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Lawrence RE, Appelbaum PS. Ethics in placebo-controlled, acute treatment trials in schizophrenia: Two rival ethical frameworks. Schizophr Res 2024; 264:372-377. [PMID: 38237358 DOI: 10.1016/j.schres.2024.01.018] [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: 09/08/2021] [Revised: 01/05/2024] [Accepted: 01/06/2024] [Indexed: 03/01/2024]
Abstract
Placebo-controlled, acute treatment trials in schizophrenia enroll acutely symptomatic persons, randomize them to receive placebo or antipsychotic medication for several weeks, and evaluate whether symptoms improve. These trials can have scientific benefits, especially when they test drugs with novel mechanisms of action. However, the use of placebo is ethically problematic inasmuch as standard treatment is withheld and participants are subjected to prolonged psychotic symptoms and associated risks. We propose that both deontological (duty-based) and utilitarian analyses are relevant, that it may be impossible to satisfy the ideals of both frameworks, and that researchers who conduct these trials will unavoidably encounter ethical tension and criticism even when they give careful attention to ethical aspects of study design.
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Affiliation(s)
- Ryan E Lawrence
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, United States of America.
| | - Paul S Appelbaum
- Center for Law, Ethics, and Psychiatry, Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons and New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America.
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Lawrence RE, Appelbaum PS, Lieberman JA. A historical review of placebo-controlled, relapse prevention trials in schizophrenia: The loss of clinical equipoise. Schizophr Res 2021; 229:122-131. [PMID: 33234427 DOI: 10.1016/j.schres.2020.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/14/2020] [Accepted: 11/15/2020] [Indexed: 11/19/2022]
Abstract
Recent ethical critiques have proposed that placebo-controlled, relapse prevention trials in schizophrenia are no longer justifiable and are therefore unethical. This review provides an historical perspective on the justifications for these trials and how arguments evolved over several decades. We identified 87 placebo-controlled, relapse prevention trials published over the last seventy years and examined the purpose for each trial. We found that first-generation trials had compelling justifications, yet these arguments changed considerably over time. Second-generation trials offered comparatively weaker-and sometimes no-justifications for their conduct. Without clear and compelling justifications for a given trial, it is not ethical to continue using this study design.
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Affiliation(s)
- Ryan E Lawrence
- Columbia University Medical Center, New York - Presbyterian Hospital, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Paul S Appelbaum
- Department of Psychiatry, Columbia University, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Jeffrey A Lieberman
- Columbia University Vagelos College of Physicians and Surgeons, New York State Psychiatric Institute, New York - Presbyterian Hospital, Columbia University Medical Center, United States of America.
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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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Sugawara N, Ishioka M, Tsuchimine S, Tsuruga K, Sato Y, Furukori H, Kudo S, Tomita T, Nakagami T, Yasui-Furukori N. Attitudes toward Placebo-Controlled Clinical Trials of Patients with Schizophrenia in Japan. PLoS One 2015; 10:e0143356. [PMID: 26600382 PMCID: PMC4658191 DOI: 10.1371/journal.pone.0143356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/03/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although the use of placebo in clinical trials of schizophrenia patients is controversial because of medical and ethical concerns, placebo-controlled clinical trials are commonly used in the licensing of new drugs. AIMS The objective of this study was to assess the attitudes toward placebo-controlled clinical trials among patients with schizophrenia in Japan. METHOD Using a cross-sectional design, we recruited patients (n = 251) aged 47.7±13.2 (mean±SD) with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder who were admitted to six psychiatric hospitals from December 2013 to March 2014. We employed a 14-item questionnaire specifically developed to survey patients' attitudes toward placebo-controlled clinical trials. RESULTS The results indicated that 33% of the patients would be willing to participate in a placebo-controlled clinical trial. Expectations for improvement of disease, a guarantee of hospital treatment continuation, and encouragement by family or friends were associated with the willingness to participate in such trials, whereas a belief of additional time required for medical examinations was associated with non-participation. CONCLUSIONS Fewer than half of the respondents stated that they would be willing to participate in placebo-controlled clinical trials. Therefore, interpreting the results from placebo-controlled clinical trials could be negatively affected by selection bias.
