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Siafis S, Wu H, Nomura N, Schneider-Thoma J, Bighelli I, Lorenz C, Dib JE, Tharyan P, Calver LA, Isbister GK, Chan EWY, Knott JC, Yap CYL, Mantovani C, Martel ML, Barbic D, Honer WG, Hansen WP, Huf G, Alexander J, Raveendran NS, Coutinho ESF, Priller J, Adams CE, Salanti G, Leucht S. Effectiveness of pharmacological treatments for severe agitation in real-world emergency settings: protocol of individual-participant-data network meta-analysis. Syst Rev 2024; 13:205. [PMID: 39095865 PMCID: PMC11295517 DOI: 10.1186/s13643-024-02623-z] [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] [Received: 11/03/2023] [Accepted: 07/20/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Severe psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision. METHODS We will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach. DISCUSSION This individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42023402365.
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Affiliation(s)
- Spyridon Siafis
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany.
- German Center for Mental Health (DZPG), Partner site München/Augsburg, Munich, Germany.
| | - Hui Wu
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany
| | - Nobuyuki Nomura
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany
- German Center for Mental Health (DZPG), Partner site München/Augsburg, Munich, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Johannes Schneider-Thoma
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany
- German Center for Mental Health (DZPG), Partner site München/Augsburg, Munich, Germany
| | - Irene Bighelli
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany
- German Center for Mental Health (DZPG), Partner site München/Augsburg, Munich, Germany
| | - Carolin Lorenz
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany
| | - Joseph E Dib
- Division of Psychiatry & Applied Psychology, Institute of Mental Health, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Prathap Tharyan
- Clinical Epidemiology Unit, Christian Medical Centre, Vellore, India
| | - Leonie A Calver
- School of Nursing and Midwifery, University of Newcastle, Callaghan, NSW, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
| | - Esther W Y Chan
- Department of Pharmacology and Pharmacy, University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Science Park, Hong Kong SAR, China
- Department of Pharmacy, HKU-Shenzhen Hospital, Shenzhen, China
- HKU-SZ Institute of Research and Innovation (SIRI), Shenzhen, China
| | - Jonathan C Knott
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Celene Y L Yap
- Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Célia Mantovani
- Department of Neurosciences and Behavior, Ribeirao Preto School of Medicine, Universidade de Sao Paulo, São Paulo, Brazil
| | - Marc L Martel
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | | | - Gisele Huf
- National Institute of Quality Control in Health, Oswaldo Cruz Foundation, Av. Brasil 4365, Manguinhos, Rio de Janeiro, Brazil
| | | | - Nirmal S Raveendran
- Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
| | - Evandro S F Coutinho
- Department of Epidemiology, Institute of Social Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Josef Priller
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany
- German Center for Mental Health (DZPG), Partner site München/Augsburg, Munich, Germany
- Neuropsychiatry and Laboratory of Molecular Psychiatry, Charité - Universitätsmedizin Berlin and DZNE, Berlin, Germany
- University of Edinburgh and UK DRI, Edinburgh, UK
| | - Clive E Adams
- Institute of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Stefan Leucht
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Munich, Germany
- German Center for Mental Health (DZPG), Partner site München/Augsburg, Munich, Germany
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Peng TR, Lin HH, Lee MC, Chen SM. Statins as an adjuvant therapy for patients with schizophrenia: An up-to-date systematic review and meta-analysis. Gen Hosp Psychiatry 2024; 89:75-83. [PMID: 38824832 DOI: 10.1016/j.genhosppsych.2024.05.001] [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] [Received: 11/20/2023] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Evidence suggests that inflammatory processes play a role in the pathophysiology of schizophrenia. Statins exert anti-inflammatory and antioxidant effects and may be effective in improving the symptoms of schizophrenia. This study explored whether statins, as an adjunctive therapy, can alleviate the symptoms of schizophrenia. METHODS PubMed, EMBASE, and the Cochrane Library were searched for articles published up to March 2023. The risk-of-bias tool for randomized trials was used to assess study quality. Two researchers independently assessed the risks of bias and extracted data. Pooled data on Positive and Negative Syndrome Scale (PANSS) scores were analyzed. A random-effects model was employed to calculate pooled effect sizes. Statistical heterogeneity across studies was assessed using the I2 statistic. All analyses were performed using RevMan5 and Comprehensive Meta-Analysis software. RESULTS Nine trials enrolling 533 patients in total were included. Add-on statin therapy was found to be associated with a significantly better total PANSS score [standardized mean difference (SMD) = -0.42, 95% confidence interval (CI) -0.75 to -0.09, I2 = 72%; P = 0.01] and PANSS negative subscale score (SMD = -0.26, 95% CI -0.45 to -0.07, I2 = 0%; P = 0.009) in comparison with placebo. However, add-on statin therapy did not appear to improve scores for the PANSS positive and general subscales at the study-defined endpoint (6-24 weeks). CONCLUSIONS Our meta-analysis indicates that adjunctive statin therapy may confer benefits in ameliorating PANSS negative and total scores. It needs more solid data to confirm the results are related to clinical improvement and functioning.
