A randomized controlled trial of venlafaxine XR for major depressive disorder after spinal cord injury: Methods and lessons learned

Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care

Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.

Beyond pain: can antidepressants improve depressive symptoms and quality of life in patients with neuropathic pain? A systematic review and meta-analysis

Neuropathic pain can be a predictor of severe emotional distress, up to full-blown depressive states. In these patients, it is important to move beyond the sole treatment of pain, to recognize depressive symptoms, and to ultimately improve the quality of life. We systematically searched for published and unpublished clinical trials assessing the efficacy and tolerability of antidepressants vs placebo on depression, anxiety and quality of life in patients with neuropathic pain, and pooled data in a meta-analysis. A total of 37 studies fulfilled eligibility criteria and 32 provided data for meta-analysis. Antidepressants were more effective than placebo in improving depressive symptoms (standardized mean difference -0.11; 95% confidence interval -0.20 to -0.02), although the magnitude of effect was small, with a number needed to treat of 24. No significant difference emerged between antidepressants and placebo in reducing anxiety. Quality of life seemed improved in patients on antidepressants, as did pain. Acceptability and tolerability were higher in patients on placebo. To the best of our knowledge, this is the first meta-analysis specifically focusing on the effect of antidepressants on psychiatric symptoms and quality of life in patients with neuropathic pain. Our findings suggest that despite their potential benefit in patients with neuropathic pain, antidepressants should be prescribed with particular care because they might be less tolerable in such a fragile population. However, our findings warrant further research to explore how a correct use of antidepressants can help patients to cope with the consequences of neuropathic pain on their psychosocial health and quality of life.

Efficacy and safety of 9 nonoperative regimens for the treatment of spinal cord injury: A network meta-analysis

OBJECTIVE

This network meta-analysis aims to compare the efficacy and safety of 9 nonoperative regimens (placebo, pregabalin, GM-1 ganglioside, venlafaxine extended-release [venlafaxine XR], fampridine, conventional over-ground training [OT], body-weight-supported treadmill training [BWSTT], robotic-assisted gait training [RAGT] + OT and body-weight-supported over-ground training [BWSOT]) in treating spinal cord injury (SCI).

METHODS

Clinical controlled trials of 9 nonoperative regimens for SCI were retrieved in the electronic database. Traditional pairwise and Bayesian network meta-analyses were performed to compare the efficacy and safety of 9 nonoperative regimens for the treatment of SCI. Weighted mean difference (WMD), odds ratios (OR), and surface under the cumulative ranking curve (SUCRA) were calculated using the Markov Chain Monte Carlo engine Open BUGS (V.3.4.0) and R (V.3.2.1) package gemtc (V.0.6).

RESULTS

A total of 9 clinical controlled trials meeting the inclusion criteria were selected in this meta-analysis. On the aspect of efficacy, the results of pairwise meta-analysis indicated that the RAGT + OT and BWSOT might have the best efficacy in SCI patients in terms of a lower extremity motor score (LEMS) compared with conventional OT; the efficacy of RAGT + OT on SCI patients was relatively better than that of conventional OT in terms of walking index for spinal cord injury (WISCI). With the aspect of safety, the constipation rate of placebo on SCI patients was relatively higher than that of venlafaxine XR; however, with respect to headache and urinary tract infection, there was no significant difference in the safety of placebo, pregabalin, GM-1 ganglioside, venlafaxine XR, and fampridine on SCI patients. The results of SUCRA values suggested that BWSOT had the highest SUCRA value (75.25%) of LEMS; RAGT + OT had the highest SUCRA value (88.50%) of WISCI; venlafaxine XR had the highest SUCRA value (94.00%) of constipation; venlafaxine XR had the highest SUCRA value (80.00%) of headache; GM-1 ganglioside had the highest SUCRA value (87.75%) of urinary tract infection.

CONCLUSION

Our results provide evidence that the RAGT + OT and BWSOT might have the best efficacy in the treatment of SCI, and the venlafaxine XR and GM-1 ganglioside showed adequate safety for SCI.

Changes in pain and quality of life in depressed individuals with spinal cord injury: does type of pain matter?

OBJECTIVE

To examine the association of neuropathic and nociceptive pain severity and interference with quality of life (QoL) in persons with spinal cord injury (SCI) who underwent a randomized controlled 12-week trial of an antidepressant to treat depression. A secondary objective was to assess the effect of changes in pain on mobility and physical independence.

