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Fava M. How should we design future mechanistic and/or efficacy clinical trials? Neuropsychopharmacology 2024; 49:197-204. [PMID: 37237086 PMCID: PMC10700333 DOI: 10.1038/s41386-023-01600-9] [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: 02/28/2023] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023]
Abstract
The emergence of new molecular targets, together with the development of new approaches to neuropsychiatric diseases, involving psychedelics as well as gene and cell therapies, are creating the need to improve the efficiency of mechanistic and/or efficacy clinical trials. This review article will discuss a number of issues that have hampered our ability to detect therapeutic signals, from excessive placebo/sham response rates to the imprecision of diagnostic and outcome assessments. In addition to reviewing the limitations of current efficacy and mechanistic neuropsychiatric clinical trials, this review presents some of the methodological approaches that may improve the overall performance of our neuropsychiatric trials, including the adoption of novel study designs such as the sequential parallel comparison design and independent confirmation of the appropriateness of subjects' enrollment. In addition, this review will discuss several designs that make mechanistic clinical trials more precise.
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Affiliation(s)
- Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
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Tabuteau H, Jones A, Anderson A, Jacobson M, Iosifescu DV. Effect of AXS-05 (Dextromethorphan-Bupropion) in Major Depressive Disorder: A Randomized Double-Blind Controlled Trial. Am J Psychiatry 2022; 179:490-499. [PMID: 35582785 DOI: 10.1176/appi.ajp.21080800] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Altered glutamatergic neurotransmission is implicated in the pathogenesis of major depressive disorder. AXS-05 (dextromethorphan-bupropion) is an oral NMDA receptor antagonist and sigma-1 receptor agonist, which utilizes inhibition of CYP2D6 to increase its bioavailability. This phase 2 trial assessed the efficacy and safety of dextromethorphan-bupropion in the treatment of major depressive disorder. METHODS This randomized, double-blind, multicenter, parallel-group trial evaluated dextromethorphan-bupropion versus the active comparator sustained-release bupropion in patients 18-65 years old with a diagnosis of major depressive disorder of moderate or greater severity. Patients were randomly assigned to receive either dextromethorphan-bupropion (45 mg/105 mg tablet) or bupropion (105 mg tablet), once daily for the first 3 days and twice daily thereafter, for a total of 6 weeks. The primary endpoint was overall treatment effect on Montgomery-Åsberg Depression Rating Scale (MADRS) score (average of the change from baseline for weeks 1-6), assessed in all randomized patients whose diagnosis and severity were confirmed by an independent assessor and who received at least one dose of study medication and had at least one postbaseline assessment. RESULTS Of 97 patients randomized, 17 did not have a confirmed diagnosis and severity based on the independent assessment, resulting in 80 patients in the efficacy population (dextromethorphan-bupropion, N=43; bupropion, N=37). The mean change from baseline in MADRS score over weeks 1-6 (overall treatment effect) was significantly greater with dextromethorphan-bupropion than with bupropion (-13.7 points vs. -8.8 points; least-squares mean difference=-4.9; 95% CI=-3.1, -6.8). MADRS score change with dextromethorphan-bupropion was significantly greater than with bupropion at week 2 and every time point thereafter (week 6: -17.3 vs. -12.1 points; least-squares mean difference=-5.2, 95% CI=-1.1, -9.3). Remission rates were significantly greater with dextromethorphan-bupropion at week 2 and every time point thereafter (week 6: 46.5% vs. 16.2%; least-squares mean difference=30.3%, 95% CI=11.2, 49.4). Response rates (≥50% decrease in MADRS score from baseline) at week 6 were 60.5% with dextromethorphan-bupropion and 40.5% with bupropion (least-squares mean difference=19.9%, 95% CI=-1.6, 41). Most secondary outcomes favored dextromethorphan-bupropion. The most common adverse events with dextromethorphan-bupropion were dizziness, nausea, dry mouth, decreased appetite, and anxiety. Dextromethorphan-bupropion was not associated with psychotomimetic effects, weight gain, or sexual dysfunction. CONCLUSIONS In patients with major depression, dextromethorphan-bupropion (AXS-05) significantly improved depressive symptoms compared with bupropion and was generally well tolerated.
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Affiliation(s)
- Herriot Tabuteau
- Axsome Therapeutics, Inc., New York (Tabuteau, Jones, Anderson, Jacobson); Nathan Kline Institute and New York University School of Medicine, New York (Iosifescu)
| | - Amanda Jones
- Axsome Therapeutics, Inc., New York (Tabuteau, Jones, Anderson, Jacobson); Nathan Kline Institute and New York University School of Medicine, New York (Iosifescu)
| | - Ashley Anderson
- Axsome Therapeutics, Inc., New York (Tabuteau, Jones, Anderson, Jacobson); Nathan Kline Institute and New York University School of Medicine, New York (Iosifescu)
| | - Mark Jacobson
- Axsome Therapeutics, Inc., New York (Tabuteau, Jones, Anderson, Jacobson); Nathan Kline Institute and New York University School of Medicine, New York (Iosifescu)
| | - Dan V Iosifescu
- Axsome Therapeutics, Inc., New York (Tabuteau, Jones, Anderson, Jacobson); Nathan Kline Institute and New York University School of Medicine, New York (Iosifescu)
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3
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Impact of chosen cutoff on response rate differences between selective serotonin reuptake inhibitors and placebo. Transl Psychiatry 2022; 12:160. [PMID: 35422023 PMCID: PMC9010419 DOI: 10.1038/s41398-022-01882-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 02/20/2022] [Accepted: 03/02/2022] [Indexed: 12/04/2022] Open
Abstract
Response defined as a 50% reduction in the sum score of the Hamilton Depression Rating Scale (HDRS-17-sum) is often used to assess the efficacy of antidepressants. Critics have, however, argued that dichotomising ratings with a cutoff close to the median may lead to scores clustering on either side, the result being inflation of miniscule drug-placebo differences. Using pooled patient-level data sets from trials of three selective serotonin reuptake inhibitors (SSRIs) (citalopram, paroxetine and sertraline) (n = 7909), and from similar trials of duloxetine (n = 3478), we thus assessed the impact of different cutoffs on response rates. Response criteria were based on (i) HDRS-17-sum, (ii) the sum score of the HDRS-6 subscale (HDRS-6-sum) and (iii) the depressed mood item. The separation between SSRI and placebo with respect to response rates increased when HDRS-17-sum was replaced by HDRS-6-sum or depressed mood as effect parameter and was markedly dependent on SSRI dose. With the exception of extreme cutoff values, differences in response rates were largely similar regardless of where the cutoff was placed, and also not markedly changed by the exclusion of subjects close to the selected cutoff (e.g., ±10%). The observation of similar response rate differences between active drugs and placebo for different cutoffs was corroborated by the analysis of duloxetine data. In conclusion, the suggestion that using a cutoff close to the median when defining response has markedly overestimated the separation between antidepressants and placebo may be discarded.
