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Pillinger T, Howes OD, Correll CU, Leucht S, Huhn M, Schneider-Thoma J, Gaughran F, Jauhar S, McGuire PK, Taylor DM, Young AH, McCutcheon RA. Antidepressant and antipsychotic side-effects and personalised prescribing: a systematic review and digital tool development. Lancet Psychiatry 2023; 10:860-876. [PMID: 37774723 PMCID: PMC10878984 DOI: 10.1016/s2215-0366(23)00262-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Side-effects of psychiatric medication impair quality of life and functioning. Furthermore, they contribute to morbidity, mortality, stigma, and poor treatment concordance resulting in relapse of psychiatric illness. Guidelines recommend discussing side-effects with patients when making treatment decisions, but a synthesis of antidepressant and antipsychotic side-effects to guide this process is missing, and considering all side-effects is a complex, multidimensional process. We aimed to create comprehensive databases of antipsychotic and antidepressant side-effects, and a digital tool to support database navigation. METHODS To create the databases, we did an umbrella review of Embase, PsycINFO, and MEDLINE from database inception to June 26, 2023. We included meta-analyses of randomised controlled trials examining antipsychotic monotherapy in the treatment of schizophrenia or antidepressant monotherapy in the treatment of major depressive disorder. We included meta-analyses in adults (aged ≥18 years) that assessed drugs with a common comparator. The search was complemented by a review of national and international guidelines and consensus statements for the treatment of major depressive disorder and schizophrenia in adults. Effect sizes for antipsychotic and antidepressant side-effects were extracted from meta-analyses examining the largest number of drugs. In cases of incomplete meta-analytic coverage, data were imputed on the basis of guideline-derived ordinal rankings or, if imputation was not possible, ordinal scores were extracted. Both meta-analytic and ordinal outcomes were normalised to provide values between 0 and 1. We then constructed a digital tool, the Psymatik Treatment Optimizer, to combine the side-effect databases with side-effect concerns of an individual user, to enable users to select side-effects of concern and the relative degree of concern for each side-effect. Concern weightings and the side-effect databases are synthesised via a multicriteria decision analysis method (technique for order of preference by similarity to ideal situation, or TOPSIS). FINDINGS Of 3724 citations, 14 articles containing 68 meta-analyses of individual side-effects met inclusion criteria. After review of 19 guidelines, seven provided ordinal data. Antipsychotic data were extracted from five studies (11 meta-analyses, n=65 594 patients) and four guidelines, and antidepressant data were extracted from three guidelines. The resultant databases included data on 32 antipsychotics (14 side-effects) and 37 antidepressants (nine side-effects). The databases highlighted the clinical dilemma associated with balancing side-effects, with avoidance of one side-effect (eg, weight gain for antipsychotics) increasing the risk of others (eg, akathisia). To aid with this dilemma, the Psymatik Treatment Optimizer synthesises the side-effect databases with individual user-defined concern weights. After computing up to 5851 pairwise comparisons for antidepressants and 5142 pairwise comparisons for antipsychotics, Psymatik ranks treatments in order of preference for the individual user, with the output presented in a heatmap. INTERPRETATION By facilitating collaborative, personalised, and evidence-based prescribing decisions, the side-effect databases and digital application supports care delivery that is consistent with international regulatory guidance for the treatment of schizophrenia and depression, and it therefore has promise for informing psychiatric practice and improving outcomes. FUNDING National Institute for Health and Care Research, Maudsley Charity, Wellcome Trust, Medical Research Council.
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Affiliation(s)
- Toby Pillinger
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Psychiatric Imaging Group, MRC London Institute of Medical Sciences, Imperial College London, London, UK.
| | - Oliver D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Psychiatric Imaging Group, MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Christoph U Correll
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, New York, NY, USA; Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Child and Adolescent Psychiatry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - Sameer Jauhar
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Psychiatric Imaging Group, MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Philip K McGuire
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - David M Taylor
- Pharmacy Department, Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College London, London, UK
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Robert A McCutcheon
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
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Leucht S, Schneider-Thoma J, Burschinski A, Peter N, Wang D, Dong S, Huhn M, Nikolakopoulou A, Salanti G, Davis JM. Long-term efficacy of antipsychotic drugs in initially acutely ill adults with schizophrenia: systematic review and network meta-analysis. World Psychiatry 2023; 22:315-324. [PMID: 37159349 PMCID: PMC10168166 DOI: 10.1002/wps.21089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 05/11/2023] Open
Abstract
Most acute phase antipsychotic drug trials in schizophrenia last only a few weeks, but patients must usually take these drugs much longer. We examined the long-term efficacy of antipsychotic drugs in acutely ill patients using network meta-analysis. We searched the Cochrane Schizophrenia Group register up to March 6, 2022 for randomized, blinded trials of at least 6-month duration on all second-generation and 18 first-generation antipsychotics. The primary outcome was change in overall symptoms of schizophrenia; secondary outcomes were all-cause discontinuation; change in positive, negative and depressive symptoms; quality of life, social functioning, weight gain, antiparkinson medication use, akathisia, serum prolactin level, QTc prolongation, and sedation. Confidence in the results was assessed by the CINeMA (Confidence in Network Meta-Analysis) framework. We included 45 studies with 11,238 participants. In terms of overall symptoms, olanzapine was on average more efficacious than ziprasidone (standardized mean difference, SMD=0.37, 95% CI: 0.26-0.49), asenapine (SMD=0.33, 95% CI: 0.21-0.45), iloperidone (SMD=0.32, 95% CI: 0.15-0.49), paliperidone (SMD=0.28, 95% CI: 0.11-0.44), haloperidol (SMD=0.27, 95% CI: 0.14-0.39), quetiapine (SMD=0.25, 95% CI: 0.12-0.38), aripiprazole (SMD=0.16, 95% CI: 0.04-0.28) and risperidone (SMD=0.12, 95% CI: 0.03-0.21). The 95% CIs for olanzapine versus aripiprazole and risperidone included the possibility of trivial effects. The differences between olanzapine and lurasidone, amisulpride, perphenazine, clozapine and zotepine were either small or uncertain. These results were robust in sensitivity analyses and in line with other efficacy outcomes and all-cause discontinuation. Concerning weight gain, the impact of olanzapine was higher than all other antipsychotics, with a mean difference ranging from -4.58 kg (95% CI: -5.33 to -3.83) compared to ziprasidone to -2.30 kg (95% CI: -3.35 to -1.25) compared to amisulpride. Our data suggest that olanzapine is more efficacious than a number of other antipsychotic drugs in the longer term, but its efficacy must be weighed against its side effect profile.
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Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Angelika Burschinski
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Natalie Peter
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Dongfang Wang
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Shimeng Dong
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- Department of Psychiatry and Psychotherapy, Sozialstiftung Bamberg, Klinikum Bamberg, Bamberg, Germany
| | - Adriani Nikolakopoulou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA
- Maryland Psychiatric Research Center, Baltimore, MD, USA
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3
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Leucht S, Chaimani A, Krause M, Schneider-Thoma J, Wang D, Dong S, Samara M, Peter N, Huhn M, Priller J, Davis JM. The response of subgroups of patients with schizophrenia to different antipsychotic drugs: a systematic review and meta-analysis. Lancet Psychiatry 2022; 9:884-893. [PMID: 36228647 DOI: 10.1016/s2215-0366(22)00304-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/10/2022] [Accepted: 08/04/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND As comparatively few trials in subgroups of patients with schizophrenia have been done, clinicians need to know whether they can rely on the results of randomised controlled trials (RCTs) in the general population of patients with schizophrenia. We aimed to compare the efficacy and side-effects of antipsychotic drugs in different subgroups. METHODS In this systematic review and meta-analysis, we searched reference lists of previous systematic reviews and meta-analyses, the Cochrane Schizophrenia Group's Study-Based Register (from database inception to April 27, 2020), and PubMed (from April 1, 2020 to June 14, 2021). We excluded studies in patients with stable schizophrenia (ie, relapse prevention studies), studies with a high risk of bias, and studies from mainland China due to quality concerns concerning allocation and masking methods. We included single-blind RCTs or better that assessed one or more of 16 second-generation and 18 first-generation antipsychotics in the general population of patients with schizophrenia or in one or more of the subgroups: children and adolescents (age range as defined in the original studies), patients with a first episode, patients with predominant or prominent negative symptoms, patients with comorbid substance use, patients with treatment-resistant schizophrenia, or older patients (age range as defined in the original studies). Two authors independently screened the results of the search, retrieved full-text articles, and checked the inclusion criteria. Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, all parameters were extracted in duplicate. The primary outcome was change in overall symptoms. We compared drug efficacy between subgroups, by sex, schizoaffective disorder versus schizophrenia, and study origin using random-effects, inverse variance meta-analyses and random-effects subgroup tests, and meta-regression. FINDINGS We included 537 RCTs with 76 382 participants, 26 627 (34·9%) women, 49 755 (65·1%) men, mean age 37·3 years (range of means 7·9-80·2; ethnicity data not available). 412 RCTs included patients in the general population of patients with schizophrenia, 42 included patients with treatment-resistant schizophrenia, 25 included children and adolescents, 20 included patients with their first episode, 20 included patients with predominant or prominent negative symptoms, 13 included patients with comorbid substance use, and 11 included older patients. Of 507 random-effects subgroup tests done, 46 (9%) showed a significant difference (p<0·05) between subgroups, but there was no clear indication as to which drug should be used in which subgroup. INTERPRETATION The effects of antipsychotics in various patient subgroups were usually similar to those in the general population of patients with schizophrenia, but comparably few studies contributed to the subgroups, in particular in terms of side-effects. If the evidence for treatment in a given subgroup is small, guideline makers and clinicians should consider using the results in the much better studied group of the general population of patients with schizophrenia. FUNDING German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung; FKZ 01KG1508).
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Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany; Department of Psychiatry, Department of Psychosis Studies, and Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
| | - Anna Chaimani
- Université Paris Cité, Centre of Research in Epidemiology and Statistics (CRESS-U1153), INSERM, Paris, France
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dongfang Wang
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Shimeng Dong
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Myrto Samara
- Department of Psychiatry, University of Thessaly, Larisa, Greece
| | - Natalie Peter
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany; Department of Psychiatry and Psychotherapy, Sozialstiftung Bamberg, Klinikum Bamberg, Bamberg, Germany
| | - Josef Priller
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - John M Davis
- Psychiatric Institute, University of Illinois, Chicago, IL, USA
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Siafis S, Çıray O, Wu H, Schneider-Thoma J, Bighelli I, Krause M, Rodolico A, Ceraso A, Deste G, Huhn M, Fraguas D, San José Cáceres A, Mavridis D, Charman T, Murphy DG, Parellada M, Arango C, Leucht S. Pharmacological and dietary-supplement treatments for autism spectrum disorder: a systematic review and network meta-analysis. Mol Autism 2022; 13:10. [PMID: 35246237 PMCID: PMC8896153 DOI: 10.1186/s13229-022-00488-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 02/02/2022] [Indexed: 12/22/2022] Open
Abstract
Background There is still no approved medication for the core symptoms of autism spectrum disorder (ASD). This network meta-analysis investigated pharmacological and dietary-supplement treatments for ASD. Methods We searched for randomized-controlled-trials (RCTs) with a minimum duration of seven days in ClinicalTrials.gov, EMBASE, MEDLINE, PsycINFO, WHO-ICTRP (from inception up to July 8, 2018), CENTRAL and PubMed (up to November 3, 2021). The co-primary outcomes were core symptoms (social-communication difficulties-SCD, repetitive behaviors-RB, overall core symptoms-OCS) measured by validated scales and standardized-mean-differences (SMDs). Associated symptoms, e.g., irritability/aggression and attention-deficit/hyperactivity disorder (ADHD) symptoms, dropouts and important side-effects, were investigated as secondary outcomes. Studies in children/adolescents and adults were analyzed separately in random-effects pairwise and network meta-analyses. Results We analyzed data for 41 drugs and 17 dietary-supplements, from 125 RCTs (n = 7450 participants) in children/adolescents and 18 RCTs (n = 1104) in adults. The following medications could improve at least one core symptom domain in comparison with placebo: aripiprazole (k = 6 studies in analysis, SCD: SMD = 0.27 95% CI [0.09, 0.44], RB: 0.48 [0.26, 0.70]), atomoxetine (k = 3, RB:0.49 [0.18, 0.80]), bumetanide (k = 4, RB: 0.35 [0.09, 0.62], OCS: 0.61 [0.31, 0.91]), and risperidone (k = 4, SCM: 0.31 [0.06, 0.55], RB: 0.60 [0.29, 0.90]; k = 3, OCS: 1.18 [0.75, 1.61]) in children/adolescents; fluoxetine (k = 1, RB: 1.20 [0.45, 1.96]), fluvoxamine (k = 1, RB: 1.04 [0.27, 1.81]), oxytocin (k = 6, RB:0.41 [0.16, 0.66]) and risperidone (k = 1, RB: 0.97 [0.21,1.74]) in adults. There were some indications of improvement by carnosine, haloperidol, folinic acid, guanfacine, omega-3-fatty-acids, probiotics, sulforaphane, tideglusib and valproate, yet imprecise and not robust. Confidence in these estimates was very low or low, except moderate for oxytocin. Medications differed substantially in improving associated symptoms, and in their side-effect profiles. Limitations Most of the studies were inadequately powered (sample sizes of 20–80 participants), with short duration (8–13 weeks), and about a third focused on associated symptoms. Networks were mainly star-shaped, and there were indications of reporting bias. There was no optimal rating scale measuring change in core symptoms. Conclusions Some medications could improve core symptoms, although this could be likely secondary to the improvement of associated symptoms. Evidence on their efficacy and safety is preliminary; therefore, routine prescription of medications for the core symptoms cannot be recommended. Trial registration PROSPERO-ID CRD42019125317. Supplementary Information The online version contains supplementary material available at 10.1186/s13229-022-00488-4.
