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Schmidt ME, Kezic I, Popova V, Melkote R, Van Der Ark P, Pemberton DJ, Mareels G, Canuso CM, Fava M, Drevets WC. Efficacy and safety of aticaprant, a kappa receptor antagonist, adjunctive to oral SSRI/SNRI antidepressant in major depressive disorder: results of a phase 2 randomized, double-blind, placebo-controlled study. Neuropsychopharmacology 2024:10.1038/s41386-024-01862-x. [PMID: 38649428 DOI: 10.1038/s41386-024-01862-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/18/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
This was a double-blind, randomized, phase 2 study of adults (18-64 years) with DSM-5 diagnosis of major depressive disorder (MDD), with moderate-to-severe episode severity (Montgomery-Åsberg Depression Rating Scale [MADRS] ≥25) despite an adequate course with ongoing antidepressant for ≥6 weeks to ≤12 months. Following a double-blind placebo lead-in period (up to 3 weeks), participants were randomized to receive once daily aticaprant 10 mg or continue placebo, added to their ongoing treatment, for 6 weeks. Of 184 participants enrolled, 169 were included in safety analyses (aticaprant n = 85, placebo n = 84) and 166 in full intent-to-treat (fITT) efficacy analyses; 121 placebo lead-in non-responders (<30% reduction in MADRS total score) in fITT were included in enriched ITT (eITT) analyses. Improvement (least squares mean difference [upper limit 1-sided 80% CI] versus placebo) in MADRS total score at week 6 for aticaprant was significant versus placebo (eITT: -2.1 [-1.09], 1-sided p = 0.044; effect size (ES) 0.23; fITT -3.1 [2.21], 1-sided p = 0.002; ES 0.36). The between-group difference was larger among participants with Snaith-Hamilton Pleasure Scale (SHAPS) score greater/equal to versus less than baseline median SHAPS. The most common treatment-emergent adverse events reported for aticaprant (versus placebo) were headache (11.8% versus 7.1%), diarrhea (8.2% versus 2.4%), nasopharyngitis (5.9% versus 2.4%), and pruritus (5.9% versus 0%). One participant (1.2%) in each arm discontinued treatment due to an adverse event. In this study of participants with MDD and inadequate response to SSRI/SNRI, adjunctive treatment with aticaprant significantly reduced depressive symptoms versus placebo, without resulting in significant safety signals, supporting further investigation in larger trials.
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Affiliation(s)
| | - Iva Kezic
- Janssen Research & Development, Beerse, Belgium
| | | | - Rama Melkote
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | | | | | - Guy Mareels
- Janssen Research & Development, Beerse, Belgium
| | - Carla M Canuso
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Maurizio Fava
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Treatment resistance in psychiatry: state of the art and new directions. Mol Psychiatry 2022; 27:58-72. [PMID: 34257409 PMCID: PMC8960394 DOI: 10.1038/s41380-021-01200-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/26/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Treatment resistance affects 20-60% of patients with psychiatric disorders; and is associated with increased healthcare burden and costs up to ten-fold higher relative to patients in general. Whilst there has been a recent increase in the proportion of psychiatric research focussing on treatment resistance (R2 = 0.71, p < 0.0001), in absolute terms this is less than 1% of the total output and grossly out of proportion to its prevalence and impact. Here, we provide an overview of treatment resistance, considering its conceptualisation, assessment, epidemiology, impact, and common neurobiological models. We also review new treatments in development and future directions. We identify 23 consensus guidelines on its definition, covering schizophrenia, major depressive disorder, bipolar affective disorder, and obsessive compulsive disorder (OCD). This shows three core components to its definition, but also identifies heterogeneity and lack of criteria for a number of disorders, including panic disorder, post-traumatic stress disorder, and substance dependence. We provide a reporting check-list to aid comparisons across studies. We consider the concept of pseudo-resistance, linked to poor adherence or other factors, and provide an algorithm for the clinical assessment of treatment resistance. We identify nine drugs and a number of non-pharmacological approaches being developed for treatment resistance across schizophrenia, major depressive disorder, bipolar affective disorder, and OCD. Key outstanding issues for treatment resistance include heterogeneity and absence of consensus criteria, poor understanding of neurobiology, under-investment, and lack of treatments. We make recommendations to address these issues, including harmonisation of definitions, and research into the mechanisms and novel interventions to enable targeted and personalised therapeutic approaches.
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Mallet J, Gorwood P, Le Strat Y, Dubertret C. Major Depressive Disorder (MDD) and Schizophrenia- Addressing Unmet Needs With Partial Agonists at the D2 Receptor: A Review. Int J Neuropsychopharmacol 2019; 22:651-664. [PMID: 31406978 PMCID: PMC6822140 DOI: 10.1093/ijnp/pyz043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/20/2019] [Accepted: 08/07/2019] [Indexed: 12/28/2022] Open
Abstract
Second-generation antipsychotics are common candidates for the adjunctive treatment of major depressive disorder and for the treatment of schizophrenia. However, unmet needs remain in the treatment of both disorders. Considering schizophrenia, antipsychotics are the most common treatment and have demonstrated good efficacy. Still, side effects of these treatments are commonly reported and may impact adherence to the medication and functioning in patients with schizophrenia. Regarding major depressive disorder, despite the availability of several classes of antidepressants, many patients do not achieve remission. Adjunctive treatment with antipsychotics may improve clinical and functional outcomes. Compared with dopamine D2 receptor antagonism that is exhibited by most antipsychotics, partial agonism may result in improved outcomes in major depressive disorder and in schizophrenia. Aripiprazole, cariprazine, and brexpiprazole have partial agonism at the dopamine D2 receptor and could potentially overcome limitations associated with D2 antagonism. The objectives of this review were (1) to discuss the goal of treatment with second-generation antipsychotics in major depressive disorder and schizophrenia, and the clinical factors that should be considered, and (2) to examine the short- and long-term existing data on the efficacy and safety of D2 receptor partial agonists (aripiprazole, cariprazine, and brexpiprazole) in the adjunctive treatment of major depressive disorder and in the treatment of schizophrenia.