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4
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Hieronymus F, Jauhar S, Østergaard SD, Young AH. One (effect) size does not fit at all: Interpreting clinical significance and effect sizes in depression treatment trials. J Psychopharmacol 2020; 34:1074-1078. [PMID: 32448035 PMCID: PMC7543017 DOI: 10.1177/0269881120922950] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The efficacy of antidepressants in major depressive disorder has been continually questioned, mainly on the basis of studies using the sum-score of the Hamilton Depression Rating Scale as a primary outcome parameter. On this measure antidepressants show a standardised mean difference of around 0.3, which some authors suggested is below the cut-off for clinical significance. Prompted by a recent review that, using this argument, concluded antidepressants should not be used for adults with major depressive disorder, we (a) review the evidence in support of the cut-off for clinical significance espoused in that article (a Hamilton Depression Rating Scale standardised mean difference of 0.875); (b) discuss the limitations of average Hamilton Depression Rating Scale sum-score differences between groups as measure of clinical significance; (c) explore alternative measures of clinical importance; and (d) suggest future directions to help overcome disagreements on how to define clinical significance. We conclude that (a) the proposed Hamilton Depression Rating Scale cut-off of 0.875 has no scientific basis and is likely misleading; (b) there is no agreed upon way of delineating clinically significant from clinically insignificant; (c) evidence suggests the Hamilton Depression Rating Scale sum-score underestimates antidepressant efficacy; and (d) future clinical trials should consider including measures directly reflective of functioning and wellbeing, in addition to measures focused on depression psychopathology.
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Affiliation(s)
- Fredrik Hieronymus
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark,Department of Affective Disorders, Aarhus University Hospital, Aarhus N, Denmark,Fredrik Hieronymus, Department of Affective Disorders, Aarhus University Hospital, Palle Juul-Jensens Boulevard 175, Aarhus N, 8200, Denmark.
| | - Sameer Jauhar
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Søren Dinesen Østergaard
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark,Department of Affective Disorders, Aarhus University Hospital, Aarhus N, Denmark
| | - Allan H Young
- Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom,South London and Maudsley NHS Foundation Trust, London, United Kingdom
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5
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Smith SM, Fava M, Jensen MP, Mbowe OB, McDermott MP, Turk DC, Dworkin RH. John D. Loeser Award Lecture: Size does matter, but it isn't everything: the challenge of modest treatment effects in chronic pain clinical trials. Pain 2020; 161 Suppl 1:S3-S13. [PMID: 33090735 PMCID: PMC7434212 DOI: 10.1097/j.pain.0000000000001849] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Shannon M. Smith
- Departments of Anesthesiology and Perioperative Medicine
- Obstetrics and Gynecology and
- Psychiatry, University of Rochester, Rochester, NY, United States
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Mark P. Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Omar B. Mbowe
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
- Department of Neurology, University of Rochester, Rochester, NY, United States
- Center for Health + Technology, University of Rochester, Rochester, NY, United States
| | - Dennis C. Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Robert H. Dworkin
- Departments of Anesthesiology and Perioperative Medicine
- Psychiatry, University of Rochester, Rochester, NY, United States
- Department of Neurology, University of Rochester, Rochester, NY, United States
- Center for Health + Technology, University of Rochester, Rochester, NY, United States
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Gewandter JS, Dworkin RH, Turk DC, Devine EG, Hewitt D, Jensen MP, Katz NP, Kirkwood AA, Malamut R, Markman JD, Vrijens B, Burke L, Campbell JN, Carr DB, Conaghan PG, Cowan P, Doyle MK, Edwards RR, Evans SR, Farrar JT, Freeman R, Gilron I, Juge D, Kerns RD, Kopecky EA, McDermott MP, Niebler G, Patel KV, Rauck R, Rice ASC, Rowbotham M, Sessler NE, Simon LS, Singla N, Skljarevski V, Tockarshewsky T, Vanhove GF, Wasan AD, Witter J. Improving Study Conduct and Data Quality in Clinical Trials of Chronic Pain Treatments: IMMPACT Recommendations. THE JOURNAL OF PAIN 2020; 21:931-942. [PMID: 31843583 PMCID: PMC7292738 DOI: 10.1016/j.jpain.2019.12.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/30/2019] [Accepted: 12/11/2019] [Indexed: 11/30/2022]
Abstract
The estimated probability of progressing from phase 3 analgesic clinical trials to regulatory approval is approximately 57%, suggesting that a considerable number of treatments with phase 2 trial results deemed sufficiently successful to progress to phase 3 do not yield positive phase 3 results. Deficiencies in the quality of clinical trial conduct could account for some of this failure. An Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials meeting was convened to identify potential areas for improvement in trial conduct in order to improve assay sensitivity (ie, ability of trials to detect a true treatment effect). We present recommendations based on presentations and discussions at the meeting, literature reviews, and iterative revisions of this article. The recommendations relate to the following areas: 1) study design (ie, to promote feasibility), 2) site selection and staff training, 3) participant selection and training, 4) treatment adherence, 5) data collection, and 6) data and study monitoring. Implementation of these recommendations may improve the quality of clinical trial data and thus the validity and assay sensitivity of clinical trials. Future research regarding the effects of these strategies will help identify the most efficient use of resources for conducting high quality clinical trials. PERSPECTIVE: Every effort should be made to optimize the quality of clinical trial data. This manuscript discusses considerations to improve conduct of pain clinical trials based on research in multiple medical fields and the expert consensus of pain researchers and stakeholders from academia, regulatory agencies, and industry.