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Affiliation(s)
- Tzu-Rong Peng
- Department of Pharmacy, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Hung-Hong Lin
- Department of Pharmacy, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ming-Chia Lee
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan; Department of Pharmacy, New Taipei City Hospital, New Taipei City, Taiwan; Department of Nursing, Cardinal Tien College of Healthcare and Management, Taipei, Taiwan.
| | - Shih-Ming Chen
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan.
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3
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Heimke F, Furukawa Y, Siafis S, Johnston BC, Engel RR, Furukawa TA, Leucht S. Understanding effect size: an international online survey among psychiatrists, psychologists, physicians from other medical specialities, dentists and other health professionals. BMJ MENTAL HEALTH 2024; 27:e300978. [PMID: 38388002 PMCID: PMC10882338 DOI: 10.1136/bmjment-2023-300978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND OBJECTIVE Various ways exist to display the effectiveness of medical treatment options. This study examined various psychiatric, medical and allied professionals' understanding and perceived usefulness of eight effect size indices for presenting both dichotomous and continuous outcome data. METHODS We surveyed 1316 participants from 13 countries using an online questionnaire. We presented hypothetical treatment effects of interventions versus placebo concerning chronic pain using eight different effect size measures. For each index, the participants had to judge the magnitude of the shown effect, to indicate how certain they felt about their own answer and how useful they found the given effect size index. FINDINGS Overall, 762 (57.9%) participants fully completed the questionnaire. In terms of understanding, the best results emerged when both the control event rate (CER) and the experimental event rate (EER) were presented. The difference in minimal importance difference units (MID unit) was understood worst. Respondents also found CER and EER to be the most useful presentation approach while they rated MID unit as the least useful. Confidence in the risk ratio ranked high, even though it was rather poorly understood. CONCLUSIONS AND CLINICAL IMPLICATIONS For dichotomous outcomes, presenting the effects in terms of the CER and EER could lead to the most correct interpretation. Relative measures including the risk ratio must be supplemented with absolute measures such as the CER and EER. Effects on continuous outcomes were better understood through standardised mean differences than mean differences. These can also be supplemented by dichotomised CER and EER.
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Affiliation(s)
- Ferdinand Heimke
- Department of Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Bavaria, Germany
| | - Yuki Furukawa
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Bavaria, Germany
- German Center for Mental Health (DZPG), partner site München/Augsburg, Munich, Germany
| | - Bradley C Johnston
- Department of Nutrition, College of Agriculture and Life Sciences, Texas A&M University, College Station, Texas, USA
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, Texas, USA
| | - Rolf R Engel
- Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität München, Munich, Bavaria, Germany
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Bavaria, Germany
- German Center for Mental Health (DZPG), partner site München/Augsburg, Munich, Germany
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4
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Tandon R, Nasrallah H, Akbarian S, Carpenter WT, DeLisi LE, Gaebel W, Green MF, Gur RE, Heckers S, Kane JM, Malaspina D, Meyer-Lindenberg A, Murray R, Owen M, Smoller JW, Yassin W, Keshavan M. The schizophrenia syndrome, circa 2024: What we know and how that informs its nature. Schizophr Res 2024; 264:1-28. [PMID: 38086109 DOI: 10.1016/j.schres.2023.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 03/01/2024]
Abstract
With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.