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Affiliation(s)
- Norio Sugawara
- Aomori Prefectural Center for Mental Health and Welfare, Aomori, Japan
- Department of Neuropsychiatry, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Masamichi Ishioka
- Department of Psychiatry, Hirosaki-Aiseikai Hospital, Hirosaki, Japan
| | - Shoko Tsuchimine
- Department of Neuropsychiatry, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Koji Tsuruga
- Department of Neuropsychiatry, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Yasushi Sato
- Department of Psychiatry, Seihoku-Chuoh Hospital, Goshogawara, Japan
| | - Hanako Furukori
- Department of Psychiatry, Kuroishi-Akebono Hospital, Kuroishi, Japan
| | - Shuhei Kudo
- Department of Psychiatry, Hirosaki-Aiseikai Hospital, Hirosaki, Japan
| | - Tetsu Tomita
- Department of Neuropsychiatry, Odate Municipal General Hospital, Odate, Japan
| | - Taku Nakagami
- Department of Neuropsychiatry, Odate Municipal General Hospital, Odate, Japan
| | - Norio Yasui-Furukori
- Department of Neuropsychiatry, Hirosaki University School of Medicine, Hirosaki, Japan
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6
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Maayan N, Quraishi SN, David A, Jayaswal A, Eisenbruch M, Rathbone J, Asher R, Adams CE. Fluphenazine decanoate (depot) and enanthate for schizophrenia. Cochrane Database Syst Rev 2015:CD000307. [PMID: 25654768 PMCID: PMC10388394 DOI: 10.1002/14651858.cd000307.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long-acting preparations, however, may be offset by a higher incidence of adverse effects. OBJECTIVES To assess the effects of fluphenazine decanoate and enanthate versus oral anti-psychotics and other depot neuroleptic preparations for individuals with schizophrenia in terms of clinical, social and economic outcomes. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Trials Register (February 2011 and October 16, 2013), which is based on regular searches of CINAHL, BIOSIS, AMED, EMBASE, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. SELECTION CRITERIA We considered all relevant randomised controlled trials (RCTs) focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations. DATA COLLECTION AND ANALYSIS We reliably selected, assessed the quality, and extracted data of the included studies. For dichotomous data, we estimated risk ratio (RR) with 95% confidence intervals (CI). Analysis was by intention-to-treat. We used the mean difference (MD) for normal continuous data. We excluded continuous data if loss to follow-up was greater than 50%. Tests of heterogeneity and for publication bias were undertaken. We used a fixed-effect model for all analyses unless there was high heterogeneity. For this update. we assessed risk of bias of included studies and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to create a 'Summary of findings' table. MAIN RESULTS This review now includes 73 randomised studies, with 4870 participants. Overall, the quality of the evidence is low to very low.Compared with placebo, use of fluphenazine decanoate does not result in any significant differences in death, nor does it reduce relapse over six months to one year, but one longer-term study found that relapse was significantly reduced in the fluphenazine arm (n = 54, 1 RCT, RR 0.35, CI 0.19 to 0.64, very low quality evidence). A very similar number of people left the medium-term studies (six months to one year) early in the fluphenazine decanoate (24%) and placebo (19%) groups, however, a two-year study significantly favoured fluphenazine decanoate (n = 54, 1 RCT, RR 0.47, CI 0.23 to 0.96, very low quality evidence). No significant differences were found in mental state measured on the Brief Psychiatric Rating Scale (BPRS) or in extrapyramidal adverse effects, although these outcomes were only reported in one small study each. No study comparing fluphenazine decanoate with placebo reported clinically significant changes in global state or hospital admissions.Fluphenazine decanoate does not reduce relapse more than oral neuroleptics in the medium term (n = 419, 6 RCTs, RR 1.46 CI 0.75 to 2.83, very low quality evidence). A small study found no difference in clinically significant changes in global state. No difference in the number of participants leaving the study early was found between fluphenazine decanoate (17%) and oral neuroleptics (18%), and no significant differences were found in mental state measured on the BPRS. Extrapyramidal adverse effects were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n = 259, 3 RCTs, RR 0.47 CI 0.24 to 0.91, very low quality evidence). No study comparing fluphenazine decanoate with oral neuroleptics reported death or hospital admissions.No significant difference in relapse rates in the medium term between fluphenazine decanoate and fluphenazine enanthate was found (n = 49, 1 RCT, RR 2.43, CI 0.71 to 8.32, very low quality evidence), immediate- and short-term studies were also equivocal. One small study reported the number of participants leaving the study early (29% versus 12%) and mental state measured on the BPRS and found no significant difference for either outcome. No significant difference was found in extrapyramidal adverse effects between fluphenazine decanoate and fluphenazine enanthate. No study comparing fluphenazine decanoate with fluphenazine enanthate reported death, clinically significant changes in global state or hospital admissions. AUTHORS' CONCLUSIONS There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. Fluphenazine decanoate produced fewer movement disorder effects than other oral antipsychotics but data were of low quality, and overall, adverse effect data were equivocal. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.