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Oğulcan Çıray
- Department of Child and Adolescent Psychiatry, Mardin State Hospital, Artuklu, Mardin, Turkey
| | - Hui Wu
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Alessandro Rodolico
- Department of Experimental and Clinical Medicine, Psychiatric Clinic University Hospital 'Gaspare Rodolico', University of Catania, Catania, Italy
| | - Anna Ceraso
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Giacomo Deste
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.,Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Bamberg, Germany
| | - David Fraguas
- Institute of Psychiatry and Mental Health, Hospital Clínico San Carlos, IdISSC CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Antonia San José Cáceres
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Tony Charman
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Declan G Murphy
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mara Parellada
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
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Schneider-Thoma J, Chalkou K, Dörries C, Bighelli I, Ceraso A, Huhn M, Siafis S, Davis JM, Cipriani A, Furukawa TA, Salanti G, Leucht S. Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysis. Lancet 2022; 399:824-836. [PMID: 35219395 DOI: 10.1016/s0140-6736(21)01997-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Schizophrenia is a common, severe, and usually chronic disorder. Maintenance treatment with antipsychotic drugs can prevent relapse but also causes side-effects. We aimed to compare the efficacy and tolerability of antipsychotics as maintenance treatment for non-treatment resistant patients with schizophrenia. METHODS In this systematic review and network meta-analysis, we searched, without language restrictions, the Cochrane Schizophrenia Group's specialised register between database inception and April 27, 2020, PubMed from April 1, 2020, to Jan 15, 2021, and the lists of included studies from related systematic reviews. We included randomised controlled trials (RCTs; ≥12 weeks of follow-up) that recruited adult participants with schizophrenia or schizoaffective disorder with stable symptoms who were treated with antipsychotics (monotherapy; oral or long-acting injectable) or placebo. We excluded RCTs of participants with specific comorbidities or treatment resistance. In duplicate, two authors independently selected eligible RCTs and extracted aggregate data. The primary outcome was the number of participants who relapsed and was analysed by random-effects, Bayesian network meta-analyses. The study was registered on PROSPERO, CRD42016049022. FINDINGS We identified 4157 references through our search, from which 501 references on 127 RCTs of 32 antipsychotics (comprising 18 152 participants) were included. 100 studies including 16 812 participants and 30 antipsychotics contributed to our network meta-analysis of the primary outcome. All antipsychotics had risk ratios (RRs) less than 1·00 when compared with placebo for relapse prevention and almost all had 95% credible intervals (CrIs) excluding no effect. RRs ranged from 0·20 (95% CrI 0·05-0·41) for paliperidone oral to 0·65 (0·16-1·14) for cariprazine oral (moderate-to-low confidence in estimates). Generally, we interpret that there was no clear evidence for the superiority of specific antipsychotics in terms of relapse prevention because most comparisons between antipsychotics included a probability of no difference. INTERPRETATION As we found no clear differences between antipsychotics for relapse prevention, we conclude that the choice of antipsychotic for maintenance treatment should be guided mainly by their tolerability. FUNDING The German Ministry of Education and Research and Oxford Health Biomedical Research Centre.
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Affiliation(s)
- Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Konstantina Chalkou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Carola Dörries
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Anna Ceraso
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany; Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Erlangen, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA; Department of Psychiatry, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK; Research and Development Department, Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan; Department of Clinical Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
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Huhn M, Arndt T, Schneider-Thoma J, Leucht S. Effects of antipsychotics on heart rate in treatment of schizophrenia: a systematic review and meta-analysis. Ther Adv Psychopharmacol 2022; 12:20451253221097261. [PMID: 35774251 PMCID: PMC9237927 DOI: 10.1177/20451253221097261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/07/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Antipsychotics are the treatment of choice in the therapy of schizophrenia. These drugs can be associated with changes in heart rate, but this question has never been examined systematically. OBJECTIVE We aimed to analyse changes in heart rate during treatment with antipsychotics using the frequency of tachycardia and bradycardia events. DESIGN For this systematic review and meta-analysis, we included all randomized controlled trials for the acute treatment of schizophrenia comparing antipsychotics head-to-head or with placebo. DATA SOURCES AND METHODS We searched Embase, MEDLINE, PsycINFO, PubMed, BIOSIS, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (last search June 2021). Two authors independently selected studies and extracted data. We conducted pairwise meta-analyses using a random-effects model. Outcomes were tachycardia and bradycardia events. RESULTS We found 469 trials meeting the inclusion criteria. Seventy-seven studies with 16,907 participants provided data on tachycardia or bradycardia events. We found no significant differences between antipsychotics and placebo or between antipsychotics for bradycardia events based on sparse data. Antipsychotics had a higher risk for tachycardia events compared with placebo [N = 37, n = 7827, risk ratio (RR) = 1.83, 95% confidence interval (CI) = 1.40-2.41], with large differences between the individual substances (iloperidone RR = 14.05, chlorpromazine RR = 4.84, loxapine RR = 4.52, risperidone RR = 3.38, quetiapine RR = 2.64, paliperidone RR = 1.65). Some head-to-head comparisons were also significantly different: olanzapine versus haloperidol RR = 2.87, chlorpromazine versus thiothixene RR = 2.92, quetiapine versus lurasidone RR = 3.22, risperidone versus aripiprazole RR = 4.37, iloperidone versus ziprasidone RR = 4.65). CONCLUSION Many studies do not report data for cardiac outcomes, but the available evidence indicates that treatment with antipsychotics raises the risk for tachycardia. Therefore, especially patients with cardiac risk factors should be monitored closely during antipsychotic treatment. REGISTRATION PROSPERO: CRD42014014919.
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Affiliation(s)
- Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675 München, Germany
| | - Thomas Arndt
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
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7
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Neumeier MS, Homan S, Vetter S, Seifritz E, Kane JM, Huhn M, Leucht S, Homan P. Examining Side Effect Variability of Antipsychotic Treatment in Schizophrenia Spectrum Disorders: A Meta-analysis of Variance. Schizophr Bull 2021; 47:1601-1610. [PMID: 34374418 PMCID: PMC8530397 DOI: 10.1093/schbul/sbab078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Side effects of antipsychotic drugs play a key role in nonadherence of treatment in schizophrenia spectrum disorders (SSD). While clinical observations suggest that side effect variability between patients may be considerable, statistical evidence is required to confirm this. Here, we hypothesized to find larger side effect variability under treatment compared with control. We included double-blind, placebo-controlled, randomized controlled trials (RCTs) of adults with a diagnosis of SSD treated with 1 out of 14 antipsychotics. Standard deviations of the pre-post treatment differences of weight gain, prolactin levels, and corrected QT (QTc) times were extracted. The outcome measure was the variability ratio of treatment to control for individual antipsychotic drugs and the overall variability ratio of treatment to control across RCTs. Individual variability ratios were weighted by the inverse-variance method and entered into a random-effects model. We included N = 16 578 patients for weight gain, N = 16 633 patients for prolactin levels, and N = 10 384 patients for QTc time. Variability ratios (VR) were significantly increased for weight gain (VR = 1.08; 95% CI: 1.02-1.14; P = .004) and prolactin levels (VR = 1.38; 95% CI: 1.17-1.62; P < .001) but did not reach significance for QTc time (VR = 1.05; 95% CI: 0.98-1.12; P = 0.135). We found marked differences between individual antipsychotics and increased variability in side effects in patients under treatment with antipsychotics suggesting that subgroups of patients or individual patients may benefit from treatment allocation through stratified or personalized medicine.
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Affiliation(s)
| | - Stephanie Homan
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Stefan Vetter
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Erich Seifritz
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - John M Kane
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, New York, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - Philipp Homan
- University Hospital of Psychiatry Zurich, Zurich, Switzerland
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Division of Psychiatry Research, Zucker Hillside Hospital, Northwell Health, New York, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
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8
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Hadas S, Huhn M, Rentrop M, Wollenberg B, Combs S, Pigorsch S, Pickhard A, Buchberger AMS. The role of psycho-oncologic screenings in the detection and evaluation of depression in head and neck cancer aftercare patients. Eur Arch Otorhinolaryngol 2021; 279:2143-2156. [PMID: 34406478 PMCID: PMC8930863 DOI: 10.1007/s00405-021-07017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/23/2021] [Indexed: 11/24/2022]
Abstract
Purpose Cancer and morbidity during a therapeutic regimen can result in somatic and psychiatric impairment. We have evaluated the need of appropriate psychological screening by analyzing a large collective of head and neck cancer (HNC) patients with particularly burdensome symptoms. Methods HNC-aftercare patients were asked about somatic and psychological symptoms by means of standardized questionnaires of the European Organization for Research and Treatment of Cancer (EORTC Q30 and QLQ-H&N35). Patients with poor well-being values on the World Health Organization-5-Well-Being Index were screened for depression by using the Mini International Neuropsychiatric Interview, and adequate treatment was initiated, if necessary. Results Our sample consisted of 453 HNC-aftercare patients (average age 64.5 years; 72.0% male; 28.0% female). 25.1% showed abnormalities based on their WHO-5 questionnaire. A current major depressive episode was observed in 8.5% of the total study group. Patients with lip and oral cavity tumors showed the highest depression prevalence (18.9%). Time since initial HNC diagnosis showed no clear trend with regard to the number of depression cases. 50.0% of patients with a current major depressive episode consented to receiving assistance and/or therapy. Within the total study population, the most burdensome symptoms were found to be “dry mouth” (48.3%), “trouble doing strenuous activities” (46.0%), “trouble taking a long walk” (38.5%), and “worry” (35.5%). Aftercare patients with a depression diagnosis tended to have heavier symptom burdens than people without major depression. Conclusions Despite the various cancer-related burdensome factors, prevalence levels of depression among the HNC-aftercare patients and the general population were similar. Nevertheless, since the number of diagnosed depression cases is high, the need for psychological treatment should be considered within the tumor collective. Furthermore, screening for depression should be implemented in clinical routines by using the appropriate standardized questionnaires. Supplementary Information The online version contains supplementary material available at 10.1007/s00405-021-07017-8.
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Affiliation(s)
- Stefan Hadas
- Hals-Nasen-Ohren Klinik und Poliklinik, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland.,Klinik für Strahlentherapie, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - Maximilian Huhn
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland.,Klinik für Psychiatrie und Psychotherapie, Sozialstiftung Bamberg, Klinikum Bamberg, Buger Straße 80, 96049, Bamberg, Deutschland
| | - Michael Rentrop
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland.,Klinik für Psychiatrie und Psychotherapie, Kbo-Inn-Salzach-Klinikum, Gabersee-Str 7, 83512, Wasserburg Am Inn, Deutschland
| | - Barbara Wollenberg
- Hals-Nasen-Ohren Klinik und Poliklinik, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland
| | - Stephanie Combs
- Klinik für Strahlentherapie und Radioonkologie, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland
| | - Steffi Pigorsch
- Klinik für Strahlentherapie und Radioonkologie, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland
| | - Anja Pickhard
- Hals-Nasen-Ohren Klinik und Poliklinik, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland
| | - Anna Maria Stefanie Buchberger
- Hals-Nasen-Ohren Klinik und Poliklinik, Klinikum Rechts der Isar, Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland.
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9
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Rentrop M, Huhn M, Schwerthöffer D. [Clozapine in the Treatment of Schizophrenic Psychosis: Patient Characteristics and Antipsychotic Combinations in One Cohort at a Psychiatric Care Hospital]. Fortschr Neurol Psychiatr 2021; 89:622-629. [PMID: 34384116 DOI: 10.1055/a-1526-2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In many studies, clozapine has been reported to have superior effectiveness compared to other antipsychotics. So far there is little systematic data on the practice of clozapine prescription and characteristics of patients treated. METHOD Retrospective evaluation of all 392 treatment courses of inpatients with schizophrenic psychoses during one year. Detailed analysis of the patients treated with clozapine including the dosages and additional psychotropic medication. RESULT Patients treated with clozapine showed a higher disease severity than patients without clozapine. They received more frequently pharmacological combination therapies, which in some cases significantly contradicted the current guideline recommendations. CONCLUSION The results underline the pronounced disease severity of patients receiving clozapine treatment and substantiate evidence from the literature on the limited implementation of guidelines in prescribing practice. The study carried out serves as a pilot survey of a multicenter research project on the practice of prescribing clozapine in psychiatric hospitals in different German regions.
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Affiliation(s)
- Michael Rentrop
- Klinische Sozialpsychiatrie, Kbo-Inn-Salzach-Klinikum Wasserburg, Wasserburg / Inn, Wasserburg, Deutschland.,Psychiatrie, Klinik für Psychiatrie und Psychotherapie der TU-München, München, Deutschland
| | - Maximilian Huhn
- Psychiatrie, Klinik für Psychiatrie und Psychotherapie, Klinikum Bamberg, Bamberg, Deutschland.,Psychiatrie, Klinik für Psychiatrie und Psychotherapie der TU-München, München, Deutschland
| | - Dirk Schwerthöffer
- Psychiatrie, Klinik für Psychiatrie und Psychotherapie der TU-München, München, Deutschland
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10
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Huhn M, Leucht C, Rothe P, Dold M, Heres S, Bornschein S, Schneider-Axmann T, Hasan A, Leucht S. Reducing antipsychotic drugs in stable patients with chronic schizophrenia or schizoaffective disorder: a randomized controlled pilot trial. Eur Arch Psychiatry Clin Neurosci 2021; 271:293-302. [PMID: 32062728 PMCID: PMC7960583 DOI: 10.1007/s00406-020-01109-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 02/03/2020] [Indexed: 11/28/2022]
Abstract
As the course of schizophrenic disorders is often chronic, treatment guidelines recommend continuous maintenance treatment to prevent relapses, but antipsychotic drugs can cause many side effects. It, therefore, seems reasonable to try to reduce doses in stable phases of the illness or even try to stop medication. We conducted a 26 weeks, randomized, rater blind, feasibility study to examine individualized antipsychotic dose reduction versus continuous maintenance treatment (Register Number: NCT02307396). We included chronic, adult patients with schizophrenia or schizoaffective disorder, who were treated with any antipsychotic drug except clozapine, who had not been hospitalized in the last 3 years and who were in symptomatic remission at baseline. The primary outcome was relapse of positive symptoms. Symptom severity, social functioning and side effects were also examined as secondary outcomes. 20 patients were randomized. Relapse rates in the two groups were not significantly different. No patient had to be hospitalized. One patient in the control group dropped out. The mean reduction of antipsychotic dose in the individualized dose-reduction group was 42%, however only one patient discontinued drug completely. There were no significant differences in efficacy or safety outcomes. This randomized trial provides evidence, that reduction of antipsychotic medication in chronic stable schizophrenic patients may be feasible. The results need to be confirmed in a larger trial with a longer follow-up period.