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Affiliation(s)
- Jasmina Mallet
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,Psychiatry Department, University Hospital Louis Mourier; Paris Diderot University, France
| | - Philip Gorwood
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,GHU Paris, CMME, Sainte-Anne hospital; University of Paris, France,Correspondence: Professor Philip Gorwood, MD, PhD, CMME, GHU Paris Psychiatrie, 100 rue de la Sante, 75014 Paris, France ()
| | - Yann Le Strat
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,Psychiatry Department, University Hospital Louis Mourier; Paris Diderot University, France
| | - Caroline Dubertret
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,Psychiatry Department, University Hospital Louis Mourier; Paris Diderot University, France
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Spielmans GI, Olson S, Keicher RM. "Salami Slicing" in Pooled Analyses of Second-Generation Antipsychotics for the Treatment of Depression. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:171-172. [PMID: 28490033 DOI: 10.1159/000464251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/16/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Glen I Spielmans
- Department of Psychology, Metropolitan State University, Saint Paul, MN, USA
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Weiller E, Weiss C, Watling CP, Edge C, Hobart M, Eriksson H, Fava M. Functioning outcomes with adjunctive treatments for major depressive disorder: a systematic review of randomized placebo-controlled studies. Neuropsychiatr Dis Treat 2018; 14:103-115. [PMID: 29343962 PMCID: PMC5751804 DOI: 10.2147/ndt.s146840] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Patients with major depressive disorder (MDD) with inadequate response to antidepressant treatment (ADT) may suffer a prolonged loss of functioning. This review aimed to determine if self-rated functional measures are informative in randomized placebo-controlled studies of adjunctive therapy in patients with MDD and inadequate response to ADT. METHODS This was a systematic literature review of articles in any language from the MEDLINE database published between January 1990 and March 2017. Eligible studies met the following criteria: patients with MDD; inadequate response to at least one ADT; adjunctive therapy (pharmacological or otherwise) to ADT; placebo control group; randomized controlled trial or a post hoc analysis of a randomized controlled trial; reported a self-rated functioning scale. Study characteristics and functioning efficacy data were extracted. RESULTS A total of 2,090 discrete records were screened, 293 full-text articles were assessed for eligibility, and 26 studies were included. All studies were acute (6-12 weeks) except for one 52-week study. The only self-rated functioning scale used in the included studies was the Sheehan Disability Scale (SDS). Of the 13 adjunctive agents identified, aripiprazole, brexpiprazole, edivoxetine, and risperidone improved functioning versus placebo (p<0.05), as measured by the SDS total or mean score. On the SDS "work/studies" item, only aripiprazole had a statistically significant benefit, in one study out of four. Thus, where a benefit was observed on the SDS total or mean, this was generally driven by improvement on the "social life" and "family life" items. A limitation of the review is that it only considered published literature from one database. CONCLUSION The SDS, a self-rated functional measure, is informative in acute randomized placebo-controlled studies of adjunctive therapy in patients with MDD and inadequate response to ADT. However, the item that measures work performance may be less relevant to this population than the items that measure social and family life.
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Affiliation(s)
| | - Catherine Weiss
- Otsuka Pharmaceutical Development & Commercialization Inc., Princeton, NJ, USA
| | | | | | - Mary Hobart
- Otsuka Pharmaceutical Development & Commercialization Inc., Princeton, NJ, USA
| | | | - Maurizio Fava
- Division of Clinical Research of the MGH Research Institute.,Department of Psychiatry.,Clinical Trials Network & Institute (CTNI), Massachusetts General Hospital, Boston, MA, USA
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Smagula SF, Wallace ML, Anderson SJ, Karp JF, Lenze EJ, Mulsant BH, Butters MA, Blumberger DM, Diniz BS, Lotrich F, Dew MA, Reynolds CF. Combining moderators to identify clinical profiles of patients who will, and will not, benefit from aripiprazole augmentation for treatment resistant late-life major depressive disorder. J Psychiatr Res 2016; 81:112-8. [PMID: 27438687 PMCID: PMC5021594 DOI: 10.1016/j.jpsychires.2016.07.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/28/2016] [Accepted: 07/05/2016] [Indexed: 01/19/2023]
Abstract
Personalizing treatment for late-life depression requires identifying and integrating information from multiple factors that influence treatment efficacy (moderators). We performed exploratory moderator analyses using data from a multi-site, randomized, placebo-controlled, double-blind trial of aripiprazole augmentation. Patients (n = 159) aged ≥60 years had major depressive disorder that failed to remit with venlafaxine monotherapy. We examined effect sizes of 39 potential moderators of aripiprazole (vs. placebo) augmentation efficacy using the outcome of percentage reduction in depressive symptom after 12 weeks. We then incorporated information from the individually relevant variables in combined moderators. A larger aripiprazole treatment effect was related to: white race, better physical function, better performance on Trail-Making, attention, immediate, and delayed memory tests, greater psychomotor agitation and suicidality symptoms, and a history of adequate antidepressant pharmacotherapy. A smaller aripiprazole treatment effect was observed in patients with: more pain and more work/activity impairment and libido symptoms. Combining information from race and Trail-Making test performance (base combined moderator (Mb*)) produced a larger effect size (Spearman effect size = 0.29 (95% confidence interval (CI): 0.15, 0.42)) than any individual moderator. Adding other individually relevant moderators in the full combined moderator (Mf*) further improved effect size (Spearman effect size = 0.39 (95% CI: 0.25, 0.52)) and identified a sub-group benefiting more from placebo plus continuation venlafaxine monotherapy than adjunctive aripiprazole. Combining moderators can help clinicians personalize depression treatment. We found the majority of our patients benefited from adjunctive aripiprazole, but a smaller subgroup that is identifiable using clinical measures appeared to benefit more from continuation venlafaxine plus placebo.
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Affiliation(s)
- Stephen F. Smagula
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Meredith L. Wallace
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stewart J. Anderson
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jordan F. Karp
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA,VAPHS, Geriatric Research, Education, and Clinical Center
| | - Eric J. Lenze
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Meryl A. Butters
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel M. Blumberger
- Centre for Addiction and Mental Health, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Breno S. Diniz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Francis Lotrich
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mary Amanda Dew
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Departments of Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles F. Reynolds
- Department of Psychiatry, Western Psychiatric Institute and Clinic of University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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McIntyre RS, Weiller E, Zhang P, Weiss C. Brexpiprazole as adjunctive treatment of major depressive disorder with anxious distress: Results from a post-hoc analysis of two randomised controlled trials. J Affect Disord 2016; 201:116-23. [PMID: 27208498 DOI: 10.1016/j.jad.2016.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/20/2016] [Accepted: 05/11/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Anxiety symptoms are prevalent in major depressive disorder (MDD) and are associated with greater illness severity, suicidality, impaired functioning and poor response to antidepressant treatment (ADT). The efficacy and safety of brexpiprazole - a serotonin-dopamine activity modulator - as adjunctive treatment in patients with MDD was recently evaluated in two phase 3 studies. We here present a post-hoc analysis of the efficacy of adjunctive brexpiprazole in patients with MDD and symptoms of anxious distress, defined using proxies for DSM-5 criteria. METHODS Eligible patients were randomized to 2mg brexpiprazole+ADT or placebo+ADT (NCT01360645); or 1mg brexpiprazole+ADT, 3mg brexpiprazole+ADT, or placebo+ADT (NCT01360632), respectively. Patients were defined as having anxious distress if they had ≥2 of the symptoms tension (MADRS item 3 score ≥3), restlessness (IDS item 24 score ≥2), concentration (MADRS item 6 score ≥3), or apprehension (HAM-D item 10 score ≥3). Primary efficacy endpoint was change in MADRS total score from baseline to Week 6. RESULTS 55% of the patients had anxious distress at baseline. Adjunctive brexpiprazole showed greater improvement than adjunctive placebo on the primary efficacy endpoint in both patients with (least square mean difference to placebo+ADT: 2mg+ADT: -2.95, p=0.0023; 3mg+ADT: -2.81, p=0.0027); and without anxious distress (1mg+ADT: -2.37, p=0.0093; 3mg+ADT: -2.23, p=0.0131). Brexpiprazole in patients with anxious distress was not associated with an increased incidence of activating adverse events (e.g., akathisia). CONCLUSIONS Adjunctive brexpiprazole 2-3mg may be efficacious in reducing depressive symptoms and is well tolerated, in patients with MDD and anxious distress.