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Affiliation(s)
- Nicola Maayan
- Enhance Reviews Ltd, Central Office, Cobweb Buildings, The Lane, Lyford, Wantage, UK, OX12 0EE
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Emsley R, Fleischhacker WW. Is the ongoing use of placebo in relapse-prevention clinical trials in schizophrenia justified? Schizophr Res 2013; 150:427-33. [PMID: 24094881 DOI: 10.1016/j.schres.2013.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/03/2013] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Placebo-controlled randomised controlled trials (RCTs) continue to be required or recommended by regulatory authorities for the licensing of new drugs for schizophrenia, despite ongoing concerns regarding the risks to trial participants. METHODS In this article we consider the scientific and ethical pros and cons associated with use of placebo in RCTs in schizophrenia, systematically review the published relapse-prevention placebo-controlled RCTs with second generation antipsychotics (SGAs) in schizophrenia, and examine the risks associated with these trials. RESULTS We identified 12 studies involving 2842 participants of which 968 received placebo. Relapse rates were 56% for placebo and 17.4% for active treatment groups. There is a lack of well-designed longitudinal studies investigating the psychosocial and biological consequences of exposure to placebo, to treatment discontinuation and to relapse in schizophrenia. CONCLUSION In the absence of such studies it is risky to assume that patients are not at risk of significant distress and long-term harm, and therefore it is difficult to justify the ongoing use of placebo in relapse-prevention RCTs in schizophrenia.
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Affiliation(s)
- Robin Emsley
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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Emsley R, Chiliza B, Asmal L. The evidence for illness progression after relapse in schizophrenia. Schizophr Res 2013; 148:117-21. [PMID: 23756298 DOI: 10.1016/j.schres.2013.05.016] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 04/23/2013] [Accepted: 05/12/2013] [Indexed: 11/25/2022]
Abstract
It has long been suspected that relapse in schizophrenia is associated with disease progression in so far as time to response is longer, negative and other symptoms persist, some patients become treatment refractory and neuroprogression in terms of structural brain changes may occur. This article examines the evidence for illness progression after relapse in patients with schizophrenia. It reports on indirect evidence obtained from retrospective, naturalistic and brain-imaging studies, as well as a few prospective studies examining pre- and post-relapse treatment response. Findings suggest that the treatment response after relapse is variable, with many patients responding rapidly, others exhibiting protracted impairment of response and a subgroup displaying emergent refractoriness. This subgroup comprises about 1 in 6 patients, irrespective of whether it is the first or a subsequent relapse, and even when the delay between onset of first symptoms of relapse and initiation of treatment is brief. While there is a lack of well-designed studies investigating the post-relapse treatment outcome, available evidence gives sufficient cause for concern that, in addition to the considerable psychosocial risks, an additional risk of biological harm may be associated with relapse.
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Affiliation(s)
- Robin Emsley
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa.