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Affiliation(s)
- Rajiv Tandon
- Department of Psychiatry, WMU Homer Stryker School of Medicine, Kalamazoo, MI 49008, United States of America.
| | - Henry Nasrallah
- Department of Psychiatry, University of Cincinnati College of Medicine Cincinnati, OH 45267, United States of America
| | - Schahram Akbarian
- Department of Psychiatry, Icahn School of Medicine at Mt. Sinai, New York, NY 10029, United States of America
| | - William T Carpenter
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Lynn E DeLisi
- Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA 02139, United States of America
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, LVR-Klinikum Dusseldorf, Heinrich-Heine University, Dusseldorf, Germany
| | - Michael F Green
- Department of Psychiatry and Biobehavioral Sciences, Jane and Terry Semel Institute of Neuroscience and Human Behavior, UCLA, Los Angeles, CA 90024, United States of America; Greater Los Angeles Veterans' Administration Healthcare System, United States of America
| | - Raquel E Gur
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States of America
| | - Stephan Heckers
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN 37232, United States of America
| | - John M Kane
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Glen Oaks, NY 11004, United States of America
| | - Dolores Malaspina
- Department of Psychiatry, Neuroscience, Genetics, and Genomics, Icahn School of Medicine at Mt. Sinai, New York, NY 10029, United States of America
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannhein/Heidelberg University, Mannheim, Germany
| | - Robin Murray
- Institute of Psychiatry, Psychology, and Neuroscience, Kings College, London, UK
| | - Michael Owen
- Centre for Neuropsychiatric Genetics and Genomics, and Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - Jordan W Smoller
- Center for Precision Psychiatry, Department of Psychiatry, Psychiatric and Neurodevelopmental Unit, Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States of America
| | - Walid Yassin
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States of America
| | - Matcheri Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, United States of America
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Davidson M, Carpenter WT. Targeted Treatment of Schizophrenia Symptoms as They Manifest, or Continuous Treatment to Reduce the Risk of Psychosis Recurrence. Schizophr Bull 2024; 50:14-21. [PMID: 37929893 PMCID: PMC10754173 DOI: 10.1093/schbul/sbad145] [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: 11/07/2023]
Abstract
Current pharmacological treatment of schizophrenia employs drugs that interfere with dopamine neurotransmission, aiming to suppress acute exacerbation of psychosis and maintenance treatment to reduce the risk of psychosis recurrence. According to this treatment scheme, available psychotropic drugs intended to treat negative symptoms, cognitive impairment, or anxiety are administered as add-ons to treatment with antipsychotics. However, an alternative treatment scheme proposes a targeted or intermittent treatment approach, by which antipsychotic drugs are administered upon psychosis exacerbation and discontinued upon remission or stabilization, while negative symptoms, cognitive impairment, or anxiety are treated with specific psychotropics as monotherapy. Along these lines, antipsychotics are renewed only in the event of recurrence of psychotic symptoms. This 50-year-old debate between targeted and continuous treatment schemes arises from disagreements about interpreting scientific evidence and discordant views regarding benefit/risk assessment. Among the debate's questions are: (1) what is the percentage of individuals who can maintain stability without antipsychotic maintenance treatment, and what is the percentage of those who exacerbate despite antipsychotic treatment? (2) how to interpret results of placebo-controlled 9- to 18-month-long maintenance trials in a life-long chronic disorder, and how to interpret results of the targeted trials, some of which are open label or not randomized; (3) how to weigh the decreased risk for psychotic recurrence vs the almost certainty of adverse effects on patient's quality of life. Patients' profiles, preferences, and circumstances of the care provision should be considered as the targeted vs continuous treatment options are considered.
