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Lutz J, Offidani E, Taraboanta L, Lakhan SE, Campellone TR. Appropriate controls for digital therapeutic clinical trials: A narrative review of control conditions in clinical trials of digital therapeutics (DTx) deploying psychosocial, cognitive, or behavioral content. Front Digit Health 2022; 4:823977. [PMID: 36060538 PMCID: PMC9436387 DOI: 10.3389/fdgth.2022.823977] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Digital therapeutics (DTx) are software programs that treat a disease or condition. Increasingly, DTx are part of medical care, and in the US healthcare system they are regulated by the FDA as Software as a Medical Device (SaMD). Randomized controlled trials (RCT) remain a key evidence generation step for most DTx. However, developing a unified approach to the design of appropriate control conditions has been a challenge for two main reasons: (1) inheriting control condition definitions from pharmacotherapy and medical device RCT that may not directly apply, and (2) challenges in establishing control conditions for psychosocial interventions that build the core of many DTx. In our critical review we summarize different approaches to control conditions and patient blinding in RCT evaluating DTx with psychosocial, cognitive or behavioral content. We identify control condition choices, ranging from very minimal digital controls to more complex and stringent digital applications that contain aspects of “fake” therapy, general wellness content or games. Our review of RCTs reveals room for improvement in describing and naming control conditions more consistently. We further discuss challenges in defining placebo controls for DTx and ways in which control choices may have a therapeutic effect. While no one-size-fits-all control conditions and study designs will apply to all DTx, we propose points to consider for defining appropriate digital control conditions. At the same time, given the rapid iterative development and optimization of DTx, treatments with low risk profile may be evaluated with minimal digital controls followed by extensive real-world effectiveness trials.
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Affiliation(s)
- Jacqueline Lutz
- Medical Office, Click Therapeutics Inc., New York, NY, United States
| | - Emanuela Offidani
- Medical Office, Click Therapeutics Inc., New York, NY, United States
- Clinical Epidemiology Research in Medicine, Weill Cornell Medicine, New York, United States
| | - Laura Taraboanta
- Medical Office, Click Therapeutics Inc., New York, NY, United States
| | - Shaheen E. Lakhan
- Medical Office, Click Therapeutics Inc., New York, NY, United States
- School of Neuroscience, Virginia Tech, Blacksburg, VA, United States
- Correspondence: Shaheen E. Lakhan
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Abstract
The issue of placebo response and the extent of its effect on psychotherapy is complex for two specific reasons: i) Current standards for drug trials, e.g., true placebo interventions, double-blinding, cannot be applied to most psychotherapy techniques, and ii) some of the "nonspecific effects" in drug therapy have very specific effects in psychotherapy, such as the frequency and intensity of patient-therapist interaction. In addition, different psychotherapy approaches share many such specific effects (the "dodo bird verdict") and lack specificity with respect to therapy outcome. Here, we discuss the placebo effect in psychotherapy under four aspects: a) nonspecific factors shared with drug therapy (context factors); b) nonspecific factors shared among all psychotherapy traditions (common factors); c) specific placebo-controlled options with different psychotherapy modalities; and d) nonspecific control options for the specific placebo effect in psychotherapy. The resulting framework proposes that the exploration and enumeration of context factors, common factors, and specific factors contributes to the placebo effects in psychotherapy.