DESIGN

Multivariable ANCOVA models controlling for relevant demographic covariates, treatment condition, and baseline pain and QoL were used.

SETTING

Six rehabilitation centers.

PARTICIPANTS

Of the 133 persons who were randomized into the trial, 108 provided pain severity and interference ratings through follow-up.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

The Satisfaction with Life Scale and the physical and mental component summary scores of the 12-Item Short-Form Health Survey (SF-12). Secondary outcome measures included the mobility and physical independence subscales of the Craig Handicap Assessment and Reporting Technique (CHART).

RESULTS

Broadly, few associations between pain and QoL were evident. Results revealed relationships between lower baseline nociceptive pain interference and higher satisfaction with life and mental health-related QoL at 12 weeks. Similarly, lower neuropathic pain interference was associated with change in physical independence, but unrelated to mobility.

CONCLUSIONS

Pain interference over time may be differentially related to QoL outcomes based on the type of pain following SCI, but overall, there were no extensive relationships between pain and QoL in this sample of depressed persons with SCI.

Evaluating the Psychometric Properties and Responsiveness to Change of 3 Depression Measures in a Sample of Persons With Traumatic Spinal Cord Injury and Major Depressive Disorder

OBJECTIVES

To compare the measurement properties and responsiveness to change of the Patient Health Questionnaire-9 (PHQ-9), the Hopkins Symptom Checklist-20 (HSCL-20), and the Hamilton Depression Rating Scale (HAM-D) in people with spinal cord injury (SCI) diagnosed with major depressive disorder (MDD).

DESIGN

Secondary analysis of depression symptoms measured at 6 occasions over 12 weeks as part of a randomized controlled trial of venlafaxine XR for MDD in persons with SCI.

SETTING

Outpatient and community settings.

PARTICIPANTS

Individuals (N=133) consented and completed the drug trial. Eligibility criteria were age at least 18 years, traumatic SCI, and diagnosis of MDD.

INTERVENTIONS

Venlafaxine XR.

MAIN OUTCOME MEASURES

Patients completed the PHQ-9 and the HSCL-20 depression scales; clinical investigators completed the HAM-D and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) Dissociative Disorders, which was used as a diagnostic criterion measure.

RESULTS

All 3 instruments were improved with rating scale analysis. The HSCL-20 and the HAM-D contained items that misfit the underlying construct and that correlated weakly with the total scores. Removing these items improved the internal consistency, with floor effects increasing slightly. The HAM-D correlated most strongly with Structured Clinical Interview for DSM-IV Dissociative Disorders diagnoses. Improvement in depression was similar on all outcome measures in both treatment and control groups.

CONCLUSIONS

The psychometric properties of the revised depression instruments are more than adequate for routine use in adults with SCI and are responsive to clinical improvement. The PHQ-9 is the simplest instrument with measurement properties as good as or better than those of the other instruments and required the fewest modifications.

Novel risk factors associated with current suicidal ideation and lifetime suicide attempts in individuals with spinal cord injury

OBJECTIVE

To determine unique associations of suicidal ideation (SI) and lifetime suicide attempts (SAs) in individuals with spinal cord injury (SCI).

DESIGN

Cross-sectional analysis.

SETTING

Outpatient.

PARTICIPANTS

Individuals with SCI (N=2533) who were 18 years or older with a history of traumatic SCI.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Any SI in the past 2 weeks (9-item Patient Health Questionnaire) and any lifetime SA.

RESULTS

Three hundred twenty-three individuals (13.3%) reported SI in the past 2 weeks and 179 (7.4%) reported lifetime SA. After controlling for other factors, both lifetime SA and current SI were associated with study site and current level of depression. In addition, SA was associated with less education, younger age at injury, having current or past treatment of depression, and having bipolar disorder or schizophrenia. SI was associated with more years since injury and lifetime SA. Several psychological factors were associated with current SI and lifetime SAs, including lower environmental reward and less positive affect. In addition, control of one's community activities and spiritual well-being were associated with current SI. In bivariate comparisons, severity of SCI was also associated with the 47% of the SAs that occurred after injury.

CONCLUSIONS

Several unique associations of SI and lifetime SA in individuals with SCI were identified, including level of environmental reward and control, spiritual well-being, and severity of SCI. These factors bear further investigation as prospective risk factors for suicidal behavior after SCI.