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Emsley R, Nuamah I, Hough D, Gopal S. Treatment response after relapse in a placebo-controlled maintenance trial in schizophrenia. Schizophr Res 2012; 138:29-34. [PMID: 22446143 DOI: 10.1016/j.schres.2012.02.030] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/10/2012] [Accepted: 02/29/2012] [Indexed: 10/28/2022]
Abstract
While placebo-controlled studies continue to be required by regulatory authorities for the licensing of new drugs for schizophrenia to demonstrate maintenance of effect, the long-term risks to participants are largely unknown. We compared the response to treatment with paliperidone palmitate before and after relapse in such a study. This was a post-hoc analysis of 97 patients with schizophrenia who relapsed while receiving placebo in a multinational relapse prevention clinical trial. Patients underwent an initial open-label treatment phase of 33 weeks (comprising a 9-week transition phase to switch patients to paliperidone palmitate, a 12-week flexible-dose phase and a 12-week fixed-dose phase); a double-blind phase of variable duration during which stabilized patients were randomized 1:1 to either continue paliperidone palmitate or receive placebo; and an optional 52-week open-label flexible-dose extension phase. There was a small but significant increase in PANSS total scores after eight months of treatment following relapse (56.7[12.68]) compared with prerelapse endpoint (54.5[11.74]) (p=0.026). Fourteen of 97 (14.4%) patients who had initially responded favorably to treatment met predefined nonresponse criteria in the postrelapse treatment phase, suggesting that treatment refractoriness may evolve in a subset of patients after relapse. However, relapses occurred in 18% of patients randomized to ongoing treatment in the double-blind phase, raising the possibility that treatment failure may also evolve in patients receiving continuous treatment. These findings may help inform decisions regarding the future of placebo-controlled trials in schizophrenia.
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Affiliation(s)
- Robin Emsley
- University of Stellenbosch, Tygerberg 7500, Cape Town, South Africa.
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Melamed Y, Doron A, Stein-Reisner O, Bleich A. Ethical and Scientific Perspectives of Placebo-controlled Trials in Schizophrenia. J Clin Med Res 2009; 1:132-6. [PMID: 22493646 PMCID: PMC3318875 DOI: 10.4021/jocmr2009.07.1247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2009] [Indexed: 11/03/2022] Open
Abstract
UNLABELLED Clinical trials for development of new medications are essential in all fields of medicine. The requirement for a placebo arm in pharmaceutical trials presents ethical and clinical dilemmas that are especially complicated with regard to mentally ill persons whose free choice and ability to provide informed consent may be questionable. On the other hand, we do not believe that this predicament justifies unconditional rejection of placebo use in psychiatry, when the investigational drug may ultimately provide substantial benefit for some patients. At the same time it is the psychiatrist's responsibility to insure that investigators are adequately trained to conduct clinical trials and that stringent regulatory committees supervise the scientific, clinical and ethical aspects of the trials. KEYWORDS Placebo-control; Schizophrenia; Medical ethics; Clinical trials.
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Affiliation(s)
- Yuval Melamed
- Lev-Hasharon Mental Health Center, Netanya, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Abstract
This study investigates the question of whether short periods of medication-free research in early episode schizophrenia result in demonstrable long-term harm to human subjects. A meta-analysis of published quasi-experimental and random assignment studies that had a majority of first- or second-episode schizophrenia spectrum subjects, at least 1 initially unmedicated group, and a minimum of 1-year results was conducted. Only 6 studies, with 623 subjects, met inclusion criteria. The initially unmedicated groups showed a small, statistically nonsignificant long-term advantage (r = -0.09). Incorporating only random assignment studies into a composite effect size produced a similar near-zero result (r = 0.01). Good-quality evidence is inadequate to support a conclusion of long-term harm resulting from short-term postponement of medication in early episode schizophrenia research. A categorical prohibition against such research should be reconsidered.
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Affiliation(s)
- John R Bola
- School of Social Work, University of Southern California, USA.