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Affiliation(s)
- Michael Davidson
- Department of Basic and Clinical Sciences, Psychiatry, University of Nicosia Medical School, 2414, Nicosia, Cyprus and Minerva Neurosciences, 1500 District Avenue, Burlington, MA 01803, USA
| | - William T Carpenter
- University of Maryland School of Medicine, Department of Psychiatry, Maryland Psychiatric Research Center, Baltimore, MD, USA
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Yildiz A, Siafis S, Mavridis D, Vieta E, Leucht S. Comparative efficacy and tolerability of pharmacological interventions for acute bipolar depression in adults: a systematic review and network meta-analysis. Lancet Psychiatry 2023; 10:693-705. [PMID: 37595997 DOI: 10.1016/s2215-0366(23)00199-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Bipolar depression constitutes a major public health problem due to its substantial burden of disease. Although pharmacological interventions are available, guidelines required updated evidence synthesis to improve their current recommendations. In order to inform evidence-based prescribing, we investigated the comparative efficacy and tolerability of pharmacological interventions for acute bipolar depression. METHODS We conducted a systematic review and network meta-analysis. We searched for randomised controlled trials comparing pharmacological interventions with each other or placebo in adults with acute bipolar depression (type I, type II, or not otherwise specified), excluding those with substance misuse, unipolar depression, or schizophrenia, in MEDLINE, Embase, PsycINFO, Google Scholar, Cochrane Library, Web of Knowledge, CINAHL, and LILACS from database inception up to April 13, 2023. Criteria for eligibility were a duration of 2-16 weeks with masked outcome assessments, and we included combination, add-on design, and monotherapy studies. The co-primary outcomes were depressive symptoms, examined with standardised mean differences (SMDs), and manic switch, examined with odds ratios (ORs). We also investigated dropouts due to any reason, inefficacy, adverse events, and important side-effects as secondary outcomes. The confidence in the evidence was evaluated using Confidence-In-Network-Meta-Analysis (CINeMA). The study was registered with PROSPERO, CRD42020171726. RESULTS We analysed data from 101 randomised controlled trials covering 20 081 participants, 8063 men (41·7%) and 11 263 women (58·3%; sex not available in four studies), mean age 41·0 years (range of means 28·7-53·6 years), and 68 medications and placebo. Ethnicity data were not available. With moderate confidence in the evidence, olanzapine plus fluoxetine, quetiapine, olanzapine, lurasidone, lumateperone, cariprazine, and lamotrigine were more efficacious than placebo in reducing depressive symptoms, with SMDs ranging from 0·41 (95% CI 0·19-0·64) for olanzapine plus fluoxetine to 0·16 (0·03-0·29) for lamotrigine. Several other drugs might also be efficacious, but the confidence in the evidence was very low to low. Antidepressants as a class seem to be efficacious, but had a higher risk for manic switch compared to antipsychotics. Medications differed in their side-effect profiles. INTERPRETATION This is, to our knowledge, the largest network meta-analysis of pharmacotherapy for bipolar depression to date. Olanzapine plus fluoxetine, quetiapine, olanzapine, lurasidone, lumateperone, cariprazine, and lamotrigine were found to be more efficacious than placebo in adults with acute bipolar depression, with good confidence in the evidence, and to differ in their side-effect profiles. These findings can inform evidence-based care and the development of treatment guidelines internationally. FUNDING None.