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Affiliation(s)
- Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany. .,Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Erlangen, Germany.
| | - Claudia Leucht
- Department of Psychiatry and Psychotherapy, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675 Munich, Germany
| | - Philipp Rothe
- Department of Forensic Psychiatry and Psychotherapy, Günzburg District Hospital, University of Ulm, Ludwig-Heilmeyer-Straße 2, Guenzburg, Germany
| | - Markus Dold
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Stephan Heres
- Klinik Nord, Isar-Amper-Klinikum München Ost, Munich, Kölner Platz, Haus 7, 80804 Munich, Germany
| | - Susanne Bornschein
- Private Practice for Psychiatry and Psychotherapy, Nymphenburger Str. 139, 80636 Munich, Germany ,Inn-Salzach-Klinikum Wasserburg Am Inn, Gabersee 7, 83512 Wasserburg Am Inn, Germany
| | - Thomas Schneider-Axmann
- Department of Psychiatry and Psychotherapy, University Medical Hospital, Nußbaumstr. 7, 80336 Munich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Medical Hospital, Nußbaumstr. 7, 80336 Munich, Germany ,Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, Augsburg, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675 Munich, Germany
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11
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Leucht S, Huhn M, Davis JM. Should 'typical', first-generation antipsychotics no longer be generally used in the treatment of schizophrenia? Eur Arch Psychiatry Clin Neurosci 2021; 271:1411-1413. [PMID: 34586466 PMCID: PMC8563551 DOI: 10.1007/s00406-021-01335-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Stefan Leucht
- Section for Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Ismaninger Straße. 22, 81675, Munich, Germany.
| | - Maximilian Huhn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Erlangen, Germany
| | - John M. Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL USA ,Department of Psychiatry, John Hopkins University, Baltimore, MD USA
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12
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Huhn M, Nikolakopoulou A, Schneider-Thoma J, Krause M, Samara M, Peter N, Arndt T, Bäckers L, Rothe P, Cipriani A, Davis J, Salanti G, Leucht S. Comparative Efficacy and Tolerability of 32 Oral Antipsychotics for the Acute Treatment of Adults With Multi-Episode Schizophrenia: A Systematic Review and Network Meta-Analysis. Focus (Am Psychiatr Publ) 2020; 18:443-455. [PMID: 33343258 DOI: 10.1176/appi.focus.18306] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
(Reprinted with permission from the Lancet 2019; 394: 939-51).
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13
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Rentrop M, Sassenberg S, Massold L, Hofmann J, Wolf E, Seidl O, Huhn M, Schwerthöffer D. [Delusional Misidentification Syndrom and Violent Behavior - Risk Assessment and Management]. Psychiatr Prax 2020; 48:99-105. [PMID: 32871598 DOI: 10.1055/a-1219-2111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE AND METHOD A case series of three patients with Delusional Misidentification Syndroms (DMS) and violent behavior is presented with respect to the correlation between DMS and violence as well as to the management of such occurrences. RESULTS AND CONCLUSION DMS could be one of the reasons for violent behavior of patients with psychiatric disorders. In such case violent behavior is not just restricted to intimates and relatives but also turns on non-familiar caregivers. DMS could be a risk factor for violent behavior and should therefore be registered with help of a nuanced psychopathological exploration at the time of clinical admission and in course of treatment. Moreover risk assessment tools and safety measures (e. g. medication, monitoring) could be considered for patients with DMS.
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Affiliation(s)
| | | | | | | | | | - Otmar Seidl
- Klinik für Psychiatrie und Psychotherapie der LMU München
| | - Maximilian Huhn
- Klinik für Psychiatrie, Psychosomatische Medizin und Psychotherapie der Sozialstiftung Bamberg, Lehrkrankenhaus der Universität Erlangen.,Klinik für Psychiatrie und Psychotherapie der TU-München
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14
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Siafis S, Çıray O, Schneider-Thoma J, Bighelli I, Krause M, Rodolico A, Ceraso A, Deste G, Huhn M, Fraguas D, Mavridis D, Charman T, Murphy DG, Parellada M, Arango C, Leucht S. Placebo response in pharmacological and dietary supplement trials of autism spectrum disorder (ASD): systematic review and meta-regression analysis. Mol Autism 2020; 11:66. [PMID: 32847616 PMCID: PMC7448339 DOI: 10.1186/s13229-020-00372-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022] Open
Abstract
Background Placebo response in autism spectrum disorder (ASD) might dilute drug-placebo differences and hinder drug development. Therefore, this meta-analysis investigated placebo response in core symptoms. Methods We searched ClinicalTrials.gov, CENTRAL, EMBASE, MEDLINE, PsycINFO, WHO-ICTRP (up to July 8, 2018), and PubMed (up to July 4, 2019) for randomized pharmacological and dietary supplement placebo-controlled trials (RCTs) with a minimum of seven days of treatment. Single-group meta-analyses were conducted using a random-effects model. Standardized mean changes (SMC) of core symptoms in placebo arms were the primary outcomes and placebo positive response rates were a secondary outcome. Predictors of placebo response were investigated with meta-regression analyses. The protocol was registered with PROSPERO ID CRD42019125317. Results Eighty-six RCTs with 2360 participants on placebo were included in our analysis (87% in children/adolescents). The majority of trials were small, single-center with a duration of 8–12 weeks and published after 2009. Placebo response in social-communication difficulties was SMC = − 0.32, 95% CI [− 0.39, − 0.25], in repetitive behaviors − 0.23[− 0.32, − 0.15] and in scales measuring overall core symptoms − 0.36 [− 0.46, − 0.26]. Overall, 19%, 95% CI [16–22%] of participants were at least much improved with placebo. Caregiver (vs. clinician) ratings, lower risk of bias, flexible-dosing, larger sample sizes and number of sites, less recent publication year, baseline levels of irritability, and the use of a threshold of core symptoms at inclusion were associated with larger placebo response in at least a core symptom domain. Limitations About 40% of the trials had an apparent focus on core symptoms. Investigation of the differential impact of predictors on placebo and drug response was impeded by the use of diverse experimental interventions with essentially different mechanisms of action. An individual-participant-data meta-analysis could allow for a more fine-grained analysis and provide more informative answers. Conclusions Placebo response in ASD was substantial and predicted by design- and participant-related factors, which could inform the design of future trials in order to improve the detection of efficacy in core symptoms. Potential solutions could be the minimization and careful selection of study sites as well as rigorous participant enrollment and the use of measurements of change not solely dependent on caregivers.
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Oğulcan Çıray
- Department of Child and Adolescent Psychiatry, School of Medicine, Balçova Dokuz Eylul University, İzmir, Turkey
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Alessandro Rodolico
- Department of Experimental and Clinical Medicine, Psychiatric Clinic University Hospital 'Gaspare Rodolico', University of Catania, Catania, Italy
| | - Anna Ceraso
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Giacomo Deste
- Department of Psychiatry, Spedali Civili Hospital, Brescia, Italy
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany.,Department of Psychiatry, Psychosomatic Medicine and Psychotherapy Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Erlangen, Germany
| | - David Fraguas
- Department of Child and Adolescent Psychiatry, Hospital General Universitario Gregorio Marañón, Institute of Psychiatry and Mental Health, IiSGM, CIBERSAM, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Tony Charman
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Declan G Murphy
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Mara Parellada
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Celso Arango
- Department of Primary Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaningerstr. 22, 81675, Munich, Germany
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15
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Samara MT, Huhn M, Chiocchia V, Schneider-Thoma J, Wiegand M, Salanti G, Leucht S. Efficacy, acceptability, and tolerability of all available treatments for insomnia in the elderly: a systematic review and network meta-analysis. Acta Psychiatr Scand 2020; 142:6-17. [PMID: 32521042 DOI: 10.1111/acps.13201] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Symptoms of insomnia are highly prevalent in the elderly. A significant number of pharmacological and non-pharmacological interventions exist, but, up-to-date, their comparative efficacy and safety has not been sufficiently assessed. METHODS We integrated the randomized evidence from every available treatment for insomnia in the elderly (>65 years) by performing a network meta-analysis. Several electronic databases were searched up to May 25, 2019. The two primary outcomes were total sleep time and sleep quality. Data for other 6 efficacy and 8 safety outcomes were also analyzed. RESULTS Fifty-three RCTs with 6832 participants (75 years old on average) were included, 43 of which examined the efficacy of one or more drugs. Ten RCTs examined the efficacy of non-pharmacological interventions and were evaluated only with pairwise meta-analyses because they were disconnected from the network. The overall confidence in the evidence was very low primarily due to the small amount of data per comparison and their sparse connectedness. Several benzodiazepines, antidepressants, and z-drugs performed better in both primary outcomes, but few comparisons had data from more than one trial. The limited evidence on non-pharmacological interventions suggested that acupressure, auricular acupuncture, mindfulness-based stress reduction program, and tart cherry juice were better than their control interventions. Regarding safety, no clear differences were detected among interventions due to large uncertainty. CONCLUSIONS Insufficient evidence exists on which intervention is more efficacious for elderly patients with insomnia. More RCTs, with longer duration, making more direct interventions among active treatments and presenting more outcomes are urgently needed.
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Affiliation(s)
- M T Samara
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - M Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Erlangen, Germany
| | - V Chiocchia
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - J Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - M Wiegand
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - G Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - S Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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16
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Huhn M, Samara M, Leucht S. Antipsychotics for schizophrenia and substance misuse - Authors' reply. Lancet 2020; 395:1903. [PMID: 32563369 DOI: 10.1016/s0140-6736(20)30233-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/24/2020] [Indexed: 11/23/2022]
Affiliation(s)
- Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, 81675 Munich, Germany.
| | - Myrto Samara
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, 81675 Munich, Germany
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17
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Bighelli I, Leucht C, Huhn M, Reitmeir C, Schwermann F, Wallis S, Davis JM, Leucht S. Are Randomized Controlled Trials on Pharmacotherapy and Psychotherapy for Positive Symptoms of Schizophrenia Comparable? A Systematic Review of Patient and Study Characteristics. Schizophr Bull 2020; 46:496-504. [PMID: 32275756 PMCID: PMC7147572 DOI: 10.1093/schbul/sbz090] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND We examined patient and study characteristics of pharmacotherapy and psychotherapy trials to establish whether the effects of these 2 treatment strategies can be compared meaningfully. METHODS We inspected all randomized controlled trials included in 2 recent meta-analyses on antipsychotics and psychotherapy in patients with positive symptoms of schizophrenia, searching EMBASE, MEDLINE, PsycINFO, Cochrane Library, and ClinicalTrials.gov. Differences between psychotherapy and pharmacotherapy trials were analyzed with Wilcoxon-Mann-Whitney and chi-square tests. RESULTS Eighty studies with 18 271 participants on antipsychotic drugs and 53 studies with 4068 participants on psychotherapy were included. Psychotherapy studies included less severely ill patients (P < .0001), with a shorter duration of illness (P = .021), lasted for a longer period (P < .0001), administered the intervention as add-on to antipsychotics (P < .0001), had higher risk of bias in some domains including blinding of outcome assessment (P < .0001), and were funded publicly more frequently (P < .0001). Antipsychotic trials had larger sample sizes (P < .0001) and more study centers (P < .0001), included more males (P = .0001), inpatients (P < .0001), and slightly older patients (P = .031), more often used diagnostic operationalized criteria (P = .006), and were sponsored by pharmaceutical companies. They did not differ in conflict of interest (P = .24). CONCLUSIONS We found key differences between the 2 groups of studies that encompass higher risk of bias in psychotherapy studies and the inclusion of more severe patients in drug trials. These differences imply that study and patient characteristics should be carefully taken into account before considering a network meta-analysis. In the interest of patients, psychopharmacologists and psychotherapists should optimize their treatments rather than seeing them in competition.