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Affiliation(s)
| | | | - Peter Zhang
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
| | - Catherine Weiss
- Otsuka Pharmaceutical Development & Commercialization, Inc., Princeton, NJ, USA
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8
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Rosenberg L, deLima Thomas J. Pharmacologic Management of Depression in Advanced Illness #309. J Palliat Med 2016; 19:783-4. [DOI: 10.1089/jpm.2016.0075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Goodwin GM, Haddad PM, Ferrier IN, Aronson JK, Barnes T, Cipriani A, Coghill DR, Fazel S, Geddes JR, Grunze H, Holmes EA, Howes O, Hudson S, Hunt N, Jones I, Macmillan IC, McAllister-Williams H, Miklowitz DR, Morriss R, Munafò M, Paton C, Saharkian BJ, Saunders K, Sinclair J, Taylor D, Vieta E, Young AH. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2016; 30:495-553. [PMID: 26979387 PMCID: PMC4922419 DOI: 10.1177/0269881116636545] [Citation(s) in RCA: 457] [Impact Index Per Article: 57.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.
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Affiliation(s)
- G M Goodwin
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - P M Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Eccles, Manchester, UK
| | - I N Ferrier
- Institute of Neuroscience, Newcastle University, UK and Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK
| | - J K Aronson
- Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Trh Barnes
- The Centre for Mental Health, Imperial College London, Du Cane Road, London, UK
| | - A Cipriani
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - D R Coghill
- MACHS 2, Ninewells' Hospital and Medical School, Dundee, UK; now Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia
| | - S Fazel
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - J R Geddes
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - H Grunze
- Univ. Klinik f. Psychiatrie u. Psychotherapie, Christian Doppler Klinik, Universitätsklinik der Paracelsus Medizinischen Privatuniversität (PMU), Salzburg, Christian Doppler Klinik Salzburg, Austria
| | - E A Holmes
- MRC Cognition & Brain Sciences Unit, Cambridge, UK
| | - O Howes
- Institute of Psychiatry (Box 67), London, UK
| | | | - N Hunt
- Fulbourn Hospital, Cambridge, UK
| | - I Jones
- MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff, UK
| | - I C Macmillan
- Northumberland, Tyne and Wear NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead, Tyne and Wear, UK
| | - H McAllister-Williams
- Institute of Neuroscience, Newcastle University, UK and Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK
| | - D R Miklowitz
- UCLA Semel Institute for Neuroscience and Human Behavior, Division of Child and Adolescent Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - R Morriss
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, Nottingham, UK
| | - M Munafò
- MRC Integrative Epidemiology Unit, UK Centre for Tobacco and Alcohol Studies, School of Experimental Psychology, University of Bristol, Bristol, UK
| | - C Paton
- Oxleas NHS Foundation Trust, Dartford, UK
| | - B J Saharkian
- Department of Psychiatry (Box 189), University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Kea Saunders
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Jma Sinclair
- University Department of Psychiatry, Southampton, UK
| | - D Taylor
- South London and Maudsley NHS Foundation Trust, Pharmacy Department, Maudsley Hospital, London, UK
| | - E Vieta
- Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - A H Young
- Centre for Affective Disorders, King's College London, London, UK
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Lam RW, Milev R, Rotzinger S, Andreazza AC, Blier P, Brenner C, Daskalakis ZJ, Dharsee M, Downar J, Evans KR, Farzan F, Foster JA, Frey BN, Geraci J, Giacobbe P, Feilotter HE, Hall GB, Harkness KL, Hassel S, Ismail Z, Leri F, Liotti M, MacQueen GM, McAndrews MP, Minuzzi L, Müller DJ, Parikh SV, Placenza FM, Quilty LC, Ravindran AV, Salomons TV, Soares CN, Strother SC, Turecki G, Vaccarino AL, Vila-Rodriguez F, Kennedy SH. Discovering biomarkers for antidepressant response: protocol from the Canadian biomarker integration network in depression (CAN-BIND) and clinical characteristics of the first patient cohort. BMC Psychiatry 2016; 16:105. [PMID: 27084692 PMCID: PMC4833905 DOI: 10.1186/s12888-016-0785-x] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/18/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Major Depressive Disorder (MDD) is among the most prevalent and disabling medical conditions worldwide. Identification of clinical and biological markers ("biomarkers") of treatment response could personalize clinical decisions and lead to better outcomes. This paper describes the aims, design, and methods of a discovery study of biomarkers in antidepressant treatment response, conducted by the Canadian Biomarker Integration Network in Depression (CAN-BIND). The CAN-BIND research program investigates and identifies biomarkers that help to predict outcomes in patients with MDD treated with antidepressant medication. The primary objective of this initial study (known as CAN-BIND-1) is to identify individual and integrated neuroimaging, electrophysiological, molecular, and clinical predictors of response to sequential antidepressant monotherapy and adjunctive therapy in MDD. METHODS CAN-BIND-1 is a multisite initiative involving 6 academic health centres working collaboratively with other universities and research centres. In the 16-week protocol, patients with MDD are treated with a first-line antidepressant (escitalopram 10-20 mg/d) that, if clinically warranted after eight weeks, is augmented with an evidence-based, add-on medication (aripiprazole 2-10 mg/d). Comprehensive datasets are obtained using clinical rating scales; behavioural, dimensional, and functioning/quality of life measures; neurocognitive testing; genomic, genetic, and proteomic profiling from blood samples; combined structural and functional magnetic resonance imaging; and electroencephalography. De-identified data from all sites are aggregated within a secure neuroinformatics platform for data integration, management, storage, and analyses. Statistical analyses will include multivariate and machine-learning techniques to identify predictors, moderators, and mediators of treatment response. DISCUSSION From June 2013 to February 2015, a cohort of 134 participants (85 outpatients with MDD and 49 healthy participants) has been evaluated at baseline. The clinical characteristics of this cohort are similar to other studies of MDD. Recruitment at all sites is ongoing to a target sample of 290 participants. CAN-BIND will identify biomarkers of treatment response in MDD through extensive clinical, molecular, and imaging assessments, in order to improve treatment practice and clinical outcomes. It will also create an innovative, robust platform and database for future research. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01655706 . Registered July 27, 2012.