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12
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Helmchen H. Ethische Implikationen plazebokontrollierter Prüfungen von Psychopharmaka. DER NERVENARZT 2005; 76:1319-29. [PMID: 15812676 DOI: 10.1007/s00115-005-1891-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The "note of clarification" of the World Medical Association to Article 29 of the Fifth Revision of the Declaration of Helsinki (Edinburgh 2000) intensified the controversial discussion of how methodologically compelling and ethically acceptable pure placebo controls are in clinical trials of new drugs if an effective standard therapy ("active control") is available. Pros and cons from this discussion are exposed and examined with regard to "minor" psychic disorders, depressions, and schizophrenia. Criteria are developed to facilitate the evaluation of each trial application. These criteria also seem to be necessary because normative authorities, which are responsible for licensing drugs such as FDA and EMEA, and legally relevant regulations such as the additional protocol for biomedical research of the European Council do not agree with regard to placebo controls. It is concluded that pure placebo-controlled clinical trials of new psychotropic drugs may be acceptable in minor psychic disorders, but in general -- at least in a pure form -- not in major disorders such as schizophrenia and major depression.
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Affiliation(s)
- H Helmchen
- Klinik für Psychiatrie und Psychotherapie, Charité -- Universitätsmedizin Berlin, Freie Universität Berlin
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David A, Adams CE, Eisenbruch M, Quraishi S, Rathbone J. Depot fluphenazine decanoate and enanthate for schizophrenia. Cochrane Database Syst Rev 2005:CD000307. [PMID: 15674872 DOI: 10.1002/14651858.cd000307] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Intramuscular injections (depot preparations) offer an advantage over oral medication for treating schizophrenia by reducing poor compliance. The benefits gained by long acting preparations, however, may be offset by a higher incidence of adverse effects. OBJECTIVES To investigate the clinical effects of fluphenazine decanoate and enanthate. SEARCH STRATEGY For this update we searched the Cochrane Schizophrenia Group's Register (May 2002). SELECTION CRITERIA We considered all relevant randomised clinical controlled trials focusing on people with schizophrenia comparing fluphenazine decanoate or enanthate with placebo or oral anti-psychotics or other depot preparations. DATA COLLECTION AND ANALYSIS We reliably selected, quality rated and data extracted studies. For dichotomous data we estimated relative risk (RR) with 95% confidence intervals (CI), and, where possible, the number needed to treat/harm (NNT/H). Analysis was by intention-to-treat. We used the weighted mean difference (WMD) for normal continuous data. Tests of heterogeneity and for publication bias were undertaken. MAIN RESULTS This review now includes 70 randomised studies. Compared with placebo, fluphenazine decanoate did not reduce relapse over 6 months to 1 year, but one longer term study found that relapse was significantly reduced in the fluphenazine arm (n=54, RR 0.35, CI 0.2 to 0.6, NNT 2 CI 2 to 4). Fluphenazine decanoate does not reduce relapse more than oral neuroleptics (n=419, 6 RCTs, RR relapse 26-52 weeks 1.46 CI 0.8 to 2.8) or other depot antipsychotics (n=581, 11 RCTs, RR relapse 26-52 weeks 0.82 CI 0.6 to 1.2). Relapse rates over 6 months to 1 year were not significantly different between standard dosage of fluphenazine decanoate over a low dose group (n=523, 4 RCTs, RR 2.09 CI 0.6 to 7.1). Movement disorders were significantly less for people receiving fluphenazine decanoate compared with oral neuroleptics (n=259, 3 RCTs, RR 0.47 CI 0.2 to 0.9, NNT 14 CI 10 to 82). For fluphenazine enanthate there were limited data but no clear difference in global change (0 to 5 weeks) when compared with oral neuroleptics (n=31, 1 RCTs, RR 0.67 CI 0.3 to 1.7), and in relapse rates over 6-26 weeks between fluphenazine enanthate and other depots. Compared with placebo, giving the enanthate caused no more people to need need anticholinergic drugs (n=25, 1 RCT, RR 9.69 CI 0.6 to 163.0) and movement disorders, tardive dyskinesia, tremor, blurred vision and dry mouth were equally prevalent when enanthate was compared with other depot neuroleptics. AUTHORS' CONCLUSIONS There are more data for fluphenazine decanoate than for the enanthate ester. Both are effective antipsychotic preparations. In the context of trials, there is little advantage of these depots over oral medications in terms of compliance but this is unlikely to be applicable to everyday clinical practice.