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Affiliation(s)
- Irene Bighelli
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Claudia Leucht
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Cornelia Reitmeir
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Felicitas Schwermann
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Sofia Wallis
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - John M Davis
- Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany,To whom correspondence should be addressed; Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaningerstrasse 22, 81675 München, Germany; tel: 0049 089 4140 4249, fax: 0049 089 4140 4888, e-mail:
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Huhn M, Nikolakopoulou A, Schneider-Thoma J, Krause M, Samara M, Peter N, Arndt T, Bäckers L, Rothe P, Cipriani A, Davis J, Salanti G, Leucht S. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet 2019; 394:939-951. [PMID: 31303314 PMCID: PMC6891890 DOI: 10.1016/s0140-6736(19)31135-3] [Citation(s) in RCA: 750] [Impact Index Per Article: 150.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/18/2019] [Accepted: 04/25/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Schizophrenia is one of the most common, burdensome, and costly psychiatric disorders in adults worldwide. Antipsychotic drugs are its treatment of choice, but there is controversy about which agent should be used. We aimed to compare and rank antipsychotics by quantifying information from randomised controlled trials. METHODS We did a network meta-analysis of placebo-controlled and head-to-head randomised controlled trials and compared 32 antipsychotics. We searched Embase, MEDLINE, PsycINFO, PubMed, BIOSIS, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov from database inception to Jan 8, 2019. Two authors independently selected studies and extracted data. We included randomised controlled trials in adults with acute symptoms of schizophrenia or related disorders. We excluded studies in patients with treatment resistance, first episode, predominant negative or depressive symptoms, concomitant medical illnesses, and relapse-prevention studies. Our primary outcome was change in overall symptoms measured with standardised rating scales. We also extracted data for eight efficacy and eight safety outcomes. Differences in the findings of the studies were explored in metaregressions and sensitivity analyses. Effect size measures were standardised mean differences, mean differences, or risk ratios with 95% credible intervals (CrIs). Confidence in the evidence was assessed using CINeMA (Confidence in Network Meta-Analysis). The study protocol is registered with PROSPERO, number CRD42014014919. FINDINGS We identified 54 417 citations and included 402 studies with data for 53 463 participants. Effect size estimates suggested all antipsychotics reduced overall symptoms more than placebo (although not statistically significant for six drugs), with standardised mean differences ranging from -0·89 (95% CrI -1·08 to -0·71) for clozapine to -0·03 (-0·59 to 0·52) for levomepromazine (40 815 participants). Standardised mean differences compared with placebo for reduction of positive symptoms (31 179 participants) varied from -0·69 (95% CrI -0·86 to -0·52) for amisulpride to -0·17 (-0·31 to -0·04) for brexpiprazole, for negative symptoms (32 015 participants) from -0·62 (-0·84 to -0·39; clozapine) to -0·10 (-0·45 to 0·25; flupentixol), for depressive symptoms (19 683 participants) from -0·90 (-1·36 to -0·44; sulpiride) to 0·04 (-0·39 to 0·47; flupentixol). Risk ratios compared with placebo for all-cause discontinuation (42 672 participants) ranged from 0·52 (0·12 to 0·95; clopenthixol) to 1·15 (0·36 to 1·47; pimozide), for sedation (30 770 participants) from 0·92 (0·17 to 2·03; pimozide) to 10·20 (4·72 to 29·41; zuclopenthixol), for use of antiparkinson medication (24 911 participants) from 0·46 (0·19 to 0·88; clozapine) to 6·14 (4·81 to 6·55; pimozide). Mean differences compared to placebo for weight gain (28 317 participants) ranged from -0·16 kg (-0·73 to 0·40; ziprasidone) to 3·21 kg (2·10 to 4·31; zotepine), for prolactin elevation (21 569 participants) from -77·05 ng/mL (-120·23 to -33·54; clozapine) to 48·51 ng/mL (43·52 to 53·51; paliperidone) and for QTc prolongation (15 467 participants) from -2·21 ms (-4·54 to 0·15; lurasidone) to 23·90 ms (20·56 to 27·33; sertindole). Conclusions for the primary outcome did not substantially change after adjusting for possible effect moderators or in sensitivity analyses (eg, when excluding placebo-controlled studies). The confidence in evidence was often low or very low. INTERPRETATION There are some efficacy differences between antipsychotics, but most of them are gradual rather than discrete. Differences in side-effects are more marked. These findings will aid clinicians in balancing risks versus benefits of those drugs available in their countries. They should consider the importance of each outcome, the patients' medical problems, and preferences. FUNDING German Ministry of Education and Research and National Institute for Health Research.
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Affiliation(s)
- Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.
| | | | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany; Institute for Evidence in Medicine (for Cochrane Germany Foundation), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Myrto Samara
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Natalie Peter
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thomas Arndt
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lio Bäckers
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Philipp Rothe
- Department of Forensic Psychiatry and Psychotherapy, University of Ulm, Günzburg District Hospital, Ulm, Germany
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - John Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA; Maryland Psychiatric Research Center, Baltimore, MD, USA
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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Schneider-Thoma J, Efthimiou O, Bighelli I, Dörries C, Huhn M, Krause M, Reichelt L, Röder H, Furukawa TA, Davis JM, Leucht S. Second-generation antipsychotic drugs and short-term somatic serious adverse events: a systematic review and meta-analysis. Lancet Psychiatry 2019; 6:753-765. [PMID: 31320283 DOI: 10.1016/s2215-0366(19)30223-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/13/2019] [Accepted: 05/29/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Antipsychotic drugs might cause acutely occurring, serious side-effects and thus contribute to the increased physical morbidity and mortality observed in patients with severe mental health disorders. We examined this hypothesis by doing a meta-analysis of International Conference on Harmonisation-Good Clinical Practice-defined serious adverse events occurring in placebo-controlled trials of antipsychotics. METHODS For this systematic review and meta-analysis, we included randomised controlled trials (RCTs) comparing second-generation antipsychotics with placebo. We searched MEDLINE, Embase, Cochrane CENTRAL, BIOSIS, PsycINFO, PubMed, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform for trials published in any language from database inception up until Jan 27, 2017. Trials were included without limitations in population (diagnostic category, age, sex, ethnicity), dosing regimen, blinding status, duration, or publication year. Only psychological studies lasting less than 1 day and trials done in mainland China were excluded. We contacted pharmaceutical companies, drug regulatory authorities, and study investigators for additional data. The primary outcome was the number of patients with at least one somatic serious adverse event. We estimated minimum and maximum numbers of patients with the outcome in each study group and synthesised the results with odds ratios (ORs) in a common-effects meta-analysis. This study is registered with PROSPERO, number CRD42016033930. FINDINGS We identified 597 RCTs, comprising 108 664 participants, that met the inclusion criteria. 314 trials (67 642 participants) with details on individual serious adverse events available constituted the main dataset for meta-analysis. 88% of these were 13 weeks (approximately 3 months) or shorter in duration (median 6 weeks, IQR 4-9). At least one somatic serious adverse event occurred in 698 (1·63%) to 862 (2·02%) of 42 600 patients on antipsychotics, and in 343 (1·37%) to 419 (1·67%) of 25 042 patients on placebo. The odds ratios (ORs) were 1·24 (95% CI 1·08-1·42) and 1·24 (1·10-1·41) based on the minimum and maximum estimate, respectively. In predefined subgroup analyses we found evidence suggesting a larger effect in older patients (>65 years; OR 1·56, 95% CI 1·22-1·98; 1·58, 1·25-1·99) as compared with adults (18-65 years; 1·09, 0·91-1·29; 1·10, 0·95-1·28); likewise in children or adolescents (<18 years) although the evidence was more uncertain (1·49, 0·81-2·75; 1·54, 0·85-2·77). Of 597 included RCTs, 30 (5%), 358 (60%), and 209 (35%) were rated at high, moderate, or low risk of bias, respectively. τ2 was zero for both analyses of the primary outcome (minimum estimate, maximum estimate). A Bayesian sensitivity analysis using external information on heterogeneity gave similar results. INTERPRETATION We found evidence that antipsychotics cause short-term somatic serious adverse events on top of somatic serious adverse events occurring independent of treatment. This effect appears to be mainly driven by results in older patients. Hence, clinicians should be aware that antipsychotics are potentially toxic, particularly when treating patients sharing risk factors with the older population. FUNDING German Ministry of Education and Research.
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Affiliation(s)
- Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Carola Dörries
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany; Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Leonie Reichelt
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Hannah Röder
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA; Maryland Psychiatric Research Center, Baltimore, MD, USA
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
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Bighelli I, Huhn M, Schneider-Thoma J, Krause M, Reitmeir C, Wallis S, Schwermann F, Pitschel-Walz G, Barbui C, Furukawa TA, Leucht S. Response rates in patients with schizophrenia and positive symptoms receiving cognitive behavioural therapy: a systematic review and single-group meta-analysis. BMC Psychiatry 2018; 18:380. [PMID: 30514268 PMCID: PMC6280425 DOI: 10.1186/s12888-018-1964-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/27/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cognitive behavioural therapy has been used for schizophrenia, but to which extent it is effective is still controversial. Results of existing meta-analyses are of difficult interpretation, because they mainly present effect sizes in the form of standardized mean differences between intervention and control groups based on rating scales, which are of unclear clinical meaning. No meta-analysis has considered the number of patients responding to treatment yet. Based on this ground, we present the first meta-analysis examining the response rates of patients with schizophrenia and positive symptoms to cognitive behavioural therapy. METHODS We searched multiple databases for randomized controlled trials on psychological interventions of schizophrenia including patients with positive symptoms, and included for this analysis the studies on cognitive behavioural therapy (last search: January 2018). We applied a validated imputation method to calculate the number of responders from rating scales for the outcomes overall symptoms and positive symptoms, based on two criteria, at least 20% and at least 50% reduction from baseline on PANSS or BPRS total scores. Data were pooled in a single-group summary meta-analysis using R software. Additionally, several potential moderators of response to cognitive behavioural therapy were examined by subgroup and meta-regression analyses. The protocol has been registered in PROSPERO (CRD42017067795). RESULTS We included 33 studies with a total of 1142 participants receiving cognitive behavioural therapy. On average, 44.5 and 13.2% of the patients reached a 20% (minimally improved) and 50% (much improved) reduction of overall symptoms. Similarly, 52.9 and 24.8% of the patients reached a 20%/50% reduction of positive symptoms. Subgroup and meta-regression analyses revealed a better treatment response in overall symptoms for patients that were not treatment resistant and in studies with researchers' allegiance. Of borderline significance was the better response in studies employing expert therapists and in patients that were more severely ill at baseline. Blinding of outcome assessor, number of sessions, treatment duration, age and gender were not significant moderators of response. CONCLUSIONS Our findings suggest that adding cognitive behavioural therapy to pharmacotherapy brings about a minimal improvement in overall symptoms among 44.5% of its recipients. Several study and patients characteristics can moderate response rates.
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Affiliation(s)
- Irene Bighelli
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
| | - Maximilian Huhn
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Johannes Schneider-Thoma
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Marc Krause
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Cornelia Reitmeir
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sofia Wallis
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Felicitas Schwermann
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Gabi Pitschel-Walz
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Corrado Barbui
- 0000 0004 1763 1124grid.5611.3WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Toshi A. Furukawa
- 0000 0004 0372 2033grid.258799.8Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Stefan Leucht
- 0000000123222966grid.6936.aDepartment of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Krause M, Huhn M, Schneider-Thoma J, Rothe P, Smith RC, Leucht S. Antipsychotic drugs for elderly patients with schizophrenia: A systematic review and meta-analysis. Eur Neuropsychopharmacol 2018; 28:1360-1370. [PMID: 30243680 DOI: 10.1016/j.euroneuro.2018.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
Elderly patients with schizophrenia are a particularly vulnerable group often excluded from clinical trials. Currently there is no evidence-synthesis about the efficacy and safety of antipsychotics in this subgroup. We reviewed all randomized-controlled-trials, about antipsychotics in elderly schizophrenics (last search Dec 12, 2017). Pairwise meta-analyses were conducted. The primary outcome was overall symptoms. Secondary outcomes included positive symptoms, negative symptoms, response, dropouts, quality of life, social functioning and side-effects. We included 29 references from 18 unique randomized-controlled-trials with 1225 participants published from 1958 to 2009. The definition of "elderly" was very heterogeneous across the studies (minimum age 46-65, mean age 57-73). There were evidence gaps for most drugs in many outcomes. In terms of efficacy paliperidone was associated with fewer dropouts due to inefficacy than placebo in the only placebo-controlled-trial. Olanzapine was superior to haloperidol in overall symptoms, negative symptoms and response, and it was associated with fewer dropouts than risperidone. Risperidone and haloperidol produced more prolactin increase than olanzapine, and olanzapine was associated with less use of antiparkinson medication than haloperidol. Although we found no marked differences of the effects of these drugs in the elderly, the evidence presented was based on very few usually small studies. To examine specifically whether there are differences in efficacy and side-effects in elderly, which differs in meaningful ways from the general population, studies in patients who are defined by critiera as truly geriatric, which incorporates older age together with multimorbidity and fraility dimensions, may be more informative.
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Affiliation(s)
- Marc Krause
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany; Ludwig-Maximilians Universität München, Germany.
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Philipp Rothe
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Robert C Smith
- New York University Medical School, Department Of Psychiatry, and Nathan Kline Institute for Psychiatric Research, New York, USA
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
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Leucht S, Chaimani A, Leucht C, Huhn M, Mavridis D, Helfer B, Samara M, Cipriani A, Geddes JR, Salanti G, Davis JM. 60 years of placebo-controlled antipsychotic drug trials in acute schizophrenia: Meta-regression of predictors of placebo response. Schizophr Res 2018; 201:315-323. [PMID: 29804928 DOI: 10.1016/j.schres.2018.05.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 05/06/2018] [Accepted: 05/12/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE A recent meta-regression had shown that the degree of placebo response, which has increased over the decades, is the major predictor of drug-placebo differences in antipsychotic drug trials in acutely ill patients with schizophrenia. Drug response, however, had remained stable. In the current meta-regression we explored the factors that are associated with placebo-response. METHOD We searched multiple electronic databases, ClinicalTrials.gov and the FDA website for randomized, placebo-controlled, antipsychotic drug trials in patients with acute exacerbations of schizophrenia. The outcome was the degree of placebo response measured by the BPRS or PANSS change from baseline to endpoint. 26 patient-, design-, and drug-related potential predictors of placebo response were analyzed by univariable and multivariable meta-regressions. RESULTS 167 double-blind randomized controlled trials with 28,102 participants were included. The mean PANSS change from baseline was 6.25 (95% CI 4.64,7.85). More recent publication year, larger study sample size, more study sites, use of the PANSS rather than the BPRS scale to measure response, shorter wash-out phases, shorter study duration, lower mean age and shorter duration of illness were associated with larger placebo response in univariable analyses. In a multivariable analysis only the number of study participants and mean participant age had an impact on placebo response. CONCLUSIONS The degree of placebo response is moderated by a number of design and patient-related factors. These explanatory variables of placebo response are only in part identical with those that moderated drug-placebo differences.
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Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Ismaningerstr. 22, 81675 Munich, Germany.
| | - Anna Chaimani
- Paris Descartes University, INSERM, UMR1153 Epidemiology and Statistics, Sorbonne Paris Cité Research Center (CRESS), METHODS Team; Cochrane France, Paris, France.
| | - Claudia Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Ismaningerstr. 22, 81675 Munich, Germany.