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Affiliation(s)
- Paul Enck
- Psychosomatic Medicine and Psychotherapy, Department of Internal Medicine VI, University Hospital Tübingen, Tübingen, Germany
| | - Stephan Zipfel
- Psychosomatic Medicine and Psychotherapy, Department of Internal Medicine VI, University Hospital Tübingen, Tübingen, Germany
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Evers AW, Colloca L, Blease C, Annoni M, Atlas LY, Benedetti F, Bingel U, Büchel C, Carvalho C, Colagiuri B, Crum AJ, Enck P, Gaab J, Geers AL, Howick J, Jensen KB, Kirsch I, Meissner K, Napadow V, Peerdeman KJ, Raz A, Rief W, Vase L, Wager TD, Wampold BE, Weimer K, Wiech K, Kaptchuk TJ, Klinger R, Kelley JM. Implications of Placebo and Nocebo Effects for Clinical Practice: Expert Consensus. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 87:204-210. [PMID: 29895014 PMCID: PMC6191882 DOI: 10.1159/000490354] [Citation(s) in RCA: 272] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/22/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Placebo and nocebo effects occur in clinical or laboratory medical contexts after administration of an inert treatment or as part of active treatments and are due to psychobiological mechanisms such as expectancies of the patient. Placebo and nocebo studies have evolved from predominantly methodological research into a far-reaching interdisciplinary field that is unravelling the neurobiological, behavioural and clinical underpinnings of these phenomena in a broad variety of medical conditions. As a consequence, there is an increasing demand from health professionals to develop expert recommendations about evidence-based and ethical use of placebo and nocebo effects for clinical practice. METHODS A survey and interdisciplinary expert meeting by invitation was organized as part of the 1st Society for Interdisciplinary Placebo Studies (SIPS) conference in 2017. Twenty-nine internationally recognized placebo researchers participated. RESULTS There was consensus that maximizing placebo effects and minimizing nocebo effects should lead to better treatment outcomes with fewer side effects. Experts particularly agreed on the importance of informing patients about placebo and nocebo effects and training health professionals in patient-clinician communication to maximize placebo and minimize nocebo effects. CONCLUSIONS The current paper forms a first step towards developing evidence-based and ethical recommendations about the implications of placebo and nocebo research for medical practice, based on the current state of evidence and the consensus of experts. Future research might focus on how to implement these recommendations, including how to optimize conditions for educating patients about placebo and nocebo effects and providing training for the implementation in clinical practice.
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Affiliation(s)
- Andrea W.M. Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands,*Andrea W.M. Evers, Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, PO Box 9555, NL–2300 RB Leiden (The Netherlands), E-Mail
| | - Luana Colloca
- Department of Pain Translational Symptoms Science and Anaesthesiology, School of Nursing and Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Charlotte Blease
- Department of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Marco Annoni
- Department of Institute of Biomedical Technologies, National Research Council, Rome, Italy
| | - Lauren Y. Atlas
- Department of Section on Affective Neuroscience and Pain, NIH, Bethesda, Massachusetts, USA
| | - Fabrizio Benedetti
- Department of Physiology and Neuroscience, University of Turin Medical School, Turin, Italy
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Christian Büchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Carvalho
- Department of Clinical and Health Psychology, Instituto Universitário de Ciências Psicológicas, Lisbon, Portugal
| | - Ben Colagiuri
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Alia J. Crum
- Department of Psychology, Stanford University, Stanford, California, USA
| | - Paul Enck
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Jens Gaab
- Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Andrew L. Geers
- Department of Psychology, University of Toledo, Toledo, Ohio, USA
| | - Jeremy Howick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Karin B. Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Irving Kirsch
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, Massachusetts, USA
| | - Karin Meissner
- Division of Health Promotion, University of Applied Sciences, Coburg, Germany
| | - Vitaly Napadow
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, USA
| | - Kaya J. Peerdeman
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Amir Raz
- Departments of Psychiatry, Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Marburg, Germany
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Tor D. Wager
- Department of Psychology and Neuroscience, University of Colorado, Boulder, Colorado, USA
| | - Bruce E. Wampold
- Department of Counseling Psychology, University of Wisconsin-Madison, Madison, Wisconsin, USA,Modum Bad Psychiatric Center, Vikersund, Norway
| | - Katja Weimer
- Clinic for Psychosomatic Medicine and Psychotherapy, University Hospital Ulm, Ulm, Germany
| | - Katja Wiech
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Ted J. Kaptchuk
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, Massachusetts, USA
| | - Regine Klinger
- Department of Pain Translational Symptoms Science and Anaesthesiology, School of Nursing and Medicine, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - John M. Kelley
- Beth Israel Deaconess Medical Center, Program in Placebo Studies, Boston, Massachusetts, USA
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