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Affiliation(s)
- A David
- Institute of Psychiatry and GKT School of Medicine, King's College School of Medicine and Dentistry, 103 Denmark Hill, London, UK, SE5 8AF.
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14
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Beasley CM, Sutton VK, Hamilton SH, Walker DJ, Dossenbach M, Taylor CC, Alaka KJ, Bykowski D, Tollefson GD. A double-blind, randomized, placebo-controlled trial of olanzapine in the prevention of psychotic relapse. J Clin Psychopharmacol 2003; 23:582-94. [PMID: 14624189 DOI: 10.1097/01.jcp.0000095348.32154.ec] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Sustained response to antipsychotic therapy is an important outcome measure for patients with psychotic disorders. Placebo control in studies of relapse prevention contributes valuable information yet provokes much debate. This study, using placebo as a control, evaluated olanzapine's efficacy in preventing a psychotic relapse. Participants were stable minimally symptomatic outpatients with schizophrenia or schizoaffective disorder. The study included 4 phases: (1) 4-day to 9-day screening/evaluation (N = 583), (2) 6-week conversion to open-label olanzapine (N = 493; 10-20 mg/d), (3) 8-week stabilization on olanzapine (N = 458; 10-20 mg/d), and (4) 52-week randomized (2:1), double-blind maintenance with olanzapine (N = 224; 10-20 mg/d) or placebo (N = 102). Primary relapse criteria were clinically significant changes in the Brief Psychiatric Rating Scale (BPRS) positive item cluster or rehospitalization due to positive symptoms. Statistical methodology allowed sequential real-time estimation of efficacy across blinded treatment groups and multiple interim analyses, which permitted study termination when efficacy was significantly different between treatments. A significant between-treatment difference emerged 210 days after first patient randomization to double-blind treatment. Thus, 151 (46.3%) of the randomized patients were discontinued early and 34 (10.4%) of the planned patient enrollment were not required. The olanzapine group had a significantly longer time to relapse (P < 0.0001) than the placebo group. The 6-month cumulative estimated relapse rate (Kaplan-Meier) was 5.5% for olanzapine-treated patients versus 55.2% for placebo-treated patients. The design of this study enabled appropriate statistical testing of the primary hypothesis while minimizing exposure of patients to a less effective treatment than olanzapine. In remitted stabilized patients with schizophrenia or schizoaffective disorder, olanzapine demonstrated a positive benefit-to-risk profile in relapse prevention.
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Affiliation(s)
- Charles M Beasley
- Lilly Research Laboratories, Eli Lilly & Company, Lilly Corporate Center, Drop Code 1730, Indianapolis, IN 46285, USA.
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15
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Roberts LW, Roberts B. Psychiatric research ethics: an overview of evolving guidelines and current ethical dilemmas in the study of mental illness. Biol Psychiatry 1999; 46:1025-38. [PMID: 10536739 DOI: 10.1016/s0006-3223(99)00205-x] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The field of psychiatry has an opportunity to construct a more refined, perhaps more enduring understanding of the ethical basis of mental illness research. The aim of this paper is to help advance this understanding by 1) tracing the evolution of the emerging ethic for biomedical experimentation, including recent recommendations of the President's National Bioethics Advisory Commission, and 2) reviewing data and concepts related to compelling ethical questions now faced in the study of mental disorders. Empirical findings on informed consent, the ethical safeguards of institutional review and surrogate decision making, and the relationship between scientific and ethical imperatives are outlined. Psychiatric researchers will increasingly be called upon to justify their scientific approaches and to seek ways of safeguarding the well-being of people with mental illness who participate in experiments. Most importantly, psychiatric investigators will need to demonstrate their appreciation and respect for ethical dimensions of investigation with special populations. Further empirical study and greater sophistication with respect to the distinct ethical issues in psychiatric research are needed. Although such measures present many challenges, they should not interfere with progress in neuropsychiatric science so long as researchers in our field seek to guide the process of reflection and implementation.