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Ismaningerstr. 22, 81675 Munich, Germany.
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina School of Education, Greece
| | - Bartosz Helfer
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Myrto Samara
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Ismaningerstr. 22, 81675 Munich, Germany
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK.
| | - John R Geddes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK.
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland.
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago (MC 912), 1601 W. Taylor St., Chicago, IL 60612, USA; Maryland Psychiatric Research Center, Baltimore, MD, USA.
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Krause M, Zhu Y, Huhn M, Schneider-Thoma J, Bighelli I, Nikolakopoulou A, Leucht S. Antipsychotic drugs for patients with schizophrenia and predominant or prominent negative symptoms: a systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci 2018; 268:625-639. [PMID: 29368205 DOI: 10.1007/s00406-018-0869-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/15/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Negative symptoms are the core of schizophrenia, but whether antipsychotics are efficacious for their treatment is unclear. Moreover, there is debate whether patients in relevant trials should have predominant negative symptoms or whether prominent negative symptoms are also acceptable. METHODS We systematically reviewed randomised, blinded antipsychotic drug trials in patients with schizophrenia and either predominant or prominent negative symptoms (last search Dec 12, 2017). Separate pairwise meta-analyses were conducted in these two populations. The primary outcome was negative symptoms. Depressive, symptoms, positive symptoms, and extrapyramidal side-effects were analysed as causes of secondary negative symptoms. FINDINGS We included 21 randomized-controlled trials with 3451 participants which revealed the following significant differences in the primary outcome: in patients with predominant negative symptoms amisulpride was superior to placebo (N = 4; n = 590, SMD 0.47, CI 0.23, 0.71), olanzapine was superior to haloperidol in a small trial (n = 35) and cariprazine outperformed risperidone (N = 1, n = 456, SMD - 0.29, CI - 0.48, - 0.11). In patients with prominent negative symptoms, olanzapine and quetiapine were superior to risperidone in single trials. Overall, studies in prominent negative symptoms were potentially more confounded by improvements of secondary negative symptoms. INTERPRETATION Amisulpride is the only antipsychotic that outperformed placebo in the treatment of predominant negative symptoms, but there was a parallel reduction of depression. Cariprazine was better than risperidone in a large trial that was well-controlled for secondary negative symptoms, but the trial was sponsored by its manufacturer. Future trials should apply scientifically developed definitions such as the deficit syndrome and the persistent negative symptoms concept.
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Affiliation(s)
- Marc Krause
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675, Munich, Germany
- Ludwig-Maximilians-Universität München, Munich, Germany
| | - Yikang Zhu
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675, Munich, Germany
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong, University School of Medicine, South Wan Ping Road 600, Shanghai, 200030, China
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675, Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675, Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675, Munich, Germany
| | | | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675, Munich, Germany.
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Bighelli I, Salanti G, Huhn M, Schneider‐Thoma J, Krause M, Reitmeir C, Wallis S, Schwermann F, Pitschel‐Walz G, Barbui C, Furukawa TA, Leucht S. Psychological interventions to reduce positive symptoms in schizophrenia: systematic review and network meta-analysis. World Psychiatry 2018; 17:316-329. [PMID: 30192101 PMCID: PMC6127754 DOI: 10.1002/wps.20577] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Psychological treatments are increasingly regarded as useful interventions for schizophrenia. However, a comprehensive evaluation of the available evidence is lacking and the benefit of psychological interventions for patients with current positive symptoms is still debated. The present study aimed to evaluate the efficacy, acceptability and tolerability of psychological treatments for positive symptoms of schizophrenia by applying a network meta-analysis approach, that can integrate direct and indirect comparisons. We searched EMBASE, MEDLINE, PsycINFO, PubMed, BIOSIS, Cochrane Library, World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov for randomized controlled trials of psychological treatments for positive symptoms of schizophrenia, published up to January 10, 2018. We included studies on adults with a diagnosis of schizophrenia or a related disorder presenting positive symptoms. The primary outcome was change in positive symptoms measured with validated rating scales. We included 53 randomized controlled trials of seven psychological interventions, for a total of 4,068 participants receiving the psychological treatment as add-on to antipsychotics. On average, patients were moderately ill at baseline. The network meta-analysis showed that cognitive behavioural therapy (40 studies) reduced positive symptoms more than inactive control (standardized mean difference, SMD=-0.29; 95% CI: -0.55 to -0.03), treatment as usual (SMD=-0.30; 95% CI: -0.45 to -0.14) and supportive therapy (SMD=-0.47; 95% CI: -0.91 to -0.03). Cognitive behavioural therapy was associated with a higher dropout rate compared with treatment as usual (risk ratio, RR=0.74; 95% CI: 0.58 to 0.95). Confidence in the estimates ranged from moderate to very low. The other treatments contributed to the network with a lower number of studies. Results were overall consistent in sensitivity analyses controlling for several factors, including the role of researchers' allegiance and blinding of outcome assessor. Cognitive behavior therapy seems to be effective on positive symptoms in moderately ill patients with schizophrenia, with effect sizes in the lower to medium range, depending on the control condition.
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Affiliation(s)
- Irene Bighelli
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of BernBernSwitzerland
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Johannes Schneider‐Thoma
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Cornelia Reitmeir
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Sofia Wallis
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Felicitas Schwermann
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Gabi Pitschel‐Walz
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
| | - Corrado Barbui
- Department of NeuroscienceBiomedicine and Movement Sciences, Section of Psychiatry, University of VeronaVeronaItaly
| | - Toshi A. Furukawa
- Department of Health Promotion and Human BehaviorKyoto University Graduate School of Medicine, Kyoto, Japan and School of Public HealthJapan
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Klinikum rechts der IsarTechnische Universität MünchenMunichGermany
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Schneider-Thoma J, Efthimiou O, Huhn M, Krause M, Reichelt L, Röder H, Davis JM, Salanti G, Leucht S. Second-generation antipsychotic drugs and short-term mortality: a systematic review and meta-analysis of placebo-controlled randomised controlled trials. Lancet Psychiatry 2018; 5:653-663. [PMID: 30042077 DOI: 10.1016/s2215-0366(18)30177-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acutely occurring, life-threatening side-effects of antipsychotic drugs might contribute to the reduced life expectancy observed in patients with severe mental disorders. We aimed to assess this hypothesis by doing a systematic review and meta-analysis of deaths occurring in placebo-controlled trials of antipsychotic drugs. METHODS For this systematic review and meta-analysis, we included randomised controlled trials comparing second-generation antipsychotics with placebo across several diagnostic categories. We searched MEDLINE, EMBASE, Cochrane CENTRAL, BIOSIS, PsycINFO, PubMed, ClinicalTrials.gov, and WHO ICTRP from inception (the last search was done on Jan 21, 2017), and contacted pharmaceutical companies and regulatory authorities for further eligible trials. We examined mortality from any cause (the primary outcome) and mortality from natural causes, suicide, and other non-natural causes. We synthesised the results with odds ratios (ORs) in a common-effects meta-analysis. We investigated the effects of age, diagnostic category, sex, study duration, antipsychotic drug used, drug dose, and polypharmacy in subgroup and meta-regression analyses. This study is registered with PROSPERO, number CRD42016033930. FINDINGS We identified 596 randomised controlled trials published between 1978 and 2017, comprising 108 747 participants. 352 studies (comprising 84 988 participants) with mortality data available constituted the main dataset for our meta-analysis. 207 (0·4%) deaths were reported in 53 804 patients on an antipsychotic drug and 99 (0·3%) deaths in 31 184 patients on placebo. 300 (85%) of 352 trials were 13 weeks (3 months) or shorter in duration (median 6 weeks; IQR 4-10). We found no evidence of a difference between antipsychotic drugs and placebo in mortality by any cause (OR 1·19; 95% CI 0·93-1·53), from natural causes (1·29; 0·85-1·94), from suicide (1·15; 0·47-2·81), and from other non-natural causes (1·55; 0·66-3·63). Most subgroup and meta-regression analyses did not indicate any important effect moderators. The exceptions were increased mortality in patients with dementia (OR 1·56; 95% CI 1·10-2·21), in elderly patients (1·38; 1·01-1·89), in aripiprazole-treated patients (2·20; 1·00-4·86), and in studies with a higher proportion of women (regression coefficient 0·025; 95% credible interval 0·010-0·040). However, the effects in elderly patients, aripiprazole-treated patients, and women were mainly based on the included dementia trials. For patients with schizophrenia there was no evidence of an increased mortality risk (OR 0·69; 95% CI 0·35-1·35). INTERPRETATION Overall, and for the main indication of schizophrenia, there is no evidence from randomised trials that antipsychotic drugs increase mortality. However, vulnerable populations (particularly patients with dementia) might be at increased risk. This meta-analysis could only address acute treatment effects leading to death in the short-term, and not long-term effects of antipsychotic drugs on mortality. FUNDING German Ministry of Education and Research.
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Affiliation(s)
- Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany; Ludwig-Maximilians-University, Munich, Germany
| | - Leonie Reichelt
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Hannah Röder
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA; Maryland Psychiatric Research Center, Baltimore, MD, USA
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.
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Krause M, Zhu Y, Huhn M, Schneider-Thoma J, Bighelli I, Chaimani A, Leucht S. Efficacy, acceptability, and tolerability of antipsychotics in children and adolescents with schizophrenia: A network meta-analysis. Eur Neuropsychopharmacol 2018; 28:659-674. [PMID: 29802039 DOI: 10.1016/j.euroneuro.2018.03.008] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/13/2018] [Accepted: 03/12/2018] [Indexed: 02/06/2023]
Abstract
Children and adolescents with schizophrenia are a particularly vulnerable group. Thus, we integrated all the randomized evidence from the available antipsychotics used for this subgroup by performing a network-meta-analysis and pairwise meta-analysis using a random-effects model. We searched multiple databases up to Nov 17, 2016 (final update search in PubMed: Dec 12, 2017). The primary outcome was efficacy as measured by overall change/endpoint in symptoms of schizophrenia. Secondary outcomes included positive and negative symptoms, response, dropouts, quality of life, social functioning, weight gain, sedation, prolactin, extrapyramidal side effects (EPS) and antiparkinsonian medication. Twenty-eight randomized controlled trials (RCTs) with 3003 unique participants (58% males; mean age 14.41 years) published from 1967 to 2017 were identified. Clozapine was significantly more effective than all other analyzed antipsychotics. Nearly all antipsychotics were more efficacious compared to placebo, but ziprasidone showed no efficacy. In terms of preventing weight gain, molindone, lurasidone and ziprasidone were benign. The highest weight gain was found for clozapine, quetiapine and olanzapine. Most antipsychotics had some sedating effects. Risperidone, haloperidol, paliperidone and olanzapine were associated with prolactin increase. There were evidence gaps for some drugs and many outcomes, especially safety outcomes. Most of the comparisons are based only on one study or just on indirect evidence. Nevertheless, the available direct and indirect evidence showed that the treatment effects were similar compared to findings in adult patients with schizophrenia.
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Affiliation(s)
- Marc Krause
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany; Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Yikang Zhu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, South Wan Ping Road 600, 200030 Shanghai, China
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Anna Chaimani
- Paris Descartes University, Paris, France; INSERM, UMR1153 Epidemiology and Statistics, Sorbonne Paris Cité Research Center (CRESS), METHODS Team, Paris, France; Cochrane France, Paris, France
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
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Leucht S, Leucht C, Huhn M, Chaimani A, Mavridis D, Helfer B, Samara M, Rabaioli M, Bächer S, Cipriani A, Geddes JR, Salanti G, Davis JM. Sixty Years of Placebo-Controlled Antipsychotic Drug Trials in Acute Schizophrenia: Systematic Review, Bayesian Meta-Analysis, and Meta-Regression of Efficacy Predictors. Am J Psychiatry 2017; 174:927-942. [PMID: 28541090 DOI: 10.1176/appi.ajp.2017.16121358] [Citation(s) in RCA: 283] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Antipsychotic drug efficacy may have decreased over recent decades. The authors present a meta-analysis of all placebo-controlled trials in patients with acute exacerbations of schizophrenia, and they investigate which trial characteristics have changed over the years and which are moderators of drug-placebo efficacy differences. METHOD The search included multiple electronic databases. The outcomes were overall efficacy (primary outcome); responder and dropout rates; positive, negative, and depressive symptoms; quality of life; functioning; and major side effects. Potential moderators of efficacy were analyzed by meta-regression. RESULTS The analysis included 167 double-blind randomized controlled trials with 28,102 mainly chronic participants. The standardized mean difference (SMD) for overall efficacy was 0.47 (95% credible interval 0.42, 0.51), but accounting for small-trial effects and publication bias reduced the SMD to 0.38. At least a "minimal" response occurred in 51% of the antipsychotic group versus 30% in the placebo group, and 23% versus 14% had a "good" response. Positive symptoms (SMD 0.45) improved more than negative symptoms (SMD 0.35) and depression (SMD 0.27). Quality of life (SMD 0.35) and functioning (SMD 0.34) improved even in the short term. Antipsychotics differed substantially in side effects. Of the response predictors analyzed, 16 trial characteristics changed over the decades. However, in a multivariable meta-regression, only industry sponsorship and increasing placebo response were significant moderators of effect sizes. Drug response remained stable over time. CONCLUSIONS Approximately twice as many patients improved with antipsychotics as with placebo, but only a minority experienced a good response. Effect sizes were reduced by industry sponsorship and increasing placebo response, not decreasing drug response. Drug development may benefit from smaller samples but better-selected patients.