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Affiliation(s)
- Raymond W Lam
- University of British Columbia and Vancouver Coastal Health Authority, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Roumen Milev
- Queen's University, Providence Care, Mental Health Services 752 King Street West, Postal Bag 603, Kingston, ON, K7L 7X3, Canada
| | - Susan Rotzinger
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada
| | - Ana C Andreazza
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada.,Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, ON, M6J 1A8, Canada
| | - Pierre Blier
- University of Ottawa Institute of Mental Health Research, 1145 Carling Avenue, Ottawa, ON, K1Z 7K4, Canada
| | - Colleen Brenner
- Loma Linda University, 24851 Circle Dr, Loma Linda, CA, 92354, USA
| | - Zafiris J Daskalakis
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada.,Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, ON, M6J 1A8, Canada
| | - Moyez Dharsee
- Indoc Research, 258 Adelaide St. East, Suite 200, Toronto, ON, M5A 1N1, Canada
| | - Jonathan Downar
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada
| | - Kenneth R Evans
- Indoc Research, 258 Adelaide St. East, Suite 200, Toronto, ON, M5A 1N1, Canada.,Department of Pathology and Molecular Medicine, Queen's University, 88 Stuart Street, Kingston, ON, K7L 3N6, Canada
| | - Faranak Farzan
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada.,Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, ON, M6J 1A8, Canada
| | - Jane A Foster
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.,McMaster University, and St. Joseph's Healthcare Hamilton, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Benicio N Frey
- McMaster University, and St. Joseph's Healthcare Hamilton, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Joseph Geraci
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Peter Giacobbe
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.,Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada
| | - Harriet E Feilotter
- Indoc Research, 258 Adelaide St. East, Suite 200, Toronto, ON, M5A 1N1, Canada.,Department of Pathology and Molecular Medicine, Queen's University, 88 Stuart Street, Kingston, ON, K7L 3N6, Canada
| | - Geoffrey B Hall
- McMaster University, and St. Joseph's Healthcare Hamilton, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Kate L Harkness
- Department of Psychology, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Stefanie Hassel
- Aston University, Aston Triangle, Birmingham, West Midlands, B4 7ET, UK
| | - Zahinoor Ismail
- University of Calgary Hotchkiss Brain Institute, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada
| | - Francesco Leri
- University of Guelph, 50 Stone Rd E, Guelph, ON, N1G 2W1, Canada
| | - Mario Liotti
- Simon Fraser University, 8888 University Dr, Burnaby, BC, V5A 1S6, Canada
| | - Glenda M MacQueen
- University of Calgary Hotchkiss Brain Institute, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada
| | - Mary Pat McAndrews
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Luciano Minuzzi
- McMaster University, and St. Joseph's Healthcare Hamilton, 1280 Main Street West, Hamilton, ON, L8S4L8, Canada
| | - Daniel J Müller
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada.,Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, ON, M6J 1A8, Canada
| | - Sagar V Parikh
- Universisty of Michigan, 500S State St, Ann Arbor, MI, 48109, USA
| | - Franca M Placenza
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Lena C Quilty
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada.,Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, ON, M6J 1A8, Canada
| | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada.,Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, ON, M6J 1A8, Canada
| | - Tim V Salomons
- University of Reading, Earley Gate, Whiteknights, Reading, RG6 6AL, UK
| | - Claudio N Soares
- St. Michael's Hospital, 193 Yonge St, Toronto, ON, M5B 1M4, Canada
| | - Stephen C Strother
- Rotman Research Institute at Baycrest Centre, 3560 Bathurst Street, Toronto, ON, M6A 2E1, Canada
| | - Gustavo Turecki
- McGill University , 845 Rue Sherbrooke O, Montréal, QC, H3A 0G4, Canada.,Douglas Mental Health University Institute Frank B. Common (FBC) F-3145, 6875 LaSalle Boulevard, Montréal, QC, H4H 1R3, Canada
| | - Anthony L Vaccarino
- Indoc Research, 258 Adelaide St. East, Suite 200, Toronto, ON, M5A 1N1, Canada
| | - Fidel Vila-Rodriguez
- University of British Columbia and Vancouver Coastal Health Authority, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Sidney H Kennedy
- University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. .,Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, ON, M5T 1R8, Canada. .,St. Michael's Hospital, 193 Yonge St, Toronto, ON, M5B 1M4, Canada.
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11
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Papakostas GI, Fava M, Baer L, Swee MB, Jaeger A, Bobo WV, Shelton RC. Ziprasidone Augmentation of Escitalopram for Major Depressive Disorder: Efficacy Results From a Randomized, Double-Blind, Placebo-Controlled Study. Am J Psychiatry 2015; 172:1251-8. [PMID: 26085041 PMCID: PMC4843798 DOI: 10.1176/appi.ajp.2015.14101251] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors sought to test the efficacy of adjunctive ziprasidone in adults with nonpsychotic unipolar major depression experiencing persistent symptoms after 8 weeks of open-label treatment with escitalopram. METHOD This was an 8-week, randomized, double-blind, parallel-group, placebo-controlled trial conducted at three academic medical centers. Participants were 139 outpatients with persistent symptoms of major depression after an 8-week open-label trial of escitalopram (phase 1), randomly assigned in a 1:1 ratio to receive adjunctive ziprasidone (escitalopram plus ziprasidone, N=71) or adjunctive placebo (escitalopram plus placebo, N=68), with 8 weekly follow-up assessments. The primary outcome measure was clinical response, defined as a reduction of at least 50% in score on the 17-item Hamilton Depression Rating Scale (HAM-D). The Hamilton Anxiety Rating scale (HAM-A) and Visual Analog Scale for Pain were defined a priori as key secondary outcome measures. RESULTS Rates of clinical response (35.2% compared with 20.5%) and mean improvement in HAM-D total scores (-6.4 [SD=6.4] compared with -3.3 [SD=6.2]) were significantly greater for the escitalopram plus ziprasidone group. Several secondary measures of antidepressant efficacy also favored adjunctive ziprasidone. The escitalopram plus ziprasidone group also showed significantly greater improvement on HAM-A score but not on Visual Analog Scale for Pain score. Ten (14%) patients in the escitalopram plus ziprasidone group discontinued treatment because of intolerance, compared with none in the escitalopram plus placebo group. CONCLUSIONS Ziprasidone as an adjunct to escitalopram demonstrated antidepressant efficacy in adult patients with major depressive disorder experiencing persistent symptoms after 8 weeks of open-label treatment with escitalopram.