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Affiliation(s)
- L W Roberts
- Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque 97131, USA
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Johnstone EC, Owens DG, Crow TJ, Davis JM. Does a four-week delay in the introduction of medication alter the course of functional psychosis? J Psychopharmacol 1999; 13:238-44. [PMID: 10512078 DOI: 10.1177/026988119901300305] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study is an analysis of findings of a follow-up study of 105 patients with functional psychotic illness who had participated in a random and blind 4-week trial of pimozide, lithium, both and placebo. The intention was to examine the question of whether a 4-week delay in initiating antipsychotic treatment has a detrimental effect 2.5 years later. Detailed follow-up measures included need for care over the 2.5 years, treatments required, occupational decline, police contact, substance misuse, psychopathology and cognitive function. There was no evidence at all that those initially randomized to placebo had a poorer outcome in terms of any of these variables. It is concluded that a 4-week delay in initiating active treatment in patients with functional psychosis has no long-term adverse effects.
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Affiliation(s)
- E C Johnstone
- Department of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, UK.
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Zipursky RB, Darby P. Placebo-controlled studies in schizophrenia--ethical and scientific perspectives: an overview of conference proceedings. Schizophr Res 1999; 35:189-200. [PMID: 10093863 DOI: 10.1016/s0920-9964(98)00124-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Much controversy has surrounded the issue of whether clinical trials of new antipsychotic medications for the treatment of schizophrenia ought to include a placebo control group. On 18 September 1997, the authors co-chaired a symposium at the University of Toronto devoted to elucidating the issues relevant to this debate. Speakers with expertise in the areas of schizophrenia research, clinical trials methodology, medical ethics and informed consent presented their perspectives. This paper aims to summarize the major scientific and ethical issues raised during the symposium.
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Affiliation(s)
- R B Zipursky
- Department of Psychiatry, University of Toronto School of Medicine, Ontario, Canada.
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Affiliation(s)
- W T Carpenter
- Maryland Psychiatric Institute, University of Maryland School of Medicine, Baltimore 21228, USA
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Abstract
The study objective was to clarify the ethical basis of psychiatric research by outlining conceptual issues and empirical findings related to the ethics of human experimentation. A systematic review of scholarly and empirical literature covering three decades was performed. The ethics of human research has come to be understood in relation to the principles of respect for persons, beneficence, justice, and the ideal of informed consent. Subjects who cannot fully participate in informed-consent processes are especially vulnerable to exploitation. Current dilemmas stem from insufficient attention to the vulnerabilities of mentally ill research participants, problems in applying ethical concepts and guidelines to psychiatric research, and claims of research misconduct. Empirical studies indicate that (1) psychiatric symptoms significantly affect informed consent, (2) psychiatric patients may possess certain strengths with respect to research involvement, (3) proxy decision-making is problematic, (4) informed consent is also difficult to attain with the medically ill and others, (5) patients are motivated to participate in research by the hope of personal benefit, (6) ethical aspects of research are poorly documented, and (7) institutional review processes may not be adequate to protect vulnerable subjects. Psychiatric research can be performed ethically, according to standards set throughout the biomedical and behavioral sciences, so long as researchers and institutions are respectful of special ethical issues in human experimentation and strive to include vulnerable study participants fully in research decisions. However, many gaps in the empirical literature exist regarding the specific nature and implementation of ethics principles in psychiatric research. Efforts to advance both science and ethics, including the study of ethical dimensions of human research itself, are essential for the future of psychiatry.