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Affiliation(s)
- Stefan Leucht
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Claudia Leucht
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Maximilian Huhn
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Anna Chaimani
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Dimitris Mavridis
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Bartosz Helfer
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Myrto Samara
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Matteo Rabaioli
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Susanne Bächer
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Andrea Cipriani
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - John R Geddes
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - Georgia Salanti
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
| | - John M Davis
- From the Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany; the Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, U.K.; the Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece; the Institute of Social and Preventive Medicine. University of Bern, Bern, Switzerland; and the Psychiatric Institute, University of Illinois at Chicago, and the Maryland Psychiatric Research Center, Baltimore
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Zhu Y, Krause M, Huhn M, Rothe P, Schneider-Thoma J, Chaimani A, Li C, Davis JM, Leucht S. Antipsychotic drugs for the acute treatment of patients with a first episode of schizophrenia: a systematic review with pairwise and network meta-analyses. Lancet Psychiatry 2017; 4:694-705. [PMID: 28736102 DOI: 10.1016/s2215-0366(17)30270-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/05/2017] [Accepted: 06/12/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The first episode of schizophrenia is a pivotal phase of this debilitating illness. Which drug to use remains controversial without a summary of all direct or indirect comparisons of drugs. We did a systematic review with pairwise and network meta-analyses of efficacy and tolerability. METHODS We searched MEDLINE, Embase, PsycINFO, Cochrane Library, PubMed, Biosis, and ClinicalTrials.gov for randomised controlled trials of antipsychotics for the acute treatment of first-episode schizophrenia, published up to Nov 17, 2016. Our primary outcome was overall change in symptoms. Secondary outcomes were change in positive and negative symptoms, categorical response to treatment, study dropout for any reason and for inefficacy of treatment, use of drugs to treat parkinsonian symptoms, weight gain, sedation, increase in prolactin release, overall functioning, and quality of life. We did the meta-analyses with a random-effects model to calculate standardised mean differences (SMDs) or odds ratios (ORs) with 95% CIs. FINDINGS We identified 19 relevant randomised controlled trials of 12 antipsychotic drugs that involved 2669 participants. 13 of the studies presented data on the primary outcome. For overall reduction of symptoms, amisulpride (SMD -0·37, 95% CI -0·61 to -0·14), olanzapine (-0·25, -0·39 to -0·12), ziprasidone (-0·25, -0·48 to -0·01), and risperidone (-0·14, -0·27 to -0·01) were significantly more efficacious than haloperidol, but the evidence was very low to moderate quality. Amisulpride was superior for reduction of symptoms to quetiapine (SMD -0·25, 95% CI -0·50 to -0·01). Olanzapine was superior to haloperidol and risperidone for reduction of negative symptoms. Several second-generation antipsychotics were superior to haloperidol in terms of all-cause discontinuation. Olanzapine was associated with at least one use of drugs to treat parkinsonian symptoms and quetiapine with less akathisia than haloperidol, aripiprazole, risperidone, and olanzapine, but, again, evidence was very low to low quality. Molindone was superior to risperidone, haloperidol, and olanzapine in terms of weight gain, and superior to risperidone in terms of increase in prolactin release. INTERPREATION Haloperidol seems to be a suboptimum treatment option for acute treatment of first-episode schizophrenia, but we found little difference between second-generation antipsychotics. The evidence was generally of low quality and the numbers of patients for each drug were small. Thus, the choice of treatment should be guided primarily by side-effects. FUNDING German Federal Ministry of Education and Research.
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Affiliation(s)
- Yikang Zhu
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany; Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Marc Krause
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Philipp Rothe
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Anna Chaimani
- Paris Descartes University, Paris, France; INSERM, UMR1153 Epidemiology and Statistics, Sorbonne Paris Cité Research Center (CRESS), Paris, France; Cochrane France, Paris, France
| | - Chunbo Li
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA; Maryland Psychiatric Research Center, Baltimore, MD, USA
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany.
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Helfer B, Samara MT, Huhn M, Klupp E, Leucht C, Zhu Y, Engel RR, Leucht S. Efficacy and Safety of Antidepressants Added to Antipsychotics for Schizophrenia: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016; 173:876-86. [PMID: 27282362 DOI: 10.1176/appi.ajp.2016.15081035] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The authors examined the safety and efficacy of antidepressants added to antipsychotic drugs in the treatment of schizophrenia. METHOD Multiple databases and previous publications were searched through June 2015 to identify all randomized controlled trials of any add-on antidepressants compared with placebo or no-treatment in schizophrenia. Depressive and negative symptoms (primary outcomes), overall symptoms, positive symptoms, side effects, exacerbation of psychosis, and responder rates were examined. Subgroup, meta-regression, and sensitivity analyses were performed, as well as investigations of publication bias and risk of bias. RESULTS Eighty-two randomized controlled trials with a total of 3,608 participants were included. Add-on antidepressants appeared more efficacious than controls for depressive symptoms (standardized mean difference: -0.25, 95% CI=-0.38 to -0.12), negative symptoms (standardized mean difference: -0.30, 95% CI=-0.44 to -0.16), overall symptoms (standardized mean difference: -0.24, 95% CI=-0.39 to -0.09), positive symptoms (standardized mean difference: -0.17, 95% CI=-0.33 to -0.01), quality of life (standardized mean difference: -0.32, 95% CI=-0.57 to -0.06), and responder rate (risk ratio: 1.52, 95% CI=1.29 to 1.78; number-needed-to-treat-to-benefit: 5, 95% CI=4 to 7). The effects on depressive and negative symptoms appeared more pronounced when minimum thresholds of these symptoms were inclusion criteria (standardized mean difference: -0.34, 95% CI=-0.58 to -0.09 and standardized mean difference: -0.58, 95% CI=-0.94 to -0.21, respectively). There were no significant differences between antidepressants and controls in terms of exacerbation of psychosis, premature discontinuation, and the number of participants with at least one adverse event. More patients taking add-on antidepressants suffered from abdominal pain, constipation, dizziness, and dry mouth. CONCLUSIONS Analysis of primary outcomes (depressive and negative symptoms) suggests small, beneficial effects of adjunctive antidepressants. It would appear that this augmentation can be accomplished with a low risk of exacerbation of psychosis and adverse effects. However, secondary and subgroup analyses should be interpreted cautiously and considered exploratory.
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Affiliation(s)
- Bartosz Helfer
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Myrto T Samara
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Maximilian Huhn
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Elisabeth Klupp
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Claudia Leucht
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Yikang Zhu
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Rolf R Engel
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
| | - Stefan Leucht
- From the Department of Psychiatry and Psychotherapy, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany; and the Department of Psychiatry and Psychotherapy, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
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Abstract
BACKGROUND Antipsychotic drugs are the core treatment for schizophrenia. Treatment guidelines state that there is no difference in efficacy between the various first-generation antipsychotics, however, low-potency first-generation antipsychotic drugs are sometimes perceived as less efficacious than high-potency first-generation compounds by clinicians, and they also seem to differ in their side effects. OBJECTIVES To review the effects of high-potency, first-generation perphenazine compared with low-potency, first-generation antipsychotic drugs for people with schizophrenia. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (October 2010). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing perphenazine with first-generation, low-potency antipsychotic drugs for people with schizophrenia or schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis and using a random-effects model. MAIN RESULTS The review currently includes four relevant randomised trials with 365 participants. The size of the included studies was between 42 and 158 participants with a study length between one and four months. Overall, the methods of sequence generation and allocation concealment were poorly reported. Most studies were rated as low risk of bias in terms of blinding. Overall, attrition bias in the studies was high.The effects of perphenazine and low-potency antipsychotic drugs seemed to be similar in terms of the primary outcome - response to treatment (perphenazine 58%, low-potency antipsychotics 59%, 2 RCTs, n = 138, RR 0.97 CI 0.74 to 1.26 - moderate quality of evidence). There was also no clear evidence of a difference in acceptability of treatment with the number of participants leaving the studies early due to any reason, however results were imprecise (perphenazine 30%, low-potency antipsychotics 28%, 3 RCTs, n = 323, RR 0.78 CI 0.35 to 1.76, very low quality of evidence).There were low numbers of studies available for the outcomes experiencing at least one adverse effect (perphenazine 33%, low-potency antipsychotics 47%, 2 RCTs, n = 165, RR 0.83 CI 0.36 to 1.95, low quality evidence) and experiencing at least one movement disorder (perphenazine 22%, low-potency first-generation antipsychotics 0%, 1 RCT, n = 69, RR 15.62 CI 0.94 to 260.49, low quality evidence), and the confidence intervals for the estimated effects did not exclude important differences. Akathisia was more frequent in the perphenazine group (perphenazine 25%, low-potency antipsychotics 22%, 2 RCTs, n = 227, RR 9.45 CI 1.69 to 52.88), whereas severe toxicity was less so (perphenazine 42%, low-potency antipsychotics 69%, 1 RCT, n = 96, RR 0.61 CI 0.41 to 0.89).There were three deaths in the low-potency group by four months but the difference between groups was not significant (perphenazine 0%, low-potency antipsychotics 2%, 1 RCT, n = 96, RR 0.14 CI 0.01 to 2.69, moderate quality evidence). No data were available for our prespecified outcomes of interest sedation or quality of life. Data were not available for other outcomes such as relapse, service use, costs and satisfaction with care.The event rates reported quote simple aggregates and are not based on the RRs. AUTHORS' CONCLUSIONS The results do not show a superiority in efficacy of high-potency perphenazine compared with low-potency first-generation antipsychotics. There is some evidence that perphenazine is more likely to cause akathisia and less likely to cause severe toxicity, but most adverse effect results were equivocal. The number of studies as well as the quality of studies is low, with quality of evidence for the main outcomes ranging from moderate to very low, so more randomised evidence would be needed for conclusions to be made.
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Affiliation(s)
- Magdolna Tardy
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieMöhlstr. 26MünchenGermany81675
| | - Maximilian Huhn
- Universitätsklinikum der Technischen Universität MünchenKlinik und Poliklinik für Psychiatrie und PsychotherapieKlinikum rechts der IsarMünchenBavariaGermany81675
| | - Rolf R Engel
- Ludwig‐Maximilians‐University MunichPsychiatric HospitalNussbaumstr. 7MuenchenGermany80336
| | - Stefan Leucht
- Technische Universität MünchenDepartment of Psychiatry and PsychotherapyIsmaningerstrasse 22MünchenGermany81675
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Abstract
BACKGROUND Antipsychotic drugs are the core treatment for schizophrenia. Treatment guidelines state that there is no difference in efficacy between any other antipsychotic compounds, however, low-potency antipsychotic drugs are often perceived as less efficacious than high-potency compounds by clinicians, and they also seem to differ in their side effects. This review examined the effects of the high-potency antipsychotic fluphenazine compared to those of low-potency antipsychotics. OBJECTIVES To review the effects of fluphenazine and low-potency antipsychotics for people with schizophrenia. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (November 2010). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing fluphenazine with first-generation low-potency antipsychotic drugs for people with schizophrenia or schizophrenia-like psychosis. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random-effects model. MAIN RESULTS The review currently includes seven randomised trials and 1567 participants that compared fluphenazine with low-potency antipsychotic drugs. The size of the included studies was between 40 and 438 participants. Overall, sequence generation, allocation procedures and blinding were poorly reported. Fluphenazine was not significantly different from low-potency antipsychotic drugs in terms of response to treatment (fluphenazine 55%, low-potency drug 55%, 2 RCTs, n = 105, RR 1.06 CI 0.75 to 1.50, moderate quality evidence). There was also no significant difference in acceptability of treatment with equivocal numbers of participants leaving the studies early due to any reason (fluphenazine 36%, low-potency antipsychotics 36%, 6 RCTs, n = 1532, RR 1.00 CI 0.88 to 1.14, moderate quality evidence). There was no significant difference between fluphenazine and low-potency antipsychotics for numbers experiencing at least one adverse effect (fluphenazine 70%, low-potency antipsychotics 88%, 1 RCT, n = 65, RR 0.79 CI 0.58 to 1.07, moderate quality evidence). However, at least one movement disorder occurred significantly more frequently in the fluphenazine group (fluphenazine 15%, low-potency antipsychotics 10%, 3 RCTs, n = 971, RR 2.11 CI 1.41 to 3.15, low quality of evidence). In contrast, low-potency antipsychotics produced significantly more sedation (fluphenazine 20%, low-potency antipsychotics 64%, 1 RCT, n = 65, RR 0.31 CI 0.13 to 0.77, high quality evidence). No data were available for the outcomes of death and quality of life. The results of the primary outcome were robust in a number of subgroup and sensitivity analyses.Adverse effects such as akathisia (fluphenazine 15%, low-potency antipsychotics 6%, 5 RCTs, n = 1209, RR 2.28 CI 1.58 to 3.28); dystonia (fluphenazine 5%, low-potency antipsychotics 2%, 4 RCTs, n = 1309, RR 2.66 CI 1.25 to 5.64); loss of associated movement (fluphenazine 20%, low-potency antipsychotics 2%, 1 RCT, n = 338, RR 11.15 CI 3.95 to 31.47); rigor (fluphenazine 27%, low-potency antipsychotics 12%, 2 RCTs, n = 403, RR 2.18 CI 1.20 to 3.97); and tremor (fluphenazine 15%, low-potency antipsychotics 6%, 2 RCTs, n = 403, RR 2.53 CI 1.37 to 4.68) occurred significantly more frequently in the fluphenazine group.For other adverse effects such as dizziness (fluphenazine 8%, low-potency antipsychotics 17%, 4 RCTs, n = 1051, RR 0.49 CI 0.32 to 0.73); drowsiness (fluphenazine 18%, low-potency antipsychotics 25%, 3 RCTs, n = 986, RR 0.67 CI 0.53 to 0.86); dry mouth (fluphenazine 11%, low-potency antipsychotics 18%, 4 RCTs, n = 1051, RR 0.63 CI 0.45 to 0.89); nausea (fluphenazine 4%, low-potency antipsychotics 15%, 3 RCTs, n = 986, RR 0.25 CI 0.14 to 0.45); and vomiting (fluphenazine 3%, low-potency antipsychotics 8%, 3 RCTs, n = 986, RR 0.36 CI 0.18 to 0.72) results favoured fluphenazine with significantly more events occurring in the low-potency antipsychotic group for these outcomes. AUTHORS' CONCLUSIONS The results do not show a clear difference in efficacy between fluphenazine and low-potency antipsychotics. The number of included studies was low and their quality moderate. Therefore, further studies would be needed to draw firm conclusions about the relative effects of fluphenazine and low-potency antipsychotics.