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Affiliation(s)
- George I. Papakostas
- Massachusetts General Hospital Clinical Trials Network and Institute,Massachusetts General Hospital Depression Clinical and Research Program,Havard Medical School
| | - Maurizio Fava
- Massachusetts General Hospital Clinical Trials Network and Institute,Massachusetts General Hospital Depression Clinical and Research Program,Havard Medical School
| | - Lee Baer
- Massachusetts General Hospital Clinical Trials Network and Institute,Havard Medical School
| | - Michaela B. Swee
- Massachusetts General Hospital Depression Clinical and Research Program
| | - Adrienne Jaeger
- Massachusetts General Hospital Depression Clinical and Research Program
| | | | - Richard C. Shelton
- University of Alabama-Birmingham Department of Psychiatry and Behavioral Neurobiology
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12
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The Role of Anger/Hostility in Treatment-Resistant Depression: A Secondary Analysis From the ADAPT-A Study. J Nerv Ment Dis 2015; 203:762-8. [PMID: 26348584 DOI: 10.1097/nmd.0000000000000364] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Major depressive disorder is often accompanied by elevated levels of anger, hostility, and irritability, which may contribute to worse outcomes. The present study is a secondary analysis examining the role of anger/hostility in the treatment response to low-dose aripiprazole added to antidepressant therapy in 225 patients with major depressive disorder and inadequate response to antidepressant treatment. Repeated-measures model demonstrated no drug-placebo difference in treatment response across levels of anger/hostility. However, within-group analyses showed significantly lower placebo response rates in patients with high anger/hostility and a trend for lower drug response rates in patients with high anger/hostility. Pooled response rates across phases and treatments revealed a lower response rate among patients with high anger/hostility. Depressed patients with high anger/hostility demonstrate greater illness severity and lower depressive treatment response rates than patients with low anger/hostility, suggesting that patients with high anger/hostility may have poorer outcomes in response to adjunctive treatment.
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13
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Han C, Wang SM, Lee SJ, Jun TY, Pae CU. Optimizing the Use of Aripiprazole Augmentation in the Treatment of Major Depressive Disorder: From Clinical Trials to Clinical Practice. Chonnam Med J 2015; 51:66-80. [PMID: 26306301 PMCID: PMC4543152 DOI: 10.4068/cmj.2015.51.2.66] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 12/12/2022] Open
Abstract
Major depressive disorder (MDD) is a recurrent, chronic, and devastating disorder leading to serious impairment in functional capacity as well as increasing public health care costs. In the previous decade, switching therapy and dose adjustment of ongoing antidepressants was the most frequently chosen subsequent treatment option for MDD. However, such recommendations were not based on firmly proven efficacy data from well-designed, placebo-controlled, randomized clinical trials (RCTs) but on practical grounds and clinical reasoning. Aripiprazole augmentation has been dramatically increasing in clinical practice owing to its unique action mechanisms as well as proven efficacy and safety from adequately powered and well-controlled RCTs. Despite the increased use of aripiprazole in depression, limited clinical information and knowledge interfere with proper and efficient use of aripiprazole augmentation for MDD. The objective of the present review was to enhance clinicians' current understanding of aripiprazole augmentation and how to optimize the use of this therapy in the treatment of MDD.
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Affiliation(s)
- Changsu Han
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Korea
| | - Sheng-Min Wang
- International Health Care Center, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Soo-Jung Lee
- Department of Psychiatry, Bucheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Busan, Korea
| | - Tae-Youn Jun
- Department of Psychiatry, St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chi-Un Pae
- Department of Psychiatry, Bucheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Busan, Korea. ; Department of Psychiatry and Behavioral Medicines, Duke University Medical Center, Durham, NC, USA
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14
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Meyer-Junco LE. Aripiprazole for the Treatment of Depression in Palliative Care. J Palliat Med 2015; 18:316. [DOI: 10.1089/jpm.2014.0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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15
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Ozaki N, Otsubo T, Kato M, Higuchi T, Ono H, Kamijima K. Efficacy of aripiprazole augmentation in Japanese patients with major depressive disorder: a subgroup analysis and Montgomery-Åsberg Depression Rating Scale and Hamilton Rating Scale for Depression item analyses of the Aripiprazole Depression Multicenter Efficacy study. Psychiatry Clin Neurosci 2015; 69:34-42. [PMID: 24965202 DOI: 10.1111/pcn.12214] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/12/2014] [Accepted: 06/21/2014] [Indexed: 12/28/2022]
Abstract
AIM Results from this randomized, placebo-controlled study of aripiprazole augmentation to antidepressant therapy (ADT) in Japanese patients with major depressive disorder (MDD) (the Aripiprazole Depression Multicenter Efficacy [ADMIRE] study) revealed that aripiprazole augmentation was superior to ADT alone and was well tolerated. In subgroup analyses, we investigated the influence of demographic- and disease-related factors on the observed responses. We also examined how individual symptom improvement was related to overall improvement in MDD. METHODS Data from the ADMIRE study were analyzed. Subgroup analyses were performed on the primary outcome measures: the mean change in the Montgomery-Åsberg Depression Rating Scale (MADRS) total score from the end of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) treatment to the end of the randomized treatment. RESULTS Changes in the MADRS total scores were consistently greater with aripiprazole than placebo in each of the subgroups. Efficacy was not related to sex, age, number of adequate ADT trials in the current episode, MDD diagnosis, number of depressive episodes, duration of the current episode, age at first depressive episode, time since the first depressive episode, type of SSRI/SNRI, or severity at the end of SSRI/SNRI treatment phase. Compared to placebo, aripiprazole resulted in significant and rapid improvement on seven of the 10 MADRS items, including sadness. CONCLUSION These post-hoc analyses indicated that aripiprazole was effective for a variety of Japanese patients with MDD who had exhibited inadequate responses to ADT. Additionally, we suggest that aripiprazole significantly and rapidly improved the core depressive symptoms.
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Affiliation(s)
- Norio Ozaki
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
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16
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Taylor DM, Cornelius V, Smith L, Young AH. Comparative efficacy and acceptability of drug treatments for bipolar depression: a multiple-treatments meta-analysis. Acta Psychiatr Scand 2014; 130:452-69. [PMID: 25283309 DOI: 10.1111/acps.12343] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Treatment of bipolar depression is complicated by variable response and risk of switch to mania. Guidance is informed by the strength of evidence rather than by comparative data. METHOD We performed a multiple-treatments meta-analysis of randomised, double-blind, controlled comparisons of 4-16 weeks in adults in bipolar depression. The primary efficacy outcome was effect size. The primary acceptability outcome was 'switch to mania'. Secondary outcomes were likelihood of response and withdrawals from trials. RESULTS Twenty-nine studies were included (8331 participants). Olanzapine + fluoxetine and olanzapine performed best on primary outcome measure being ranked highest for effect size. Switch to mania was least likely with ziprasidone and then quetiapine. Olanzapine + fluoxetine was also ranked the highest for response with lurasidone second, but olanzapine + fluoxetine and olanzapine had the optimal effect on response and withdrawal from treatment when the two parameters were considered together. Several treatments [monoamine oxidase inhibitors (MAOIs), ziprasidone, aripiprazole and risperidone] have limited or no therapeutic activity in bipolar depression. CONCLUSION Olanzapine + fluoxetine should be first-line treatment. Olanzapine, quetiapine, lurasidone, valproate and selective serotonin re-uptake inhibitors are also recommended. Tricyclic antidepressants and lithium are worthy of consideration but lamotrigine (high risk of switching, less robust efficacy) and MAOIs, ziprasidone, aripiprazole and risperidone (no evidence of efficacy) should not be used.