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Affiliation(s)
| | | | | | | | | | | | - Nathaniel P Katz
- Analgesic Solutions, Natick, Massachusetts; Tufts University, Boston, Massachusetts
| | - Amy A Kirkwood
- CR UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK
| | | | - John D Markman
- University of Rochester Medical Center, Rochester, New York
| | | | | | | | - Daniel B Carr
- Tufts University School of Medicine, Boston, Massachusetts
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, California
| | | | | | - Scott R Evans
- George Washington University, Washington, District of Columbia
| | - John T Farrar
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roy Freeman
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Ian Gilron
- Queen's University, Kingston, Ontario, Canada
| | - Dean Juge
- Horizon Pharma, Lake Forest, Illinois
| | | | | | | | | | | | - Richard Rauck
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Neil Singla
- Lotus Clinical Research, Pasadena, California
| | | | | | | | - Ajay D Wasan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James Witter
- National Institutes of Health, Bethesda, Maryland
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Krol FJ, Hagin M, Vieta E, Harazi R, Lotan A, Strous RD, Lerer B, Popovic D. Placebo-To be or not to be? Are there really alternatives to placebo-controlled trials? Eur Neuropsychopharmacol 2020; 32:1-11. [PMID: 31959380 DOI: 10.1016/j.euroneuro.2019.12.117] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 12/19/2022]
Abstract
Recent success of established treatment has driven concerns about the ethics of using placebo-controlled trials in psychiatry. Active-controlled (superiority or non-inferiority) trials do not include a placebo-arm and thus avoid the associated ethical concerns but show disadvantages in other respects. The aim of this paper is to review the available literature and critically discuss the evidence regarding the use of placebo-controlled- versus active-controlled trials. A MEDLINE/PubMed and Google Scholar search was performed. Studies included focused on the deliberation on placebo-controlled- versus active-controlled trials. Twenty-six studies were included. The most cited benefits of placebo-controlled trials were greater scientific reliability of the results and no average impact on patients' health. Disadvantages were mainly related to withholding effective treatment and limited generalizability. The most frequent argument in favor of active-controlled trials is the lower chance of receiving ineffective medication during the trial. Downsides include larger sample sizes, higher costs and lower scientific reliability of results. Most authors agree that all trial designs are relevant to psychiatric research depending on study goals. Whatsoever, data does not support forgoing placebo-controlled trials. Expert consensus is warranted to permit drawing conclusions on the debate on the relevance of placebo-controlled trials.
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Affiliation(s)
- Fas Jacob Krol
- Leiden University Medical Center, the Netherlands; Bipolar Disorders Program, Sheba Medical Center, 52621 Ramat Gan, Israel
| | - Michal Hagin
- Bipolar Disorders Program, Sheba Medical Center, 52621 Ramat Gan, Israel
| | - Eduard Vieta
- Bipolar and Depressive Disorders Program, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Rephael Harazi
- Bipolar Disorders Program, Sheba Medical Center, 52621 Ramat Gan, Israel
| | - Amit Lotan
- Biological Psychiatry Laboratory Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Rael D Strous
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Maayenei Hayeshua Medical Center
| | - Bernard Lerer
- Biological Psychiatry Laboratory Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Dina Popovic
- Bipolar Disorders Program, Sheba Medical Center, 52621 Ramat Gan, Israel.
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Thase ME, Mahableshwarkar AR, Dragheim M, Loft H, Vieta E. A meta-analysis of randomized, placebo-controlled trials of vortioxetine for the treatment of major depressive disorder in adults. Eur Neuropsychopharmacol 2016; 26:979-93. [PMID: 27139079 DOI: 10.1016/j.euroneuro.2016.03.007] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 03/09/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
Abstract
The efficacy and safety of vortioxetine, an antidepressant approved for the treatment of adults with major depressive disorder (MDD), was studied in 11 randomized, double-blind, placebo-controlled trials of 6/8 weeks׳ treatment duration. An aggregated study-level meta-analysis was conducted to estimate the magnitude and dose-relationship of the clinical effect of approved doses of vortioxetine (5-20mg/day). The primary outcome measure was change from baseline to endpoint in Montgomery-Åsberg Depression Rating Scale (MADRS) total score. Differences from placebo were analyzed using mixed model for repeated measurements (MMRM) analysis, with a sensitivity analysis also conducted using last observation carried forward. Secondary outcomes included MADRS single-item scores, response rate (≥50% reduction in baseline MADRS), remission rate (MADRS ≤10), and Clinical Global Impressions scores. Across the 11 studies, 1824 patients were treated with placebo and 3304 with vortioxetine (5mg/day: n=1001; 10mg/day: n=1042; 15mg/day: n=449; 20mg/day: n=812). The MMRM meta-analysis demonstrated that vortioxetine 5, 10, and 20mg/day were associated with significant reductions in MADRS total score (Δ-2.27, Δ-3.57, and Δ-4.57, respectively; p<0.01) versus placebo. The effects of 15mg/day (Δ-2.60; p=0.105) were not significantly different from placebo. Vortioxetine 10 and 20mg/day were associated with significant reductions in 9 of 10 MADRS single-item scores. Vortioxetine treatment was also associated with significantly higher rates of response and remission and with significant improvements in other depression-related scores versus placebo. This meta-analysis of vortioxetine (5-20mg/day) in adults with MDD supports the efficacy demonstrated in the individual studies, with treatment effect increasing with dose.