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Affiliation(s)
- Magdolna Tardy
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München Klinikum rechts der Isar, Möhlstr. 26, München, Germany, 81675
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Abstract
BACKGROUND Antipsychotic drugs are the core treatment for schizophrenia. Treatment guidelines state that there is no difference in efficacy between antipsychotic compounds, however, low-potency antipsychotic drugs are often clinically perceived as less efficacious than high-potency compounds, and they also seem to differ in their side-effects. OBJECTIVES To review the effects in clinical response of haloperidol and low-potency antipsychotics for people with schizophrenia. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (July 2010). SELECTION CRITERIA We included all randomised trials comparing haloperidol with first-generation low-potency antipsychotic drugs for people with schizophrenia or schizophrenia-like psychosis. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data, we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD), again based on a random-effects model. MAIN RESULTS The review currently includes 17 randomised trials and 877 participants. The size of the included studies was between 16 and 109 participants. All studies were short-term with a study length between two and 12 weeks. Overall, sequence generation, allocation procedures and blinding were poorly reported. We found no clear evidence that haloperidol was superior to low-potency antipsychotic drugs in terms of clinical response (haloperidol 40%, low-potency drug 36%, 14 RCTs, n = 574, RR 1.11, CI 0.86 to 1.44 lowquality evidence). There was also no clear evidence of benefit for either group in acceptability of treatment with equivocal difference in the number of participants leaving the studies early due to any reason (haloperidol 13%, low-potency antipsychotics 17%, 11 RCTs, n = 408, RR 0.82, CI 0.38 to 1.77, low quality evidence). Similar equivocal results were found between groups for experiencing at least one adverse effect (haloperidol 70%, low-potency antipsychotics 35%, 5 RCTs n = 158, RR 1.97, CI 0.69 to 5.66, very low quality evidence ). More participants from the low-potency drug group experienced sedation (haloperidol 14%, low-potency antipsychotics 41%, 2 RCTs, n = 44, RR 0.30, CI 0.11 to 0.82, moderate quality evidence), orthostasis problems (haloperidol 25%, low-potency antipsychotics 71%, 1 RCT, n = 41, RR 0.35, CI 0.16 to 0.78) and weight gain (haloperidol 5%, low-potency antipsychotics 29%, 3 RCTs, n = 88, RR 0.22, CI 0.06 to 0.81). In contrast, the outcome 'at least one movement disorder' was more frequent in the haloperidol group (haloperidol 72%, low-potency antipsychotics 41%, 5 RCTs, n = 170, RR 1.64, CI 1.22 to 2.21, low quality evidence). No data were available for death or quality of life. The results of the primary outcome were robust in several subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS The results do not clearly show a superiority in efficacy of haloperidol compared with low-potency antipsychotics. Differences in adverse events were found for movement disorders, which were more frequent in the haloperidol group, and orthostatic problems, sedation and weight gain, which were more frequent in the low-potency antipsychotic group. The quality of studies was low, and the quality of evidence for the main outcomes of interest varied from moderate to very low, so more newer studies would be needed in order to draw a definite conclusion about whether or not haloperidol is superior or inferior to low-potency antipsychotics.
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Affiliation(s)
- Magdolna Tardy
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieMöhlstr. 26MünchenGermany81675
| | - Maximilian Huhn
- Universitätsklinikum der Technischen Universität MünchenKlinik und Poliklinik für Psychiatrie und PsychotherapieKlinikum rechts der IsarMünchenBavariaGermany81675
| | - Werner Kissling
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieMöhlstr. 26MünchenGermany81675
| | - Rolf R Engel
- Ludwig‐Maximilians‐University MunichPsychiatric HospitalNussbaumstr. 7MuenchenGermany80336
| | - Stefan Leucht
- Technische Universität MünchenDepartment of Psychiatry and PsychotherapyIsmaningerstrasse 22MünchenGermany81675
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Huhn M, Tardy M, Spineli LM, Kissling W, Förstl H, Pitschel-Walz G, Leucht C, Samara M, Dold M, Davis JM, Leucht S. Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: a systematic overview of meta-analyses. JAMA Psychiatry 2014; 71:706-15. [PMID: 24789675 DOI: 10.1001/jamapsychiatry.2014.112] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is debate about the effectiveness of psychiatric treatments and whether pharmacotherapy or psychotherapy should be primarily used. OBJECTIVES To perform a systematic overview on the efficacy of pharmacotherapies and psychotherapies for major psychiatric disorders and to compare the quality of pharmacotherapy and psychotherapy trials. EVIDENCE REVIEW We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Library (April 2012, with no time or language limit) for systematic reviews on pharmacotherapy or psychotherapy vs placebo, pharmacotherapy vs psychotherapy, and their combination vs either modality alone. Two reviewers independently selected the meta-analyses and extracted efficacy effect sizes. We assessed the quality of the individual trials included in the pharmacotherapy and psychotherapy meta-analyses with the Cochrane risk of bias tool. FINDINGS The search yielded 45,233 results. We included 61 meta-analyses on 21 psychiatric disorders, which contained 852 individual trials and 137,126 participants. The mean effect size of the meta-analyses was medium (mean, 0.50; 95% CI, 0.41-0.59). Effect sizes of psychotherapies vs placebo tended to be higher than those of medication, but direct comparisons, albeit usually based on few trials, did not reveal consistent differences. Individual pharmacotherapy trials were more likely to have large sample sizes, blinding, control groups, and intention-to-treat analyses. In contrast, psychotherapy trials had lower dropout rates and provided follow-up data. In psychotherapy studies, wait-list designs showed larger effects than did comparisons with placebo. CONCLUSIONS AND RELEVANCE Many pharmacotherapies and psychotherapies are effective, but there is a lot of room for improvement. Because of the multiple differences in the methods used in pharmacotherapy and psychotherapy trials, indirect comparisons of their effect sizes compared with placebo or no treatment are problematic. Well-designed direct comparisons, which are scarce, need public funding. Because patients often benefit from both forms of therapy, research should also focus on how both modalities can be best combined to maximize synergy rather than debate the use of one treatment over the other.
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Affiliation(s)
- Maximilian Huhn
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
| | - Magdolna Tardy
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
| | - Loukia Maria Spineli
- Department of Hygiene and Epidemiology, School of Medicine, University of Ioannina, University Campus, Ioannina, Greece
| | - Werner Kissling
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
| | - Hans Förstl
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
| | - Gabriele Pitschel-Walz
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
| | - Claudia Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany2Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England
| | - Myrto Samara
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
| | - Markus Dold
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technische Universität München, München, Germany2Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England5Institute of Psychiatry, King's College London, London, England
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Al-Mossawi M, De Wit J, Huhn M, Ridley A, Bunting H, Arancibia C, Powrie F, Bowness P. THU0503 In-Vitro Supression of TH17 Responses in Inflammatory Arthritis Patients Using Small Molecule Ror-Gamma-T Inhibitors. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.1110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
BACKGROUND Amitriptyline is a tricyclic antidepressant that was synthesised in 1960 and introduced as early as 1961 in the USA, but is still regularly used. It has also been frequently used as an active comparator in trials on newer antidepressants and can therefore be called a 'benchmark' antidepressant. However, its efficacy and safety compared to placebo in the treatment of major depression has not been assessed in a systematic review and meta-analysis. OBJECTIVES To assess the effects of amitriptyline compared to placebo or no treatment for major depressive disorder in adults. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) to August 2012. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). The reference lists of reports of all included studies were screened and manufacturers of amitriptyline contacted for details of additional studies. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing amitriptyline with placebo or no treatment in patients with major depressive disorder as diagnosed by operationalised criteria. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. For dichotomous data, we calculated the odds ratio (OR) with 95% confidence intervals (CI). We analysed continuous data using standardised mean differences (with 95% CI). We used a random-effects model throughout. MAIN RESULTS The review includes 39 trials with a total of 3509 participants. Study duration ranged between three and 12 weeks. Amitriptyline was significantly more effective than placebo in achieving acute response (18 RCTs, n = 1987, OR 2.67, 95% CI 2.21 to 3.23). Significantly fewer participants allocated to amitriptyline than to placebo withdrew from trials due to inefficacy of treatment (19 RCTs, n = 2017, OR 0.20, 95% CI 0.14 to 0.28), but more amitriptyline-treated participants withdrew due to side effects (19 RCTs, n = 2174, OR 4.15, 95% CI 2.71 to 6.35). Amitriptyline also caused more anticholinergic side effects, tachycardia, dizziness, nervousness, sedation, tremor, dyspepsia, sedation, sexual dysfunction and weight gain. In subgroup and meta-regression analyses the results of the primary outcome were robust towards publication year (1971 to 1997), mean participant age at baseline, mean amitriptyline dose, study duration in weeks, pharmaceutical sponsor, inpatient versus outpatient setting and two-arm versus three-arm design. However, higher severity at baseline was associated with higher superiority of amitriptyline (P = 0.02), while higher responder rates in the placebo groups were associated with lower superiority of amitriptyline (P = 0.05). The results of the primary outcome were rather homogeneous, reflecting comparability of the trials. However, methods of randomisation, allocation concealment and blinding were usually poorly reported. Not all studies used intention-to-treat analyses and in many of them standard deviations were not reported and often had to be imputed. Funnel plots suggested a possible publication bias, but the trim and fill method did not change the overall effect size much (seven adjusted studies, OR 2.64, 95% CI 2.24 to 3.10). AUTHORS' CONCLUSIONS Amitriptyline is an efficacious antidepressant drug. It is, however, also associated with a number of side effects. Degree of placebo response and severity of depression at baseline may moderate drug-placebo efficacy differences.
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Affiliation(s)
- Claudia Leucht
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München Klinikum rechts der Isar, München,Germany.
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Huhn M, Wolf T, Dreßler M, Lohmann T, Koschel D, Höffken G. Interdisziplinäre Behandlung der Morbiden Adipositas. Pneumologie 2011. [DOI: 10.1055/s-0031-1297378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Jansen H, Pildner von Steinburg S, Ortiz Velasquez JU, Huhn M, Schneider KTM. Selbst beigebrachte tiefe Messerstichverletzung des Oberbauches in 23+1 SSW bei Patientin mit Borderline-Persönlichkeitsstörung. Z Geburtshilfe Neonatol 2011. [DOI: 10.1055/s-0031-1293398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Tardy M, Leucht S, Potapov A, Engel R, Huhn M, Kissling W. Perphenazine versus low-potency first generation antipsychotic drugs for schizophrenia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009369] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Tardy M, Leucht S, Potapov A, Engel R, Huhn M, Kissling W. Fluphenazine versus low-potency first generation antipsychotic drugs for schizophrenia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Tardy M, Leucht S, Potapov A, Kissling W, Engel R, Huhn M, Komossa K. Haloperidol versus low-potency first-generation antipsychotic drugs for schizophrenia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ribbert T, Thepen T, Tur MK, Fischer R, Huhn M, Barth S. Recombinant, ETA'-based CD64 immunotoxins: improved efficacy by increased valency, both in vitro and in vivo in a chronic cutaneous inflammation model in human CD64 transgenic mice. Br J Dermatol 2010; 163:279-86. [PMID: 20426788 DOI: 10.1111/j.1365-2133.2010.09824.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dysregulated, activated macrophages play a pivotal role in chronic inflammatory diseases such as arthritis and atopic dermatitis. These cells display increased expression of the high-affinity Fcgamma receptor (CD64), making them ideal targets for CD64-specific immunotoxins. We previously showed that a chemically linked immunotoxin, the monoclonal H22-RicinA, specifically eliminated infiltrating activated macrophages and resolved chronic cutaneous inflammation. However, several disadvantages are associated with classic immunotoxins, and we therefore followed a fusion protein strategy to express the antigen-binding site alone (scFv H22) fused to a derivative of Pseudomonas exotoxin A (ETA'). OBJECTIVES To assess the potential effect of increased valency on efficacy, we produced monovalent [H22(scFv)-ETA'] and bivalent [H22(scFv)(2)-ETA'] versions and evaluated their potential for eliminating activated macrophages both in vitro and in vivo. METHODS Both immunotoxins were produced by bacterial fermentation. Binding was assessed by flow cytometry on the monocytic CD64+ cell line U937. Toxicity was analysed by XTT and apoptosis induction by annexin V bioassay. The in vivo effect was tested in a human CD64 transgenic mouse model for cutaneous inflammation. RESULTS The cytotoxic effects of both immunotoxins were clearly due to apoptosis with an IC(50) of 140 pmol L(-1) for monovalent and only 14 pmol L(-1) for the divalent version. In vivo treatment with H22(scFv)-ETA' reduced CD64+ activated macrophages to 21% of their initial numbers whereas H22(scFv)(2)-ETA' treatment reduced these cells to 4.8% (P < 0.001). CONCLUSIONS These data clearly show increased efficacy due to increased valency of the anti-CD64 immunotoxin. Both recombinant immunotoxins have a low IC(50), making them suitable for the treatment of diseases involving dysregulated, activated macrophages.