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Affiliation(s)
- D M Taylor
- Pharmacy Department, Maudsley Hospital, Denmark Hill, London, UK; Institute of Pharmaceutical Science, King's College London, London, UK
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17
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Weisler R, McIntyre RS, Bauer M. Extended-release quetiapine fumarate in the treatment of patients with major depressive disorder: adjunct therapy. Expert Rev Neurother 2014; 13:1183-200. [DOI: 10.1586/14737175.2013.846519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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18
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Han C, Wang SM, Kato M, Lee SJ, Patkar AA, Masand PS, Pae CU. Second-generation antipsychotics in the treatment of major depressive disorder: current evidence. Expert Rev Neurother 2014; 13:851-70. [DOI: 10.1586/14737175.2013.811901] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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19
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Halpern R, Nadkarni A, Kalsekar I, Nguyen H, Song R, Baker RA, Nelson JC. Medical costs and hospitalizations among patients with depression treated with adjunctive atypical antipsychotic therapy: an analysis of health insurance claims data. Ann Pharmacother 2013; 47:933-45. [PMID: 23715066 DOI: 10.1345/aph.1r622] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Depression is frequently debilitating. The American Psychiatric Association recommends adjunctive atypical antipsychotics as a treatment option when response to antidepressants is inadequate. OBJECTIVE To compare medical costs and hospitalizations among patients with depression treated with adjunctive aripiprazole, olanzapine, or quetiapine. METHODS This retrospective analysis used medical and pharmacy claims data and enrollment information from a large US health plan. Patients were adult members of a commercial health plan who were diagnosed with depression (ie, ICD-9-CM 296.2x, 296.3x, or 311) and who received an antidepressant with adjunctive atypical antipsychotic therapy (aripiprazole, olanzapine, or quetiapine) between January 1, 2004, and January 31, 2010. Patients were continuously enrolled for 6-month pre- and 12-month postaugmentation periods. Those with schizophrenia or bipolar disorder were excluded. Postaugmentation outcomes were total and mental health-related medical costs and hospitalizations. Costs and hospitalizations were modeled with generalized linear models (ie, gamma distribution, log link) and logistic regression, respectively. Regressions controlled for dose, demographics, and general and medical health-related health status. RESULTS A total of 10,292 patients were identified across atypical antipsychotic cohorts: 3849 used aripiprazole, 1033 used olanzapine, and 5410 used quetiapine. Mean (SD) age was 44.1 (11.6) years and 70.3% were female. Compared with patients in the aripiprazole cohort, those in the olanzapine cohort had higher total medical costs (cost ratio [CR] 1.22, 95% CI 1.07-1.39) and higher mental health-related medical costs (CR 1.33, 95% CI 1.11-1.59), as well as higher odds of any (total) hospitalization (OR 1.58, 95% CI 1.30-1.92) and any mental health-related hospitalization (OR 1.81, 95% CI 1.38-2.38). Similarly, the quetiapine cohort had higher total medical costs (CR 1.27, 95% CI 1.16-1.39) and higher mental health-related medical costs (CR 1.23, 95% CI 1.09-1.39), as well as higher odds of any (total) hospitalization (OR 1.65, 95% CI 1.44-1.90) and any mental health-related hospitalizations (OR 1.78, 95% CI 1.45-2.18), compared with the aripiprazole cohort. CONCLUSIONS Compared with adjunctive olanzapine or quetiapine, adjunctive aripiprazole was associated with lower mean total and mental health-related medical costs and with lower odds of total and mental health-related hospitalizations in patients with depression.
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Patkar AA, Pae CU. Atypical antipsychotic augmentation strategies in the context of guideline-based care for the treatment of major depressive disorder. CNS Drugs 2013; 27 Suppl 1:S29-37. [PMID: 23709359 DOI: 10.1007/s40263-012-0031-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
There is a growing body of evidence that supports the use of atypical antipsychotics as augmentation agents for nonpsychotic unipolar major depressive disorder (MDD) in adults. Unfortunately, varying definitions of treatment-resistant depression, the limited evidence available for interventions after two or more treatment failures, and when and whether to use medications from nonantidepressant classes, remain a key gap in the knowledge base for clinicians. We identified and reviewed the following guidelines to discuss the status of augmentation therapy with atypical antipsychotic agents in MDD: American Psychiatric Association practice guidelines for treatment of patients with MDD; Canadian Network for Mood and Anxiety Treatments clinical guidelines for the management of MDD in adults; National Institute for Health and Clinical Excellence guidelines for treatment and management of depression in adults; British Association of Psychopharmacology guidelines for treatment of depressive disorders; Institute for Clinical Systems Improvement healthcare guideline for MDD in adults in primary care; clinical practice recommendations for depression; international consensus statement on MDD; German Society of Psychiatry, Psychotherapy and Neurology guidelines for unipolar depression; and World Federation of Societies of Biological Psychiatry guidelines for biological treatment of unipolar depressive disorders in primary care. Reflecting the cumulative evidence in the past decade, augmentation strategies including atypical antipsychotic augmentation are recommended in most guidelines for partial or nonresponders, at the same stage as switching or combination strategies. However, there are few direct comparisons of different augmentation strategies and little information about the optimal duration of augmentation strategies or use in special populations. Clinicians should note that guidelines are derived from an evolving database of evidence and cannot take into account the myriad of clinical variables that differ between individual patients. Therefore, they are intended to provide a useful framework for the management of depression and should be used in conjunction with other recognized sources of patient information and the application of clinical wisdom.
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Affiliation(s)
- Ashwin A Patkar
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA.
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Han C, Yeh TL, Kato M, Sato S, Chang CM, Pae CU. Management of chronic depressive patients with residual symptoms. CNS Drugs 2013; 27 Suppl 1:S53-7. [PMID: 23709362 DOI: 10.1007/s40263-012-0034-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Various clinical issues are involved in the appropriate diagnosis and proper treatment interventions for patients with major depressive disorder (MDD). Despite a number of diverse antidepressants for treating MDD now, response and remission rates following adequate trials of antidepressant intervention are still not satisfactory. Furthermore, a significant proportion of MDD patients have residual symptoms, which are associated with increased relapse and recurrence of MDD, leading to negative impacts on the clinical course and outcomes of MDD. Timely and appropriate decision-making regarding the proper management of such cases is required in our routine daily practice. These issues are illustrated and also framed by one MDD case with a complicated clinical course. This review paper may give physicians clinical insight into how we can effectively and properly evaluate and manage such patients in clinical practice.