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Affiliation(s)
- Michael E Thase
- University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
| | | | | | | | - Eduard Vieta
- Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
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9
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Abstract
Although the early antidepressant trials which included severely ill and hospitalized patients showed substantial drug-placebo differences, these robust differences have not held up in the trials of the past couple of decades, whether sponsored by pharmaceutical companies or non-profit agencies. This narrowing of the drug-placebo difference has been attributed to a number of changes in the conduct of clinical trials. First, the advent of DSM-III and the broadening of the definition of major depression have led to the inclusion of mildly to moderately ill patients into antidepressant trials. These patients may experience a smaller magnitude of antidepressant-placebo differences. Second, drug development regulators, such as the U.S. Food and Drug Administration and the European Medicines Agency, have had a significant, albeit underappreciated, role in determining how modern antidepressant clinical trials are designed and conducted. Their concerns about possible false positive results have led to trial designs that are poor, difficult to conduct, and complicated to analyze. Attempts at better design and patient selection for antidepressant trials have not yielded the expected results. As of now, antidepressant clinical trials have an effect size of 0.30, which, although similar to the effects of treatments for many other chronic illnesses, such as hypertension, asthma and diabetes, is less than impressive.
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Affiliation(s)
- Arif Khan
- Northwest Clinical Research CenterBellevue, WA, USA,Department of Psychiatry and Behavioral Science, Duke University School of MedicineDurham, NC, USA
| | - Walter A Brown
- Department of Psychiatry and Human Behavior, Brown UniversityProvidence, RI, USA
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10
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Mahableshwarkar AR, Jacobsen PL, Chen Y, Serenko M, Trivedi MH. A randomized, double-blind, duloxetine-referenced study comparing efficacy and tolerability of 2 fixed doses of vortioxetine in the acute treatment of adults with MDD. Psychopharmacology (Berl) 2015; 232:2061-70. [PMID: 25575488 PMCID: PMC4432084 DOI: 10.1007/s00213-014-3839-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/02/2014] [Indexed: 12/24/2022]
Abstract
RATIONALE Vortioxetine has reduced depressive symptoms in adults with major depressive disorder (MDD) in multiple clinical trials. OBJECTIVES The aim of this study is to evaluate the efficacy, safety, and tolerability of vortioxetine 15 and 20 mg vs placebo in adults with MDD. METHODS Patients were randomized 1:1:1:1 to vortioxetine 15 mg, vortioxetine 20 mg, duloxetine 60 mg (active reference), or placebo. The primary efficacy endpoint was mean change in Montgomery-Åsberg Depression Rating Scale (MADRS) total score at week 8 (MMRM). Safety/tolerability assessments included physical examinations, vital signs, laboratory evaluations, electrocardiograms, adverse events (AEs), Columbia-Suicide Severity Rating Scale, Arizona Sexual Experiences Scale, and Discontinuation-Emergent Signs and Symptoms checklist. RESULTS Six hundred and fourteen patients were randomized. Mean changes in MADRS scores were -12.83 (±0.834), -14.30 (±0.890), -15.57 (±0.880), and -16.90 (±0.884) for placebo, vortioxetine 15 mg (P = .224), vortioxetine 20 mg (P = .023), and duloxetine 60 mg (P < .001) (P vs placebo), respectively. AEs reported by ≥5 % of vortioxetine patients included nausea, headache, diarrhea, dizziness, dry mouth, constipation, vomiting, insomnia, fatigue, and upper respiratory infection. Treatment-emergent sexual dysfunction, suicidal ideation or behavior, and discontinuation symptoms were not significantly different between vortioxetine and placebo. CONCLUSIONS Vortioxetine 20 mg significantly reduced MADRS total scores after 8 weeks of treatment. Both vortioxetine doses were well tolerated. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01153009; www.clinicaltrials.gov/ .
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Affiliation(s)
- Atul R Mahableshwarkar
- CNS Medicine, Clinical Science, CNS Statistics, Pharmacovigilance, Takeda Development Center Americas, 1 Takeda Parkway, Deerfield, IL, 60015, USA,
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11
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Rutherford BR, Wall MM, Glass A, Stewart JW. The role of patient expectancy in placebo and nocebo effects in antidepressant trials. J Clin Psychiatry 2014; 75:1040-6. [PMID: 25006812 PMCID: PMC4221413 DOI: 10.4088/jcp.13m08797] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine whether patient expectancy plays a role in observed placebo and nocebo effects in 2 clinical trials. METHOD Data were reanalyzed from 2 fluoxetine-discontinuation studies conducted from March 1990 to September 1992 and from May 1997 to December 2002. The 673 outpatients included were aged 18-65 years with DSM-III-R major depressive disorder (MDD), responded to 12-week duration open treatment, and were randomized to continued fluoxetine or placebo for an additional year. Participants in 1 of the included studies received a fixed dose of fluoxetine 20 mg daily, while the second study utilized flexible fluoxetine doses up to 60 mg daily. Mixed effects longitudinal models determined whether the possible randomization to placebo at 12 weeks resulted in significant depressive symptom worsening across treatments. Correlations were computed between early symptom change (weeks 1-3 of open treatment) and postrandomization symptom change (weeks 13-16 following randomization). RESULTS Participants continuing to receive fluoxetine and those switched to placebo had significantly higher mean Hamilton Depression Rating Scale (HDRS) scores immediately postrandomization compared to the final weeks of open treatment (P < .001 for both fluoxetine- and placebo-treated patients). In both studies, early HDRS change was significantly correlated with postrandomization HDRS change for patients receiving fluoxetine (r = -0.46, P < .001) as well as placebo (r = -0.48, P < .001). CONCLUSIONS The possibility of receiving placebo following 12 weeks of open fluoxetine was associated with significant symptom worsening in 2 large fluoxetine discontinuation studies. Worsening depression scores following randomization were significantly associated with the degree of improvement participants experienced during weeks 1-3 of open treatment. These results suggest that treatment changes influence patients' expectations of improvement, which, in turn, affect their depressive symptoms.