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Affiliation(s)
- L W Roberts
- Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque 87131-5326, USA
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Abstract
The main current application of placebo is in clinical research. The term placebo effect refers to diverse non-specific, desired or non-desired effects of substances or procedures and interactions between patient and therapist. Unpredictability of the placebo effect necessitates placebo-controlled designs for most trials. Therapeutic and diagnostic use of placebo is ethically acceptable only in few well-defined cases. While "therapeutic" application of placebo almost invariably implies deception, this is not the case for its use in research. Conflicts may exist between the therapist's Hippocratic and scientific obligations. The authors provide examples in neuropsychiatry, illustrating that objective scientific data and well-considered guidelines may solve the ethical dilemma. Placebo control might even be considered an ethical obligation but some provisos should be kept in mind: (a) no adequate therapy for the disease should exist and/or (presumed) active therapy should have serious side-effects; (b) placebo treatment should not last too long; (c) placebo treatment should not inflict unacceptable risks, and (d) the experimental subject should be adequately informed and informed consent given.
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Affiliation(s)
- P P De Deyn
- Department of Neurology, Middelheim General Hospital, Antwerp, Belgium
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Freedman B, Glass KC, Weijer C. Placebo orthodoxy in clinical research. II: Ethical, legal, and regulatory myths. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 1996; 24:252-259. [PMID: 9069852 DOI: 10.1111/j.1748-720x.1996.tb01860.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Placebo-controlled trials are held by many, including regulators at agencies like the United States Food and Drug Administration (FDA), to be the gold standard in the assessment of new medical interventions. Yet the use of placebo controls in clinical trials has been the focus of considerable controversy. In this two-part article, we challenge a number of common beliefs concerning the value of placebo controls. Part I critiques statistical and other scientific justifications for the use of placebo controls in clinical research. The continued use of placebo controls in clinical trials on diseases for which accepted treatment exists raises equally important ethical, legal, and regulatory issues for which various justifications have been given. Defense of this practice relies on normative as well as empirical myths.In their attack on the prevailing use of placebo controls, Kenneth Rothman and Karin Michels emphasize that this practice stands in violation of the World Medical Association's guidelines on the ethics of human experimentation, most commonly known as the Helsinki Declaration.
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Freedman B, Weijer C, Glass KC. Placebo orthodoxy in clinical research. I: Empirical and methodological myths. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 1996; 24:243-251. [PMID: 9069851 DOI: 10.1111/j.1748-720x.1996.tb01859.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The use of statistics in medical research has been compared to a religion: it has its high priests (statisticians), supplicants (journal editors and researchers), and orthodoxy (for example, p <.05 is significant). Although the comparison may be more unfair to religion than to research, a useful lesson can nonetheless be drawn: the practice of clinical research may benefit—as does the spirit—from critical self-examination. Arguably, no aspect of the conduct of clinical trials is currently more controversial—and thus in as dire need of critical examination—than the use of placebo controls. The ethical and scientific controversies associated with placebo-controlled trials, never far below the surface, have once again seized public attention. Clearly, concern about these issues within the professional community runs deep and wide, as evidenced by the volume of response generated by Kenneth Rothman and Karin Michels's recent Critique. Criticisms of the use of placebo controls in clinical research are scattered through the literatureo; our objective is to present the case against placebos in a compendious form that takes account of scientific and statistical as well as normative issues.
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Addington D. The use of placebos in clinical trials for acute schizophrenia. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1995; 40:171-6. [PMID: 7621385 DOI: 10.1177/070674379504000403] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This review examines the scientific and ethical justification for the use of randomized concurrent placebo-controlled trials in the treatment of acute relapse in chronic schizophrenia. A literature search was conducted, and the national regulatory authority was consulted. Many placebo-controlled studies of acute or chronic schizophrenia are being published and it is the official position of both the Canadian and US regulatory authorities that such studies are required for both scientific and ethical reasons. The specific strengths and limitations of placebo-controlled studies are reviewed. Examples, drawn from Canadian studies, are presented to illustrate their benefits. It is concluded that the use of placebos in the particular situation of acute or chronic schizophrenia is ethically and scientifically justified. It forms an essential component of a comprehensive drug evaluation for new antipsychotic medications.
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Affiliation(s)
- D Addington
- Department of Psychiatry, University of Calgary, Alberta
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