 and a generated distribution of subgroup Cohen’s d’s with mean d = 1.22, std d = 0.09). In addition, our modeling approach produces simple logical statements (if–then-else), termed a “rule list”, to ease interpretability for clinicians. A majority of the rule lists generated from cross-validation found two general psychopathology symptoms, disturbance of volition and uncooperativeness, to predict membership in the paliperidone-indicated subgroup. Conclusions These results help to technically validate our explainable AI approach to patient selection for a clinical trial by identifying a subgroup with an improved treatment effect. With these data, the explainable rule lists also suggest that paliperidone may provide an improved therapeutic benefit for the treatment of schizophrenia patients with either of the symptoms of high disturbance of volition or high uncooperativeness. Trial Registration: clincialtrials.gov identifier: NCT 00,083,668; prospectively registered May 28, 2004 Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01510-0.
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Affiliation(s)
- Monika S Mellem
- BlackThorn Therapeutics, 780 Brannan St., San Francisco, CA, 94103, USA.
| | - Matt Kollada
- BlackThorn Therapeutics, 780 Brannan St., San Francisco, CA, 94103, USA
| | - Jane Tiller
- BlackThorn Therapeutics, 780 Brannan St., San Francisco, CA, 94103, USA
| | - Thomas Lauritzen
- BlackThorn Therapeutics, 780 Brannan St., San Francisco, CA, 94103, USA
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Frohlich F, Riddle J. Conducting double-blind placebo-controlled clinical trials of transcranial alternating current stimulation (tACS). Transl Psychiatry 2021; 11:284. [PMID: 33980854 PMCID: PMC8116328 DOI: 10.1038/s41398-021-01391-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 12/13/2022] Open
Abstract
Many psychiatric and neurological illnesses can be conceptualized as oscillopathies defined as pathological changes in brain network oscillations. We previously proposed the application of rational design for the development of non-invasive brain stimulation for the modulation and restoration of cortical oscillations as a network therapeutic. Here, we show how transcranial alternating current stimulation (tACS), which applies a weak sine-wave electric current to the scalp, may serve as a therapeutic platform for the treatment of CNS illnesses. Recently, an initial series of double-blind, placebo-controlled treatment trials of tACS have been published. Here, we first map out the conceptual underpinnings of such trials with focus on target identification, engagement, and validation. Then, we discuss practical aspects that need to be considered for successful trial execution, with particular regards to ensuring successful study blind. Finally, we briefly review the few published double-blind tACS trials and conclude with a proposed roadmap to move the field forward with the goal of moving from pilot trials to convincing efficacy studies of tACS.
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Affiliation(s)
- Flavio Frohlich
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
- Carolina Center for Neurostimulation, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
- Neuroscience Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Justin Riddle
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Carolina Center for Neurostimulation, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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He J, Perez DG, Le-Rademacher JL, Dodge A, Enck P, Loprinzi CL, Zahrieh D. Does the placebo effect on hot flashes depend on the placebo dose? Support Care Cancer 2021; 29:6741-6749. [PMID: 33973082 DOI: 10.1007/s00520-021-06244-3] [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: 11/30/2020] [Accepted: 04/20/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the presence of a placebo dose-response effect in four randomized, double-blind, placebo-controlled, multi-dose hot flash clinical trials conducted at Mayo Clinic. METHODS Hot flash score, frequency, and hot flash-related distress for each placebo dose level were summarized at each time point by mean and standard deviation and changes from baseline were plotted to visualize a possible placebo dose-effect response. Furthermore, a meta-analysis was conducted for each endpoint in the highest and lowest dosage arms across the four trials. RESULTS Longitudinal plots of mean hot flash scores, frequencies, and hot flash-related distress scores in patients taking placebo in each study showed a decline in hot flash scores over time without any clinically meaningful differences between the lowest and highest dosage arms in each study. The meta-analysis for each endpoint in the highest and lowest dosage arms across the four trials revealed no clinically important differences either. CONCLUSION While the current study cannot rule out the existence of a placebo dose-response effect in multi-dose placebo-controlled trials in patients with hot flashes or other conditions, it suggests, along with the available data in the placebo literature, that, at least in well-conducted multi-dose clinical trials in which the placebo was used as control, such an effect, if it exists at all, should be very small. Therefore, pooling data from different placebo subgroups is unlikely to compromise the validity of comparisons between the combined placebo arms and each treatment arm.
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Affiliation(s)
- Jun He
- Biomedical Statistics and Informatics - Cancer Statistics, Mayo Clinic, MN, Rochester, USA
| | - Domingo G Perez
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew Dodge
- Biomedical Statistics and Informatics - Kern Center HSA, Mayo Clinic, MN, Rochester, USA
| | - Paul Enck
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | | | - David Zahrieh
- Biomedical Statistics and Informatics - Cancer Statistics, Mayo Clinic, MN, Rochester, USA
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Schienle A, Gremsl A, Wabnegger A. Placebo Effects in the Context of Religious Beliefs and Practices: A Resting-State Functional Connectivity Study. Front Behav Neurosci 2021; 15:653359. [PMID: 34025370 PMCID: PMC8134677 DOI: 10.3389/fnbeh.2021.653359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Placebos (inert substances or procedures) can positively influence a person’s psychological and physical well-being, which is accompanied by specific changes in brain activity. There are many different types of placebos with different effects on health-related variables. This study investigated placebo effects in the context of religious beliefs and practices. The participants received an inert substance (tap water) along with the verbal suggestion that the water would come from the sanctuary in Lourdes (a major Catholic pilgrimage site with reports of miracle cures). We investigated changes in resting-state functional connectivity (rsFC) in three brain networks (default-mode, salience, cognitive control) associated with the drinking of the placebo water. Methods: A total of 37 females with the belief that water from the sanctuary in Lourdes has positive effects on their spiritual, emotional, and physical well-being participated in this placebo study with two sessions. The participants drank tap water that was labeled “Lourdes water” (placebo) before a 15-min resting-state scan in one session. In the other (control) session, they received tap water labeled as tap water. The participants rated their affective state (valence, arousal) during the session and were interviewed concerning specific thoughts, feelings, and bodily sensations directly after each of the two sessions. Results: The placebo reduced rsFC in the frontoparietal cognitive control network and increased rsFC in the salience network (insular-cerebellar connectivity). During the session, the participants rated their affective state as very pleasant and calm. The ratings did not differ between the two conditions. Immediately after the session, the participants reported increased intensity of pleasant bodily sensations (e.g., feelings of warmth, tingling) and feelings (e.g., gratefulness) for the “Lourdes water” condition. Conclusions: The present findings provide the first evidence that placebos in the context of religious beliefs and practices can change the experience of emotional salience and cognitive control which is accompanied by connectivity changes in the associated brain networks.