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Affiliation(s)
- Bret R Rutherford
- Columbia University College of Physicians and Surgeons, Department of Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, Box 98, New York, NY 10032
| | - Melanie M. Wall
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute
| | - Andrew Glass
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute
| | - Jonathan W. Stewart
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute
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12
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Alvarez E, Perez V, Artigas F. Pharmacology and clinical potential of vortioxetine in the treatment of major depressive disorder. Neuropsychiatr Dis Treat 2014; 10:1297-307. [PMID: 25075188 PMCID: PMC4106971 DOI: 10.2147/ndt.s41387] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
VORTIOXETINE IS A NEW MULTIMODAL ACTION ANTIDEPRESSANT WITH TWO TYPES OF ACTION: serotonin transporter (SERT) blockade and a strong affinity for several serotoninergic receptors. It is an antagonist of the 5-HT3 and 5-HT7 receptors, a partial agonist of 5-HT1B, and an agonist of 5-HT1A. Its combined action on SERT and four subtypes of serotoninergic receptors increases the extracellular concentration of serotonin, dopamine, and noradrenaline. Twelve clinical trials have been carried out, nine of which had positive results versus placebo. When active comparators were included in the study design, no significant differences were found except in one study in which the efficacy of vortioxetine was superior to the comparator (agomelatine) in depression resistant to selective serotonin reuptake inhibitors (SSRI)/serotonin-norepinephrine reuptake inhibitors (SNRI) treatment. Tolerability studies indicate that the drug does not cause any important problems on blood tests, vital signs, or on electrocardiography. The lack of weight gain and induction of metabolic syndrome and the lack of significant changes in the QTc are especially important. The incidence rate of sexual dysfunction is low and similar to placebo in various trials. Similarly, cognitive function remains intact with vortioxetine.
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Affiliation(s)
- Enric Alvarez
- Department of Psychiatry, Hospital de Sant Pau, Universitat Autonoma de Barcelona, Institut de Recerca Biomedica Sant Pau, Barcelona, Spain
- Ministry of Science and Innovation, CIBERSAM, Madrid, Spain
| | - Victor Perez
- Ministry of Science and Innovation, CIBERSAM, Madrid, Spain
- Institut de Neuropsiquiatria I Adiccions, Universitat Autonoma de Barcelona, Hospital del Mar, Barcelona, Spain
| | - Francesc Artigas
- Ministry of Science and Innovation, CIBERSAM, Madrid, Spain
- Institut d’Investigacions Biomediques de Barcelona, CSIC, Barcelona, Spain
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13
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Mancini M, Wade AG, Perugi G, Lenox-Smith A, Schacht A. Impact of patient selection and study characteristics on signal detection in placebo-controlled trials with antidepressants. J Psychiatr Res 2014; 51:21-9. [PMID: 24462042 DOI: 10.1016/j.jpsychires.2014.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 12/06/2013] [Accepted: 01/03/2014] [Indexed: 12/19/2022]
Abstract
An increasing rate of antidepressant trials fail due to large placebo responses. This analysis aimed to identify variables influencing signal detection in clinical trials of major depressive disorder. Patient-level data of randomized patients with a duloxetine dose ≥ 60 mg/day were obtained from Lilly. Total scores of the Hamilton Depression Rating scale (HAM-D) were used as efficacy endpoints. In total, 4661 patients from 14 studies were included in the analysis. The overall effect size (ES), based on the HAM-D total score at endpoint, between duloxetine and placebo was -0.272. Although no statistically significant interactions were found, the following results for factors influencing ES were seen: a very low ES (-0.157) in patients in the lowest baseline HAM-D category and in patients recruited in the last category of the recruitment period (-0.122). A higher ES in patients recruited in centers with a site-size at but not more than 2.5 times the average site-size for the study (-0.345). Study characteristics that resulted in low signal detection in our database were: <80% study completers, a HAM-D placebo response >5 points, a high variability of placebo response (SD > 7 points HAM-D), >6 post baseline visits per study, and use of an active control drug. Simpler trial designs, more homogeneous and mid-sized study sites, a primary analysis based on a higher cutoff blinded to investigators to avoid the influence of score inflation in mild patients and, if possible, studies without an active control group could lead to a better signal detection of antidepressive efficacy.
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Affiliation(s)
- Michele Mancini
- Eli Lilly Italia S.p.A., Neuroscience, Via A. Gramsci 731/733, 50019 Sesto Fiorentino, FI, Italy.
| | | | - Giulio Perugi
- University of Pisa, Institute of Psychiatry, Pisa, Italy
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14
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Abstract
Placebo response in clinical trials of antidepressant medications is substantial and has been increasing. High placebo response rates hamper efforts to detect signals of efficacy for new antidepressant medications, contributing to trial failures and delaying the delivery of new treatments to market. Media reports seize upon increasing placebo response and modest advantages for active drugs as reasons to question the value of antidepressant medication, which may further stigmatize treatments for depression and dissuade patients from accessing mental health care. Conversely, enhancing the factors responsible for placebo response may represent a strategy for improving available treatments for major depressive disorder. A conceptual framework describing the causes of placebo response is needed in order to develop strategies for minimizing placebo response in clinical trials, maximizing placebo response in clinical practice, and talking with depressed patients about the risks and benefits of antidepressant medications. In this review, the authors examine contributors to placebo response in antidepressant clinical trials and propose an explanatory model. Research aimed at reducing placebo response should focus on limiting patient expectancy and the intensity of therapeutic contact in antidepressant clinical trials, while the optimal strategy in clinical practice may be to combine active medication with a presentation and level of therapeutic contact designed to enhance treatment response.