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Affiliation(s)
- Ayşegül Yildiz
- Department of Psychiatry, Dokuz Eylül University, Izmir, Turkey
| | - Spyridon Siafis
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Eduard Vieta
- Bipolar Disorders Program, Institute of Clinical Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Stefan Leucht
- Section for Evidence-Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
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7
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Siafis S, McCutcheon R, Chiocchia V, Ostinelli EG, Wright S, Stansfield C, Juma DO, Mantas I, Howes OD, Rutigliano G, Ramage F, Tinsdeall F, Friedrich C, Milligan L, Moreno C, Elliott JH, Thomas J, Macleod MR, Sena ES, Seedat S, Salanti G, Potts J, Cipriani A, Leucht S. Trace amine-associated receptor 1 (TAAR1) agonists for psychosis: protocol for a living systematic review and meta-analysis of human and non-human studies. Wellcome Open Res 2023; 8:365. [PMID: 38634067 PMCID: PMC11021884 DOI: 10.12688/wellcomeopenres.19866.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND There is an urgent need to develop more effective and safer antipsychotics beyond dopamine 2 receptor antagonists. An emerging and promising approach is TAAR1 agonism. Therefore, we will conduct a living systematic review and meta-analysis to synthesize and triangulate the evidence from preclinical animal experiments and clinical studies on the efficacy, safety, and underlying mechanism of action of TAAR1 agonism for psychosis. METHODS Independent searches will be conducted in multiple electronic databases to identify clinical and animal experimental studies comparing TAAR1 agonists with licensed antipsychotics or other control conditions in individuals with psychosis or animal models for psychosis, respectively. The primary outcomes will be overall psychotic symptoms and their behavioural proxies in animals. Secondary outcomes will include side effects and neurobiological measures. Two independent reviewers will conduct study selection, data extraction using predefined forms, and risk of bias assessment using suitable tools based on the study design. Ontologies will be developed to facilitate study identification and data extraction. Data from clinical and animal studies will be synthesized separately using random-effects meta-analysis if appropriate, or synthesis without meta-analysis. Study characteristics will be investigated as potential sources of heterogeneity. Confidence in the evidence for each outcome and source of evidence will be evaluated, considering the summary of the association, potential concerns regarding internal and external validity, and reporting biases. When multiple sources of evidence are available for an outcome, an overall conclusion will be drawn in a triangulation meeting involving a multidisciplinary team of experts. We plan trimonthly updates of the review, and any modifications in the protocol will be documented. The review will be co-produced by multiple stakeholders aiming to produce impactful and relevant results and bridge the gap between preclinical and clinical research on psychosis. PROTOCOL REGISTRATION PROSPERO-ID: CRD42023451628.
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Robert McCutcheon
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England, UK
| | - Virginia Chiocchia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Canton of Bern, Switzerland
| | - Edoardo G. Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | - Simonne Wright
- Department of Psychiatry, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Claire Stansfield
- EPPI Centre, Social Research Institute, University College London, London, England, UK
| | | | - Ioannis Mantas
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Oliver D. Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England, UK
| | - Grazia Rutigliano
- Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, England, UK
| | - Fiona Ramage
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Francesca Tinsdeall
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Claire Friedrich
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | | | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense de Madrid, Madrid, Community of Madrid, Spain
| | - Julian H. Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Future Evidence Foundation, Melbourne, Australia
| | - James Thomas
- EPPI Centre, Social Research Institute, University College London, London, England, UK
| | - Malcolm R. Macleod
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Emily S. Sena
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Canton of Bern, Switzerland
| | - Jennifer Potts
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - the GALENOS team
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England, UK
- Institute of Social and Preventive Medicine, University of Bern, Bern, Canton of Bern, Switzerland
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
- Department of Psychiatry, Stellenbosch University, Stellenbosch, Western Cape, South Africa
- EPPI Centre, Social Research Institute, University College London, London, England, UK
- My Mind Our Humanity, Mombasa, Kenya
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, England, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- MQ Mental Health Research, London, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense de Madrid, Madrid, Community of Madrid, Spain
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Future Evidence Foundation, Melbourne, Australia
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8
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Ostinelli EG, Efthimiou O, Naci H, Furukawa TA, Leucht S, Salanti G, Wainwright L, Zangani C, De Crescenzo F, Smith K, Stevens K, Liu Q, Cipriani A. Vitruvian plot: a visualisation tool for multiple outcomes in network meta-analysis. EVIDENCE-BASED MENTAL HEALTH 2022; 25:e65-e70. [PMID: 35613849 PMCID: PMC9811072 DOI: 10.1136/ebmental-2022-300457] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/10/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE A network meta-analysis (NMA) usually assesses multiple outcomes across several treatment comparisons. The Vitruvian plot aims to facilitate communication of multiple outcomes from NMAs to patients and clinicians. METHODS We developed this tool following the recommendations on the communication of benefit-risk information from the available literature. We collected and implemented feedback from researchers, statisticians, methodologists, clinicians and people with lived experience of physical and mental health issues. RESULTS We present the Vitruvian plot, which graphically presents absolute estimates and relative performance of competing interventions against a common comparator for several outcomes of interest. We use two alternative colour schemes to highlight either the strength of statistical evidence or the confidence in the evidence. Confidence in the evidence is evaluated across six domains (within-study bias, reporting bias, indirectness, imprecision, heterogeneity and incoherence) using the Confidence in Network Meta-Analysis (CINeMA) system. CONCLUSIONS The Vitruvian plot allows reporting of multiple outcomes from NMAs, with colourings appropriate to inform credibility of the presented evidence.