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Affiliation(s)
- Anne Schienle
- Department of Clinical Psychology, University of Graz, BioTechMed, Graz, Austria
| | - Andreas Gremsl
- Department of Clinical Psychology, University of Graz, BioTechMed, Graz, Austria
| | - Albert Wabnegger
- Department of Clinical Psychology, University of Graz, BioTechMed, Graz, Austria
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Tan XW, Abdin E, Tor PC. Accelerated transcranial magnetic stimulation (aTMS) to treat depression with treatment switching: study protocol of a pilot, randomized, delayed-start trial. Pilot Feasibility Stud 2021; 7:104. [PMID: 33952345 PMCID: PMC8097929 DOI: 10.1186/s40814-021-00845-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 04/28/2021] [Indexed: 12/28/2022] Open
Abstract
Background Repetitive transcranial magnetic stimulation (rTMS) is a technique for stimulating brain activity using a transient magnetic field to induce an electrical current in the brain producing depolarization of focal groups of brain cells. TMS is a protocol approved by the U.S. Food and Drug Administration in routine clinical practice as a treatment for depression. A major limitation of rTMS is the large amount of time taken for a standard protocol (38 min a day for 20–30 working days). The optimal type and duration of TMS are still uncertain, as is the optimal strategy for continuing or changing the type of rTMS if there is a poor initial response. Objectives The trial aims to assess whether a 1-week compressed course of left dorsolateral prefrontal (L DLPFC) 5 Hz accelerated rTMS (aTMS) treatment is as effective as an established 4-week course of non-accelerated rTMS and if additional 5 Hz L DLPFC aTMS treatments will be efficacious in non-responders as compared to 1 Hz right DLPFC aTMS treatment. Methods A randomized, single-blind, delayed-start trial was planned to commence in Jan 2020. A total of 60 patients will be enrolled from the Institute of Mental Health Singapore within a 2-year period and randomized into the early or delayed-start phase of the trial. The primary outcome of the trial is the improvement of Montgomery-Asberg Depression Rating scale at the end of the active treatment phase. Discussion If this study protocol proves to be effective, the findings of this trial will be updated to the College of Psychiatrists, Academy of Medicine Singapore, as well as published in a peer-reviewed journal to enhance local and international TMS treatment guidelines. Trial registration ClinicalTrials.gov ID: NCT03941106
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Affiliation(s)
- Xiao Wei Tan
- Department of Mood and Anxiety, Institute of Mental Health, 10 Buangkok View, Singapore, 539747, Singapore
| | - Edimansyah Abdin
- Research Division, Institute of Mental Health, Singapore, 539747, Singapore
| | - Phern Chern Tor
- Department of Mood and Anxiety, Institute of Mental Health, 10 Buangkok View, Singapore, 539747, Singapore. .,Neurostimulation Service, Institute of Mental Health, Singapore, 539747, Singapore. .,Duke-NUS Graduate Medical School, Singapore, 169857, Singapore.
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Enck P, Klosterhalfen S. The Placebo and Nocebo Responses in Clinical Trials in Inflammatory Bowel Diseases. Front Pharmacol 2021; 12:641436. [PMID: 33867990 PMCID: PMC8044413 DOI: 10.3389/fphar.2021.641436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/28/2021] [Indexed: 12/12/2022] Open
Abstract
Placebo and nocebo responses are mostly discussed in clinical trials with functional bowel disorders. Much less has been investigated and is known in gastrointestinal diseases beyond irritable bowel syndrome (IBS), especially in inflammatory bowel diseases (IBD). For the purpose of this review, we screened the Journal of Interdisciplinary Placebo Studies (JIPS) database with approximately 4,500 genuine placebo research articles and identified nine meta-analyses covering more than 135 randomized and placebo-controlled trials (RCTs) with more than 10,000 patients with Crohn´s disease (CD) and another five meta-analyses with 150 RCTs and more than 10,000 patients with ulcerative colitis (UC). Only three discussed nocebo effects, especially in the context of clinical use of biosimilars to treat inflammation. The articles were critically analyzed with respect to the size of the placebo response in CD and UC, its effects on clinical improvement versus maintenance of remission, and mediators and moderators of the response identified. Finally, we discussed and compared the differences and similarities of the placebo responses in IBD and IBS and the nocebo effect in switching from biologics to biosimilars in IBD management.
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Affiliation(s)
- Paul Enck
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Sibylle Klosterhalfen
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
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