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Affiliation(s)
- Bret R Rutherford
- Columbia University College of Physicians and Surgeons and New York State Psychiatric Institute, New York, USA.
| | - Steven P. Roose
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute
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15
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Kunugi H, Koga N, Hashikura M, Noda T, Shimizu Y, Kobayashi T, Yamanaka J, Kanemoto N, Higuchi T. Validation of computer-administered clinical rating scale: Hamilton Depression Rating Scale assessment with Interactive Voice Response technology--Japanese version. Psychiatry Clin Neurosci 2013; 67:253-8. [PMID: 23683156 DOI: 10.1111/pcn.12048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 12/27/2012] [Accepted: 01/09/2013] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to examine the reliability and validity of the Interactive Voice Response (IVR) program to rate the 17-item Hamilton Rating Scale for Depression (HAM-D) score in Japanese depressive patients. METHODS Depression severity was assessed in 60 patients by a clinician and psychologists using HAM-D. Scoring by the IVR program was conducted on the same and the following days. Test-retest reliability, internal consistency, and concurrent validity for total HAM-D scores were examined by calculating intraclass correlation coefficient, Cronbach's alpha, and Pearson's correlation coefficient. Inter-rater consistency for each HAM-D item was examined by Cohen's kappa. RESULTS Test-retest reliability of the IVR program was high (intraclass correlation coefficient: 0.93). Internal consistency of each total score obtained by the clinician, psychologists, and IVR program was high (Cronbach's alpha: 0.77, 0.79, 0.78, and 0.83). Regarding concurrent validity, correlation coefficients between total scores obtained by the clinician versus IVR and that by the clinician versus psychologists were high (0.81 and 0.93). The HAM-D total score rated by the clinician was 3 points lower than that of IVR. Inter-rater consistency for each HAM-D item evaluated by the clinician versus IVR was estimated to be fair (Cohen's kappa coefficient: 0.02-0.50). CONCLUSION Our results suggest that the Japanese IVR HAM-D program is reliable and valid to assess 17-item HAM-D total score in Japanese depressive patients. However, the current program tends to overestimate depression severity, and the score of each item did not always show high agreement with clinician's rating, which warrants further improvement in the program.
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Affiliation(s)
- Hiroshi Kunugi
- Department of Mental Disorder Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
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16
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A randomized, double-blind, placebo-controlled 6-wk trial of the efficacy and tolerability of 5 mg vortioxetine in adults with major depressive disorder. Int J Neuropsychopharmacol 2013; 16:313-21. [PMID: 22963932 DOI: 10.1017/s1461145712000727] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Vortioxetine (Lu AA21004) is a multi-modal antidepressant in clinical development for the treatment of major depressive disorder (MDD). The current study evaluated the efficacy and tolerability of 5 mg vortioxetine compared to placebo after 6 wk of treatment in adults with MDD in an out-patient setting. Adults aged 18-75 yr, with a diagnosis of MDD and a baseline Montgomery-Asberg Depression Rating Scale (MADRS) total score ≥30, were randomized to receive either 5 mg vortioxetine or placebo over 6 wk, followed by a 2-wk medication-free discontinuation period. The primary efficacy measure was change from baseline in Hamilton Rating Scale for Depression (HAMD)-24 total score at week 6 compared to placebo. Additional measures included response and remission rates, Clinical Global Impression Scale - Improvement scores, HAMD-24 total score in subjects with baseline Hamilton Anxiety Scale (HAMA) >19 and MADRS-S total score. Adverse events (AEs) were assessed throughout the study. A total of 600 adults were randomized. There were no significant differences in efficacy measures between subjects in the 5 mg vortioxetine and placebo groups at week 6. HAMD-24 total score in subjects with baseline HAMA >19 in the 5 mg vortioxetine group was improved at weeks 3-6 compared to the placebo group (nominal p value <0.05). The most common AEs for the vortioxetine and placebo groups were nausea (19.1 and 9.4%), headache (17.1 and 15.1%) and diarrhoea (11.4 and 7.0%), respectively. In this study of adults with MDD, 5 mg vortioxetine did not differ significantly from placebo in reducing depression symptoms after 6 wk of treatment.
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17
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Koshino Y, Bahk WM, Sakai H, Kobayashi T. The efficacy and safety of bupropion sustained-release formulation for the treatment of major depressive disorder: a multi-center, randomized, double-blind, placebo-controlled study in Asian patients. Neuropsychiatr Dis Treat 2013; 9:1273-80. [PMID: 24039429 PMCID: PMC3770623 DOI: 10.2147/ndt.s48158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This study was conducted to compare the efficacy and safety of bupropion sustained-release (SR) formulation orally administered at daily doses of 150 mg/day (once daily) and 300 mg/day (150 mg twice daily) for 8 weeks versus placebo in Asian patients with major depressive disorder. The mean change from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) total score at week 8 was compared between each of the bupropion SR dose groups and the placebo group using an analysis of covariance with the multiplicity adjustment by Dunnett's step-down procedure. A total of 569 subjects met all of the inclusion criteria and proceeded to the treatment phase. The subjects proceeding to the treatment phase included 454 Japanese patients and 115 Korean patients. There was no statistically significant difference between each of the bupropion SR dose groups and the placebo group in the primary efficacy endpoint of change from baseline in MADRS total score at week 8. Similar results were generally obtained for all of the secondary efficacy endpoints. The secondary analysis and the other subgroup analysis did not show a statistically significant difference in efficacy. There was no substantial difference in the type, severity, and incidence of adverse events (AEs) between the bupropion SR dose groups and the placebo group, which indicates a favorable safety profile for bupropion SR. There were no significant findings in subjects treated with bupropion SR in regard to sexual dysfunction, weight change, and withdrawal syndrome, which are frequently recognized as clinical concerns associated with selective serotonin reuptake inhibitors, widely used for the treatment of depression.