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Affiliation(s)
- T Ribbert
- Department of Pharmaceutical Product Development, Fraunhofer IME, Forckenbeckstrasse 6, 52074 Aachen, Germany
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Gattenlöhner S, Jörißen H, Huhn M, Vincent A, Beeson D, Tzartos S, Mamalaki A, Etschmann B, Muller-Hermelink HK, Koscielniak E, Barth S, Marx A. A human recombinant autoantibody-based immunotoxin specific for the fetal acetylcholine receptor inhibits rhabdomyosarcoma growth in vitro and in a murine transplantation model. J Biomed Biotechnol 2010; 2010:187621. [PMID: 20204062 PMCID: PMC2829619 DOI: 10.1155/2010/187621] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Accepted: 11/18/2009] [Indexed: 11/28/2022] Open
Abstract
Rhabdomyosarcoma (RMS) is the most common malignant soft tissue tumor in children and is highly resistant to all forms of treatment currently available once metastasis or relapse has commenced. As it has recently been determined that the acetylcholine receptor (AChR) gamma-subunit, which defines the fetal AChR (fAChR) isoform, is almost exclusively expressed in RMS post partum, we recombinantly fused a single chain variable fragment (scFv) derived from a fully human anti-fAChR Fab-fragment to Pseudomonas exotoxin A to generate an anti-fAChR immunotoxin (scFv35-ETA). While scFv35-ETA had no damaging effect on fAChR-negative control cell lines, it killed human embryonic and alveolar RMS cell lines in vitro and delayed RMS development in a murine transplantation model. These results indicate that scFv35-ETA may be a valuable new therapeutic tool as well as a relevant step towards the development of a fully human immunotoxin directed against RMS. Moreover, as approximately 20% of metastatic malignant melanomas (MMs) display rhabdoid features including the expression of fAChR, the immunotoxin we developed may also prove to be of significant use in the treatment of these more common and most often fatal neoplasms.
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Affiliation(s)
- S. Gattenlöhner
- Institute of Pathology, University of Würzburg, 97080 Würzburg, Germany
| | - H. Jörißen
- Department of Pharmaceutical Product Development, Fraunhofer Institute for Molecular Biology and Applied Ecology, Forckenbeckstraße 6, 52074 Aachen, Germany
| | - M. Huhn
- Neurosciences Group, Department of Clinical Neurology, Weatherall Institute of Molecular Medicine, University of Oxford, OX3 9DU Oxford, UK
| | - A. Vincent
- Neurosciences Group, Department of Clinical Neurology, Weatherall Institute of Molecular Medicine, University of Oxford, OX3 9DU Oxford, UK
| | - D. Beeson
- Neurosciences Group, Department of Clinical Neurology, Weatherall Institute of Molecular Medicine, University of Oxford, OX3 9DU Oxford, UK
| | - S. Tzartos
- Hellenic Pasteur Institute, 127, Vas. Sofias Avenue 11521, Athens, Greece
| | - A. Mamalaki
- Hellenic Pasteur Institute, 127, Vas. Sofias Avenue 11521, Athens, Greece
| | - B. Etschmann
- Institute of Pathology, University of Würzburg, 97080 Würzburg, Germany
| | | | - E. Koscielniak
- Department of Pediatric Oncology, Olga Hospital, 70176 Stuttgart, Germany
| | - S. Barth
- Department of Pharmaceutical Product Development, Fraunhofer Institute for Molecular Biology and Applied Ecology, Forckenbeckstraße 6, 52074 Aachen, Germany
- Department of Experimental Medicine and Immunotherapy, Helmholtz-Institute for Biomedical Engineering, University Hospital RWTH Aachen, Pauwelsstraße 20, 52074 Aachen, Germany
| | - A. Marx
- Institute of Pathology, University of Würzburg, 97080 Würzburg, Germany
- Institute of Pathology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68135 Mannheim, Greece
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Koschel D, Huhn M, Cardoso C, Höffken G. Pneumomediastinum bei ulzeröser Tracheobronchitis bei Colitis ulcerosa. Pneumologie 2008. [DOI: 10.1055/s-0028-1096568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Olsson L, Flodström M, Hjelte L, Huhn M, Nilsson Å. 126 Sphingomyelinase and ceramidase activities in tissues of delta-F508 CFTR mice. J Cyst Fibros 2007. [DOI: 10.1016/s1569-1993(07)60115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wicklein D, Stöcker M, Klockenbring T, Huhn M, Wodrich M, Haas H, Becker WM, Barth S, Petersen A. In contrast to specific B cells, human basophils are unaffected by the toxic activity of an allergen toxin due to lack of internalization of immunoglobulin E-bound allergen. Clin Exp Allergy 2006; 36:531-42. [PMID: 16630160 DOI: 10.1111/j.1365-2222.2006.02461.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Specific immunotherapy is the only curative therapy for type I allergies and the alarming increase in allergy prevalence emphasizes the need for additional/alternative strategies for curative treatment. Allergen toxins (AT), fusion products of an allergen with an apoptosis inducing cytotoxin, are a new kind of immunotoxin. OBJECTIVE AT should allow allergen-specific targeting and elimination of allergy-relevant cells, with B cells being the primary target. An important question is the fate of the effector cells, e.g. mast cells and basophils, which carry allergen-specific IgE: the immunotoxin might even prove to be harmful. METHODS We established a reliable in vitro B cell model (using two mouse hybridoma cell lines) for testing specificity and toxicity of P5-ETA', a fusion protein of the major timothy grass pollen allergen Phl p 5b and truncated Pseudomonas Exotoxin A. In a second step, we investigated the impact of the AT on human basophils. RESULTS P5-ETA' reliably eliminated Phl p 5-specific cells in the in vitro B cell model, leaving unspecific B cells unharmed. Human basophils of grass pollen allergic donors specifically bound P5-ETA', released IL-4 and up-regulated the activation marker CD203c, but were not subject to the toxic effect because of lack of internalization of IgE-bound allergen. CONCLUSION According to our data, basophils are pure effector cells in the context of IgE-bound allergen and not involved in classical antigen presentation.
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Affiliation(s)
- D Wicklein
- Research Center Borstel, Division of Molecular and Clinical Allergology, Parkallee, Borstel, Germany
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Rothe A, Klimka A, Tur MK, Pfitzner T, Huhn M, Sasse S, Mallmann P, Engert A, Barth S. Construction of phage display libraries from reactive lymph nodes of breast carcinoma patients and selection for specifically binding human single chain Fv on cell lines. Int J Mol Med 2005; 14:729-35. [PMID: 15375609 DOI: 10.3892/ijmm.14.4.729] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The display of recombinant antibody fragments on the surface of filamentous phage mimicks B cells and is therefore a technology ideal to generate antibodies against any potential target antigen in vitro. In order to obtain tumor specific, high-affinity single chain antibody fragments (scFv), it has been speculated that lymph node tissue from cancer patients infiltrated with activated B cells must be a valuable source of antibody V-genes. The aim of this study was to generate a human scFv-phage library from lymph nodes of patients with breast cancer and to develop a stringent depletion and selection protocol in order to isolate specific single chain antibodies recognizing potentially new antigens in breast cancer. The amplification of the V-genes cloned from regional lymph node tissue and their assembly to single chain variable fragments was optimized in terms of library size and diversity. A large set of degenerated primers, annealing to all known V-gene families, was designed and used under optimized PCR conditions. The amplified V-genes were genetically fused in all possible combinations and cloned into a phagemid vector. Depletion and selection on mammary epithelial and primary breast carcinoma cell lines, respectively led to the isolation of a breast cancer cell line specific scFv (BCK-1 scFv) from this patient-derived scFv-phage display library as demonstrated in polyclonal and monoclonal ELISA, using immobilized cell membrane fractions of the indicated cell lines. A new recombinant breast cancer cell line specific antibody based on V-genes derived from reactive B-lymphocyte-infiltrated lymph nodes of patients with breast cancer was isolated via phage display, performing stringent depletion and selection protocols. We believe that this combination of antibody V-gene source and elaborated phage display depletion and selection strategy will be successful for the retrieval of numerous other recombinant, tumor specific antibody fragments.
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Affiliation(s)
- A Rothe
- Department I of Internal Medicine, Laboratory of Immunotherapy, University Hospital Cologne, D-50931 Cologne, Germany
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Thiel M, Drews O, Behrendt H, Görg A, Traidl-Hoffmann C, Kasche A, Klaus S, Buters J, Weichenmeier I, Krämer U, Gehlhar K, Betzel C, Werner S, Weber W, Bufe A, Rozynek P, Gaspar Â, Rihs HP, Pires G, Brüning T, Raulf-Heimsoth M, Boldt A, Bade S, Gorris HH, Reese G, Riecken S, Becker WM, Viebranz J, Randow S, Lauer I, Moncin MSM, Lehrer SB, Vieths S, van Kampen V, Haamann F, Merget R, Sander I, Jappe U, Hoffmann M, Burow G, Enk A, Kespohl S, Foerster S, Eyerich K, Lubitz S, Schober W, Belloni B, Eberlein-König B, Stassen M, Klein M, Klein-Heßling S, Palmetshofer A, Serfling E, Bopp T, Richter C, Schild H, Schmitt E, Blume C, Förster S, Petersen A, Güttsches A, Zähringer U, Löseke S, Ebling A, Draheim R, Rundfeldt C, Rieber EP, Schäkel K, Abraham S, Meurer M, Rieber P, Gutermuth J, O’Keeffe M, Alessandrini F, Schlatter B, Ring J, Hochrein H, Jakob T, Heib V, Schmitt S, Kubach J, Lutter P, Huter E, Ohlemacher S, Weingarten P, Müller C, Bailey S, Becker C, Knop J, Blüggel M, Hüls C, Jonuleit H, Bellinghausen I, König B, Böttcher I, Saloga J, Hüter E, Schneider FJ, Wicklein D, Stöcker M, Klockenbring T, Huhn M, Barth S, Trujillo-Vargas CM, Erb KJ, Milovanovic M, Heine G, Landeck L, Sabat R, Worm M, Veres T, Weikum O, Weigt H, Krug N, Braun A, Hahn C, Schuhmann B, Mkhlof S, Pirayesh A, Renz H, Nockher WA, Erpenbeck VJ, Sommer S, Malherbe DC, Wright JR, Hohlfeld JM, Bilitewski C, Reinitz-Rademacher K, Rohde G, Ewig S, Schmelz S, Zindler E, Montermann E, Reske-Kunz AB, Sudowe S, Darcan Y, Galle J, Ahmed J, Seitzer U, Sel S, Wegmann M, Nassenstein C, Pollock K, Dawbarn D, Allen SJ, Gupta S, Schulz-Maronde S, Kutzleb C, Kapp A, Forssmann WG, Forssmann U, Elsner J, Fuchs B, Bälder R, Escher SE, Heitland A, Borelli C, Scharrer E, Oppel T, Przybilla B, Ludwig R, Schindewolf M, Hirsch K, Lindhoff-Last E, Kaufmann R, Boehncke WH, Ruäff F, Albert K, Bauer C, Weimer G, Tas E, Bircher A, Kleine-Tebbe J, Herold DA, Ribel M, Hartz C, Miguel-Moncin MMS, Cistero-Bahima A, Conti A, Scheurer S, Fiedler EM, Illner AK, Lee H, Ernst D, Backhaus B, Raithel M, Hahn EG, Nabe A, Straube S, Weidenhiller M, Konturek P, Simon K, Kressel J, Wildner S, Simon D, Mart H, Heer P, Simon HU, Braathen LR, Straumann A, Brockow K, Huss-Marp J, Braun-Falco M, Schmelz M, Darsow U, Preussner LM, Ristau T, Sotlar K, Hartmann K, Gerbaulet A, Baldus SE, Magerl M, Siebenhaar F, Maurer M, Wittmann M, Purwar R, Hartmann C, Stünkel T, Werfel T, Mrabet-Dahbi S, Ahmad-Nejad P, Breuer K, Klotz M, Herz U, Heeg K, Neumaier M, Langer K, Wollenberg A, Soost S, Zuberbier T, Biedermann T, Günther C, Tangemann K, Schwärzler C, Lametschwandtner G, Rot A, Carballido JM, Gibbs BF, Zillikens D, Grabbe J, Zahradnik E, Fleischer C, Dorn I, Eberhardt F, Hartwig D, Rueff F, Hipler UC, Vetter M, Heitmann M, Bauer A, Elsner P, Herzinger T, Summer B, Maier S, Ghoreschi K, Roider G, Thomas P, Freising C, Glaser S, Schäfer T. 17. Mainzer Allergie-Workshop. Allergo J 2005. [DOI: 10.1007/bf03370389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kahlert H, Weber B, Suck R, Cromwell O, Fiebig H, Kleinhans D, Blume C, Lindner B, Becker WM, Petersen A, Sander I, van Kampen V, Fleischer C, Meurer U, Brüning T, Merget R, Raulf-Heimsoth M, Boldt A, Ballmer-Weber B, Darcan Y, Galle J, Ahmed J, Seitzer U, Fölster-Holst R, Jensen JM, Frinken AL, Ho H, Stick C, von Wahl PG, Ott H, Wurpts G, Krieg R, Al Masaoudi T, Joussen S, Kiehl K, Neis M, Merk HF, Baron JM, Rihs HP, Kowal A, Degens PO, Landt O, Mariani V, Jakob T, Ring J, Behrendt H, Traidl-Hoffmann C, Wicklein D, Stöcker M, Klockenbring T, Huhn M, Barth S, Schürer NY, Sudowe S, Zindler E, Ludwig-Portugall I, Montermann E, Ross R, Reske-Kunz AB, Fang J, Ambach A, König W, Bonnekoh B, Gollnick H, König B, Bellinghausen I, Böttcher I, Knop J, Saloga J, Kurek M, Maleszka R, Staszyńska-Kurek M, Załuga E, Biedermann T, Günther C, Tangemann K, Schwärzler C, Lametschwandtner G, Rot A, Carballido JM, Pommer AJ, Böckelmann R, Malykh Y, Philipsen L, Schubert W, Schupp P, Gutgesell C, Fuchs T. Freie Vorträge. Allergo J 2004. [DOI: 10.1007/bf03371917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Louati A, Huhn M. Electrochemical oxidation of nickel-phosphine complexes of the type [NiII(.eta.5-C5Ph5){Ph2PCH:C(O)R}] (R = Ph, ferrocenyl). Direct and indirect generation of nickel(III) and nickel(II)-cation radical species. Inorg Chem 2002. [DOI: 10.1021/ic00069a011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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