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Affiliation(s)
- Changsu Han
- Department of Psychiatry, Korea University College of Medicine, Seoul, Korea
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22
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Kalsekar I, Wagner JS, DiBonaventura M, Bates J, Forbes R, Hebden T. Comparison of health-related quality of life among patients using atypical antipsychotics for treatment of depression: results from the National Health and Wellness Survey. Health Qual Life Outcomes 2012; 10:81. [PMID: 22805425 PMCID: PMC3411477 DOI: 10.1186/1477-7525-10-81] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 07/17/2012] [Indexed: 12/28/2022] Open
Abstract
Background Use of atypical antipsychotics (AA) in combination with an antidepressant is recommended as an augmentation strategy for patients with depression. However, there is a paucity of data comparing aripiprazole and other AAs in terms of patient reported outcomes. Therefore, the objective of this study was to examine the levels of HRQoL and health utility scores in patients with depression using aripiprazole compared with patients using olanzapine, quetiapine, risperidone and ziprasidone. Methods Data were obtained from the 2009, 2010, and 2011 National Health and Wellness Survey (NHWS), a cross-sectional, internet-based survey that is representative of the adult US population. Only those patients who reported being diagnosed with depression and taking an antidepressant and an atypical antipsychotic for depression were included. Patients taking an atypical antipsychotic for less than 2 months or who reported being diagnosed with bipolar disorder or schizophrenia were excluded. Patients taking aripiprazole were compared with patients taking other atypical antipsychotics. Health-related quality of life (HRQoL) and health utilities were assessed using the Short Form 12-item (SF-12) health survey. Differences between groups were analyzed using General Linear Models (GLM) controlling for demographic and health characteristics. Results Overall sample size was 426 with 59.9% taking aripiprazole (n = 255) and 40.1% (n = 171) taking another atypical antipsychotic (olanzapine (n = 19), quetiapine (n = 127), risperidone (n = 14) or ziprasidone (n = 11)). Of the SF-12 domains, mean mental component summary (MCS) score (p = .018), bodily pain (p = .047), general health (p = .009) and emotional role limitations (p = .009) were found to be significantly higher in aripiprazole users indicating better HRQoL compared to other atypical antipsychotics. After controlling for demographic and health characteristics, patients taking aripiprazole reported significantly higher mean mental SF-12 component summary (34.10 vs. 31.43, p = .018), bodily pain (55.19 vs. 49.05, p = .047), general health (50.05 vs. 43.07, p = .009), emotional role limitations (49.44 vs. 41.83, p = .009), and SF-6D utility scores (0.59 vs. 0.56, p = .042). Conclusions Comparison of patients taking aripiprazole with a cohort of patients using another AA for depression demonstrated that aripiprazole was independently associated with better (both statistically and clinically) HRQoL and health utilities.
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Affiliation(s)
- Iftekhar Kalsekar
- Bristol-Myers Squibb, 777 Scudders Mill Road, Plainsboro, NJ 08536, USA
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23
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Dunner DL, Laubmeier KK, Manos G, Forbes RA, Baker RA, Berman RM. Beneficial effects of adjunctive aripiprazole in major depressive disorder are not dependent on antidepressant therapy history: a post hoc analysis of 3 randomized, double-blind, placebo-controlled trials. Prim Care Companion CNS Disord 2012; 14:12m01380. [PMID: 23585997 DOI: 10.4088/pcc.12m01380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 08/15/2012] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To determine whether switching within or between antidepressant therapy (ADT) classes prior to the use of adjunctive antipsychotic treatment is associated with different outcomes in major depressive disorder (MDD). METHOD This was a post hoc analysis of pooled data from 3 similar, multicenter, randomized, double-blind, placebo-controlled registrational studies of aripiprazole adjunctive to ADT conducted between September 2004 and April 2008. The trials comprised the following 3 phases: a 7- to 28-day screening phase, an 8-week single-blind prospective treatment phase, and a 6-week double-blind, randomized phase. Patients were aged 18-65 years and met DSM-IV-TR criteria for MDD. Patients with an inadequate response to ADT during the screening phase entered the prospective treatment phase, during which they were switched to another ADT medication of either the same or a different class. Those patients with an inadequate response were then randomized to double-blind adjunctive aripiprazole or adjunctive placebo and followed for 6 weeks. RESULTS Mean improvement in Montgomery-Asberg Depression Rating Scale total score was significantly greater with adjunctive aripiprazole versus adjunctive placebo for both between-class (-9.2 vs -6.2, P < .001) and within-class (-9.8 vs -6.6, P < .001) switch groups. Relative risks for response were 1.6 (95% CI = 1.3-2.1) for those who switched between classes and 1.7 (95% CI = 1.2-2.2) for those who switched within class. CONCLUSIONS Augmentation with aripiprazole, after either a between-class or within-class switch following initial ADT failure, is an effective option for patients with nonresponsive MDD. In contrast to current strategies employed in clinical practice, these results suggest that adjunctive aripiprazole is a logical strategy in patients unresponsive to ADT. TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT00105196, NCT00095758, NCT00095823.
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Affiliation(s)
- David L Dunner
- Center for Anxiety and Depression, Mercer Island, Washington (Dr Dunner); Otsuka Pharmaceutical Development and Commercialization, Inc, Princeton, New Jersey (Drs Baker and Forbes); and Bristol-Myers Squibb, Wallingford, Connecticut (Drs Berman, Laubmeier, and Manos). Dr Laubmeier is currently an employee of Otsuka, and Dr Forbes is currently employed by Genentech
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Connolly KR, Thase ME. If at first you don't succeed: a review of the evidence for antidepressant augmentation, combination and switching strategies. Drugs 2011; 71:43-64. [PMID: 21175239 DOI: 10.2165/11587620-000000000-00000] [Citation(s) in RCA: 341] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Major depressive disorder is a common and disabling illness that leads to significant reductions in quality of life and considerable cost to society. Despite numerous advances in the pharmacological treatment of depression, many patients remain ill despite initial treatment. Beyond first-line treatment, current guidelines recommend either augmentation or switching of the initial antidepressant. In this narrative review, we summarize the data from randomized controlled trials and meta-analyses in order to concisely discuss how the impact of current research can be translated into clinical practice and, ultimately, into lasting improvements in patient outcomes. The augmentation strategies reviewed are lithium, thyroid hormone, pindolol, psychostimulants and second-generation antipsychotics. The data on switching from first-line antidepressants to other antidepressants are also reviewed, and include switching within the same class, switching to other first-line antidepressant classes and switching to less commonly prescribed antidepressants. Finally, the strategy of antidepressant combinations is examined. Overall, the strength of evidence supporting a trial of augmentation or a switch to a new agent is very similar, with remission rates between 25% and 50% in both cases. Our review of the evidence suggests several conclusions. First, although it is true that adjunctive lithium and thyroid hormone have established efficacy, we can only be confident that this is true for use in combination with tricyclic antidepressants (TCAs), and the trials were done in less treatment-resistant patients than those who typically receive TCAs today. Of these two options, triiodothyronine augmentation seems to offer the best benefit/risk ratio for augmentation of modern antidepressants. After failure of a first-line selective serotonin reuptake inhibitor (SSRI), neither a switch within class nor a switch to a different class of antidepressant is unequivocally supported by the data, although switching from an SSRI to venlafaxine or mirtazapine may potentially offer greater benefits. Interestingly, switching from a newer antidepressant to a TCA after a poor response to the former is not supported by strong evidence. Of all strategies to augment response to new-generation antidepressants, quetiapine and aripiprazole are best supported by the evidence, although neither the cost effectiveness nor the longer-term benefit of these strategies has been established. The data to guide later steps in the treatment of resistant depression are sparse. Given the wide variety of options for the treatment of major depressive disorder, and the demonstrated importance of truly adequate treatment to the long-term outcomes of patients facing this illness, it is clear that further well conducted studies are needed.