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18
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Rothschild AJ, Mahableshwarkar AR, Jacobsen P, Yan M, Sheehan DV. Vortioxetine (Lu AA21004) 5 mg in generalized anxiety disorder: results of an 8-week randomized, double-blind, placebo-controlled clinical trial in the United States. Eur Neuropsychopharmacol 2012; 22:858-66. [PMID: 22901736 DOI: 10.1016/j.euroneuro.2012.07.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 06/20/2012] [Accepted: 07/20/2012] [Indexed: 12/29/2022]
Abstract
The goal of the current clinical study, conducted in the United States (US), was to evaluate the efficacy and tolerability of vortioxetine 5mg vs placebo in adults with a primary diagnosis of generalized anxiety disorder (GAD; HAM-A total score ≥20 and MADRS score ≤16). Subjects were randomized (1:1) to receive vortioxetine 5mg (n=152) or placebo (n=152) for 8 weeks. Efficacy was assessed using change from baseline in HAM-A total scores after 8 weeks of treatment compared with placebo, using mixed-model repeated measures (MMRM) analyses. Adverse events (AEs) were assessed throughout the study. A total of 304 subjects were randomized (mean age, 41.2 years). After 8 weeks of treatment, there was no statistically significant difference in the reduction in HAM-A total score from baseline between the Vortioxetine (n=145) and placebo (n=145) groups. There were no statistically significant differences in any key secondary efficacy outcome between vortioxetine and placebo. Factors potentially contributing to the differences between the results of this study and those of one of identical design conducted outside the US are discussed. The most common treatment-emergent AEs were nausea, headache, dizziness, and dry mouth. Nausea was more frequently reported in the vortioxetine group (25% vs 4.6% for the placebo group). Most AEs were mild to moderate in severity. In conclusion, in this trial, vortioxetine did not improve symptoms of GAD (compared with placebo) over 8 weeks of treatment. Vortioxetine was well tolerated in this study.
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Affiliation(s)
- Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial HealthCare, Worcester, MA, United States
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19
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Mundt JC, Vogel AP, Feltner DE, Lenderking WR. Vocal acoustic biomarkers of depression severity and treatment response. Biol Psychiatry 2012; 72:580-7. [PMID: 22541039 PMCID: PMC3409931 DOI: 10.1016/j.biopsych.2012.03.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 02/13/2012] [Accepted: 03/16/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Valid, reliable biomarkers of depression severity and treatment response would provide new targets for clinical research. Noticeable differences in speech production between depressed and nondepressed patients have been suggested as a potential biomarker. METHODS One hundred five adults with major depression were recruited into a 4-week, randomized, double-blind, placebo-controlled research methodology study. An exploratory objective of the study was to evaluate the generalizability and repeatability of prior study results indicating vocal acoustic properties in speech may serve as biomarkers for depression severity and response to treatment. Speech samples, collected at baseline and study end point using an automated telephone system, were analyzed as a function of clinician-rated and patient-reported measures of depression severity and treatment response. RESULTS Regression models of speech pattern changes associated with clinical outcomes in a prior study were found to be reliable and significant predictors of outcome in the current study, despite differences in the methodological design and implementation of the two studies. Results of the current study replicate and support findings from the prior study. Clinical changes in depressive symptoms among patients responding to the treatments provided also reflected significant differences in speech production patterns. Depressed patients who did not improve clinically showed smaller vocal acoustic changes and/or changes that were directionally opposite to treatment responders. CONCLUSIONS This study supports the feasibility and validity of obtaining clinically important, biologically based vocal acoustic measures of depression severity and treatment response using an automated telephone system.
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Affiliation(s)
- James C. Mundt
- Center for Psychological Consultation (Madison, WI),University of Arkansas for Medical Sciences (Little Rock, AR)
| | - Adam P. Vogel
- Speech Neuroscience Unit, Melbourne Medical School, The University of Melbourne (Melbourne, AU)
| | - Douglas E. Feltner
- formerly Pfizer Global Research & Development – Groton Laboratories (Groton, CT),Douglas E. Feltner, LLC (Novi, MI)
| | - William R. Lenderking
- formerly Pfizer Global Research & Development – Groton Laboratories (Groton, CT),United BioSource Corporation (Bethesda, MD)
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20
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Abstract
PURPOSE OF REVIEW The magnitude of placebo response is an important factor in the outcome of clinical trials, in that excessive placebo response can obscure true drug-placebo differences. There is ample evidence of the impact of elevated placebo response in trials of major depression, but less intensive research has been done in the area of schizophrenia. We present a current review of placebo response in clinical trials of schizophrenia. RECENT FINDINGS The existing evidence suggests that placebo response in schizophrenia trials may be similar in magnitude, quality, and impact to that observed in depression trials, and has similarly increased over the past several years. We discuss factors influencing excessive placebo response during the conduct of clinical trials and how they may be managed to help minimize placebo response. SUMMARY There does not appear to be any single major factor contributing to the high levels of placebo response in schizophrenia clinical trials; therefore, a multipronged approach to minimizing excessive placebo response or its impact is recommended.