Review of cross-cultural issues related to quality of life after spinal cord injury

Quality of life (QOL) is a dynamic concept that means different things to different people, both in the general public and within the research community. Because of this, a common definition of QOL has been hard to achieve. This article reviews cross-cultural issues related to QOL research in spinal cord injury (SCI). Many factors influence QOL for persons with SCI, including observable and objective indicators and subjective self-report ones. The World Health Organization's International Classification of Function, Disability and Health is used in this article as a framework to better understand how these factors may influence QOL. A number of important steps are summarized with respect to measurement issues in QOL. A comparison between data from 2 countries (United States and Brazil) using the International SCI QOL Basic Data Set shows similarities in scores and good reliability in the Brazilian sample. Substantial, significant correlations were observed among the SCI QOL Basic Data Set items and the WHOQOL-BREF within the US sample. The article ends with a set of recommendations for the development of cross-cultural measures of QOL for use in the SCI population.

Differences in quality of life outcomes among depressed spinal cord injury trial participants

OBJECTIVE

To assess the role that treatment response plays in a randomized controlled trial of an antidepressant among people with spinal cord injury (SCI) diagnosed with major depressive disorder (MDD) in explaining quality of life (QOL), assessed both globally as life satisfaction and in terms of physical and mental health-related QOL.

DESIGN

Multivariable analyses were conducted, controlling for demographic, neurologic, and participatory factors and perceived functional limitations.

SETTING

Rehabilitation centers.

PARTICIPANTS

Of the 133 persons who were randomized into the Project to Improve Symptoms and Mood after Spinal Cord Injury randomized controlled trial, 124 participated in this study. All participants were between the ages of 18 and 64 years, at least 1 month post-SCI, met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for MDD, and completed the core measures used in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Satisfaction with Life Scale and the physical and mental component summary scores of the Medical Outcomes Study 12-Item Short-Form Health Survey.

RESULTS

Reduction in depressive symptoms over the course of a 12-week trial was predictive of increased QOL, which was measured as life satisfaction and mental well-being, within the context of other explanatory factors. However, reduction in symptoms did not explain differences in physical well-being among those with MDD. Perceived functional disability explained all 3 indices of QOL.

CONCLUSIONS

Greater recognition has been given to QOL outcomes as endpoints of clinical trials because these often reflect participants' reported outcomes. Our findings support the association of QOL to the reduction of depression symptoms among trial participants. This association differs depending on how QOL is defined and measured, with stronger relations observed with life satisfaction and mental well-being among those diagnosed with MDD. The lack of association between depression and physical well-being may be explained by participants' subjective interpretation of physical well-being after SCI and their expectations and perceptions of improved physical health-related QOL based on the use of assistive technology. Consistent with our findings, pain is likely to play a role in decreasing physical QOL among those with incomplete injuries. Practicing caution is suggested in using physical well-being as an endpoint in trials among people with SCI.

Systematic review of the effect of individual and combined nutrition and exercise interventions on weight, adiposity and metabolic outcomes after delivery: evidence for developing behavioral guidelines for post-partum weight control

BACKGROUND

Post-partum weight retention contributes to the risk of chronic obesity and metabolic alterations. We conducted a systematic review of randomized controlled trials (RCTs) on the effect of post-partum nutrition and exercise interventions on weight loss and metabolic outcomes.

DATA SOURCES

Four electronic databases were searched from inception to January, 2012. Two investigators reviewed titles and abstracts, performed data abstraction on full articles and assessed study quality.

METHODS

We included RCTs comparing nutrition, exercise or combined nutrition and exercise interventions with a control condition. Thirteen studies met our inclusion criteria (N = 1,310 participants). Data were abstracted on study characteristics, intervention components, enrollment period, and length of follow-up. Outcomes of interest included weight, adiposity, cardio-metabolic measures (glucose, lipids) and obesity-related inflammatory markers.

RESULTS

Nine trials compared combined interventions to standard post-partum care; three trials assessed the effect of exercise interventions, one trial evaluated a nutrition-only intervention. Four good quality RCTs on combined interventions had inconsistent findings, with the larger RCT (N = 450) reporting no difference in weight between groups. Four fair-to good quality RCTs reported greater weight loss in the combined intervention group vs. standard care, ranging from 0.17 kg to 4.9 kg. Results from exercise only interventions were inconclusive. Evidence for nutrition only interventions was insufficient. There was insufficient evidence for the effect of post-partum interventions on metabolic risk factors and inflammatory biomarkers.

CONCLUSIONS

Combined nutrition and exercise interventions can achieve weight loss, but evidence is limited due to a small number of trials and limitations in study design.