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Affiliation(s)
- K Ryan Connolly
- University of Pennsylvania School of Medicine, Philadelphia VA Medical Center, 19104, USA.
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Pae CU, Forbes A, Patkar AA. Aripiprazole as adjunctive therapy for patients with major depressive disorder: overview and implications of clinical trial data. CNS Drugs 2011; 25:109-27. [PMID: 21254788 DOI: 10.2165/11538980-000000000-00000] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aripiprazole was initially approved to treat schizophrenia and later approved for bipolar mania, as a monotherapy and an adjunctive therapy (manic or mixed episodes), and for irritability associated with autism. Aripiprazole is a partial agonist at dopamine D(2) and D(3) and serotonin 5-HT(1A) receptors, and is an antagonist at 5-HT(2A) receptors. This profile, and convincing preliminary data from small-scale studies, provided the rationale for the large-scale exploration of aripiprazole for unipolar depression. Recently, three 6-week, large-scale, randomized, double-blind, placebo-controlled clinical trials demonstrated clinically meaningful efficacy for aripiprazole as an adjunctive therapy to antidepressants for treating major depressive disorder (MDD). In November 2007, aripiprazole was approved by the US FDA as an adjunctive therapy to antidepressants for treating MDD, with support from two of the above-mentioned trials. In the trials, aripiprazole was demonstrated to be safe and well tolerated, and showed a minimal trend for weight gain over the course of a 6-week treatment. The incidence of akathisia was higher than that reported in studies of patients with schizophrenia; however, most cases were mild to moderate and infrequently lead to discontinuation (5/1090 from all three trials). This comprehensive review provides an overview of the data from all three 6-week studies (including a pooled analysis) and from an unpublished 52-week, open-label extension study, to inform physicians and facilitate reasonable treatment decisions. In addition, specific issues associated with the use of aripiprazole as an adjunctive therapy in patients with MDD, including possible early treatment effect, appropriate timing of therapy initiation, appropriate dosing and duration of treatment, possible differential effect on depressive subgroups and long-term tolerability, are also discussed.
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Affiliation(s)
- Chi-Un Pae
- Department of Psychiatry, Bucheon St. Marys Hospital, The Catholic University of Korea College of Medicine, Bucheon, Kyounggi-Do, Republic of Korea.
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Chen J, Gao K, Kemp DE. Second-generation antipsychotics in major depressive disorder: update and clinical perspective. Curr Opin Psychiatry 2011; 24:10-7. [PMID: 21088586 DOI: 10.1097/yco.0b013e3283413505] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The aim of this systematic review was to examine the efficacy and safety of second-generation antipsychotics (SGAs) in nonpsychotic major depressive disorder (MDD). RECENT FINDINGS In MDD, SGA monotherapy or adjunctive therapy to conventional antidepressants showed rapid onset of antidepressant efficacy. Although maintenance data are limited, quetiapine monotherapy, risperidone adjunctive therapy, and amisulpride adjunctive therapy significantly delayed the time to relapse as compared with placebo. In general, extrapyramidal symptoms appeared to be low with SGAs, but a higher incidence of akathisia was observed with aripiprazole. An elevated risk of weight gain was observed with olanzapine-fluoxetine combination, risperidone, aripiprazole, and quetiapine compared with placebo. At present, there are insufficient data to confidently distinguish between different SGAs in the treatment of MDD. A recent meta-analysis found that adjunctive SGAs were significantly more effective than placebo, but differences in efficacy were not identified among the studied agents, nor were outcomes affected by trial duration or the method of establishing treatment resistance. SUMMARY Both SGA monotherapy and adjunctive therapy showed greater efficacy in the treatment of MDD than placebo, but augmentation is more widely utilized in treatment-resistant depression. Clinicians should routinely monitor for cardiometabolic side-effects and extrapyramidal symptoms during SGA therapy.
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Affiliation(s)
- Jun Chen
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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Lenderts S, Kalali AH, Weisler R. Analysis of Classes Used in the Treatment of Depression by Physician-reported Severity. PSYCHIATRY (EDGMONT (PA. : TOWNSHIP)) 2010; 7:17-23. [PMID: 20376271 PMCID: PMC2848467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
We analyzed use of therapeutic drug classes for the treatment of depression by the three levels of physician-reported disease severity (mild, moderate, and severe) to understand if the mix of therapeutic classes used to treat depression changes as disease severity increases. Prior to analyzing drug uses in each severity category, we established that in the 12 months ending November 2009, the majority of patients (65%) were assigned a severity rating of 'moderate' by their physician; 27 percent and eight percent of patients were designated as 'mild' and 'severe,' respectively. In general, we found that as disease severity changes, so too do the proportions of the various therapeutic classes used in depression. The differences in class mix by severity have persisted at least since the 12 months ending December 2008, and it appears that the mix of drug classes used in severe depression are becoming less similar to the class mix for moderate depression over time.
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Affiliation(s)
- Susan Lenderts
- Ms. Lenderts is Manager, Strategic Analytics, Quintiles Commercial, Falls Church, Virginia
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Wisniewski PhD SR, Chen PhD CC, Kim MD MBA E, Kan PhD HJ, Guo PhD Z, Carlson PhD BX, Tran Pharm D BCPP QV, Pikalov MD PhD A. Global benefit-risk analysis of adjunctive aripiprazole in the treatment of patients with major depressive disorder. Pharmacoepidemiol Drug Saf 2009; 18:965-72. [DOI: 10.1002/pds.1805] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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