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21
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Mundt JC, Greist JH, Gelenberg AJ, Katzelnick DJ, Jefferson JW, Modell JG. Feasibility and validation of a computer-automated Columbia-Suicide Severity Rating Scale using interactive voice response technology. J Psychiatr Res 2010; 44:1224-8. [PMID: 20553851 DOI: 10.1016/j.jpsychires.2010.04.025] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 04/07/2010] [Accepted: 04/20/2010] [Indexed: 11/25/2022]
Abstract
To evaluate a computer-automated version of the Columbia-Suicide Severity Rating Scale (C-SSRS) using interactive voice response technology (eC-SSRS™). The eC-SSRS assesses "Lifetime" ideations and behaviors at baseline and monitors suicidality prospectively thereafter. Ten control volunteers and ten psychiatric inpatients participated and were administered the C-SSRS at baseline and 4-8 days later by two experienced clinical trial raters. Study participants also completed the eC-SSRS using touch-tone telephones. Kappa measures of agreement compared inter-rater reliability of the C-SSRS administrations and the C-SSRS administrations with the eC-SSRS. Convergent validity with the Beck Scale for Suicide Ideation BSS and patient feedback forms were also evaluated. Twenty baseline and nineteen follow-up assessments were completed. In general, agreement between the eC-SSRS and each rater was comparable or superior to the agreement between both raters. Subject feedback and personal preferences varied across individuals, but were generally supportive of the feasibility and validity of the eC-SSRS. The reliability and validity of the C-SSRS and eC-SSRS for assessing suicidal ideation and behaviors were comparable in this first study comparing the methods. These data were obtained from relatively small patient samples recruited from a single investigational site over a relatively short follow-up period. They support the feasibility and validity of the eC-SSRS for prospective monitoring of suicidality for use in clinical trials or clinical care, but further research with larger samples, other patient populations, and longer follow-up periods is needed.
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Affiliation(s)
- James C Mundt
- Healthcare Technology Systems, Inc., 7617 Mineral Point Road, Ste. 300, Madison, WI 53717, USA
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22
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The Center for Clinical Computing Appreciation. J Clin Psychopharmacol 2010; 30:355-6. [PMID: 20571435 DOI: 10.1097/jcp.0b013e3181e6f495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Khan A, Bhat A, Kolts R, Thase ME, Brown W. Why has the antidepressant-placebo difference in antidepressant clinical trials diminished over the past three decades? CNS Neurosci Ther 2010; 16:217-26. [PMID: 20406269 PMCID: PMC6493812 DOI: 10.1111/j.1755-5949.2010.00151.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The increasing rate of failure of antidepressant clinical trials has led to the assertion that antidepressants do not have meaningful clinical benefits. Our hypothesis was that the decrease in antidepressant-placebo differences in antidepressant clinical trials over the past three decades could be explained by changes in research design features rather than a lack of potency of the antidepressants being tested. We collected data from 130 double blind placebo controlled antidepressant clinical trials conducted between 1981 and 2008 that included 35,122 depressed patients with 23,157 patients assigned to antidepressants and 11,965 assigned to placebo. We conducted a hierarchical regression analysis of change in HAM-D scores in antidepressant and placebo groups separately with year of publication, and research design features as independent variables. We found that antidepressant-placebo differences in antidepressant clinical trials have declined markedly over the past three decades. Decline in change scores in the antidepressant group was related to mean total baseline HAM-D scores in the trial, the version of HAM-D used, and duration of trial. Similarly, decline in change scores in the placebo group was related to mean total baseline HAM-D scores, duration of trial, and year of publication. Overall, we found that antidepressant-placebo differences were statistically significantly higher in trials that used HAM-D 21 rather than HAM-D 17 and in trials that lasted 6 weeks or less. These data suggest that, apart from the efficacy of the antidepressant being tested, factors such as baseline HAM-D scores, version of HAM-D used and duration of trial have a significant impact on outcome. As such a clinician's assessment of the usefulness of antidepressants should not be based solely on the results of such clinical trials. In the meantime there is a need for continuing research to improve the methodology of antidepressant clinical trials. These data suggest that many aspects of the design of antidepressant trials have a significant impact on outcome. Further, these data suggest that the results of more recent placebo controlled trials do not adequately inform clinicians about the potential utility of antidepressants.
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Affiliation(s)
- Arif Khan
- Northwest Clinical Research Center, Bellevue, WA 98007, USA.
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Feltner D, Hill C, Lenderking W, Williams V, Morlock R. Development of a patient-reported assessment to identify placebo responders in a generalized anxiety disorder trial. J Psychiatr Res 2009; 43:1224-30. [PMID: 19423131 DOI: 10.1016/j.jpsychires.2009.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 03/19/2009] [Accepted: 04/08/2009] [Indexed: 11/16/2022]
Abstract
Placebo response is thought to be a primary contributor to uninformative (failed) trials in clinical drug development. This study describes the development of a patient-reported assessment to detect likely placebo responders. A novel scale, the Placebo Response Screening Scale (PRSS), was developed to assess domains expected to be associated with placebo response. The scale was administered during the screening visit of a 4-week, placebo-controlled study of alprazolam and an investigational compound in 211 patients with generalized anxiety disorder (GAD). Items that predicted placebo response were identified. Sensitivity and specificity of the instrument were used to determine a threshold score for use in screening likely placebo response. The PRSS was then evaluated by comparing active treatment and placebo groups and subsetting the groups based on subject PRSS scores. Twenty items were selected for being predictive of patient global improvement rating, clinician global improvement rating, or improvement on Hamilton Rating Scale for Anxiety (HAM-A) scores in placebo-arm patients. Receiver operating characteristic concordance values ranged from 0.77 to 0.96 for the different definitions of placebo responder. A cut-score of 50 on a scale of 0-100 was chosen to maximize sensitivity (range 0.67-0.79) and specificity (range 0.78-1.00). Fifty-six patients with scores of 50 or higher were flagged as potential placebo responders. Excluding these 56 patients from the analysis resulted in a greater separation of active treatment from placebo. The PRSS is a promising tool for predicting placebo response in clinical trials and requires further use and validation.
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Affiliation(s)
- Douglas Feltner
- Pfizer Global Research and Development, MS 6025-B2234, New London, CT 06320, USA.
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Greist J, Mundt J, Jefferson J, Katzelnick D. Comments on "Why do clinical trials fail? The problem of measurement error in clinical trials: time to test new paradigms?". J Clin Psychopharmacol 2007; 27:535-7. [PMID: 17873702 DOI: 10.1097/jcp.0b013e31814f2c14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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