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Affiliation(s)
- Edoardo Giuseppe Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Orestis Efthimiou
- Department of Psychiatry, University of Oxford, Oxford, UK,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, School of Public Health, Kyoto, Japan
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Munchen, Germany
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Laurence Wainwright
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Caroline Zangani
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Franco De Crescenzo
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Katharine Smith
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Katherine Stevens
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Qiang Liu
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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9
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Siafis S, Bursch N, Müller K, Schmid L, Schuster F, Waibel J, Huynh T, Matthes F, Rodolico A, Brieger P, Bühner M, Heres S, Leucht S, Hamann J. Evidence-based Shared-Decision-Making Assistant (SDM-assistant) for choosing antipsychotics: protocol of a cluster-randomized trial in hospitalized patients with schizophrenia. BMC Psychiatry 2022; 22:406. [PMID: 35715740 PMCID: PMC9204887 DOI: 10.1186/s12888-022-04036-5] [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: 05/03/2022] [Accepted: 06/01/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Choosing an antipsychotic medication is an important medical decision in the treatment of schizophrenia. This decision requires risk-benefit assessments of antipsychotics, and thus, shared-decision making between physician and patients is strongly encouraged. Although the efficacy and side-effect profiles of antipsychotics are well-established, there is no clear framework for the communication of the evidence between physicians and patients. For this reason, we developed an evidence-based shared-decision making assistant (SDM-assistant) that presents high-quality evidence from network meta-analysis on the efficacy and side-effect profile of antipsychotics and can be used as a basis for shared-decision making between physicians and patients when selecting antipsychotic medications. METHODS The planned matched-pair cluster-randomised trial will be conducted in acute psychiatric wards (n = 14 wards planned) and will include adult inpatients with schizophrenia or schizophrenia-like disorders (N = 252 participants planned). On the intervention wards, patients and their treating physicians will use the SDM-assistant, whenever a decision on choosing an antipsychotic is warranted. On the control wards, antipsychotics will be chosen according to treatment-as-usual. The primary outcome will be patients' perceived involvement in the decision-making during the inpatient stay as measured with the SDM-Q-9. We will also assess therapeutic alliance, symptom severity, side-effects, treatment satisfaction, adherence, quality of life, functioning and rehospitalizations as secondary outcomes. Outcomes could be analysed at discharge and at follow-up after three months from discharge. The analysis will be conducted per-protocol using mixed-effects linear regression models for continuous outcomes and logistic regression models using generalised estimating equations for dichotomous outcomes. Barriers and facilitators in the implementation of the intervention will also be examined using a qualitative content analysis. DISCUSSION This is the first trial to examine a decision assistant specifically designed to facilitate shared-decision making for choosing antipsychotic medications, i.e., SDM-assistant, in acutely ill inpatients with schizophrenia. If the intervention can be successfully implemented, SDM-assistant could advance evidence-based medicine in schizophrenia by putting medical evidence on antipsychotics into the context of patient preferences and values. This could subsequently lead to a higher involvement of the patients in decision-making and better therapy decisions. TRIAL REGISTRATION German Clinical Trials Register (ID: DRKS00027316 , registration date 26.01.2022).
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
| | - Nicola Bursch
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Lisa Schmid
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Jakob Waibel
- Department of Informatics, Technical University of Munich, Munich, Germany
| | - Tri Huynh
- Department of Informatics, Technical University of Munich, Munich, Germany
| | - Florian Matthes
- Department of Informatics, Technical University of Munich, Munich, Germany
| | - Alessandro Rodolico
- Department of Clinical and Experimental Medicine, Institute of Psychiatry, University of Catania, Catania, Italy
| | | | - Markus Bühner
- Psychological Methodology and Diagnostics, Ludwig Maximilian University, Munich, Germany
| | | | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johannes Hamann
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
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