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Principle standards and problems regarding proof of efficacy in clinical psychopharmacology

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Abstract

Proof of efficacy of a psychotropic medicinal product is the key point of clinical psychopharmacology. This especially concerns the licensing of a new compound, but apart from this special case, lots of efficacy questions need to be answered in clinical psychopharmacology, such as, e.g. the question of the efficacy of a combination therapy. The methodology of the scientific proof of efficacy has already had a long tradition and has been developed further in the recent past under different aspects. Especially the double-blind randomised parallel group comparison has been developed as a design of highest methodological standard. However, often designs have their place and justification under certain conditions and in relation to certain questions. Although in the recent past, with the over-emphasis of so-called effectiveness studies, the inherent methodological limitations of these studies have not been addressed properly (Möller in Eur Arch Psychiatry Clin Neurosci 258:257–270, 2008), which in consequence devaluated the scientific merits of the classical double-blind randomised control group study designs in the view of those colleagues, who are not that experienced in study design issues. Therefore, it seems to be timely and necessary to review the principle standards and problems concerning the proof of efficacy in clinical psychopharmacology.

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References

  1. Adam D, Kasper S, Möller HJ, Singer EA (2005) Placebo-controlled trials in major depression are necessary and ethically justifiable: how to improve the communication between researchers and ethical committees. Eur Arch Psychiatry Clin Neurosci 255:258–260

    Article  PubMed  Google Scholar 

  2. Angst J, Bech P, Boyer P et al (1989) Consensus conference on the methodology of clinical trials of antidepressants. Zürich, March; Report of the Consensus Committee. Pharmacopsychiatry 23:171–175

    Google Scholar 

  3. Aspinall RL, Goodman NW (1995) Denial of effective treatment and poor quality of clinical information in placebo controlled trials of ondansetron for postoperative nausea and vomiting: a review of published trials. BMJ 311:844–846

    CAS  PubMed  Google Scholar 

  4. Baldwin D, Broich K, Fritze J, Kasper S, Westenberg H, Möller HJ (2003) Placebo-controlled studies in depression: necessary, ethical and feasible. Eur Arch Psychiatry Clin Neurosci 253:22–28

    Article  PubMed  Google Scholar 

  5. Beatty WW (1972) How blind is blind? A simple procedure for estimating observer naivete. Psychol Bull 78:70–71

    Article  Google Scholar 

  6. Beckmann H, Schmauss M (1983) Clinical investigations into antidepressive mechanisms. I. Antihistaminic and cholinolytic effects: amitriptyline versus promethazine. Arch Psychiatr Nervenkr 233:59–70

    Article  CAS  PubMed  Google Scholar 

  7. Brown WA, Johnson MF, Chen MG (1992) Clinical features of depressed patients who do and do not improve with placebo. Psychiatry Res 41:203–214

    Article  CAS  PubMed  Google Scholar 

  8. Carpenter WT Jr, Schooler NR, Kane JM (1997) The rationale and ethics of medication-free research in schizophrenia. Arch Gen Psychiatry 54:401–407

    PubMed  Google Scholar 

  9. EMEA Europena Medicines Agency (EMEA) (2009) http://emea.europa.eu.Anonymous

  10. Fischer-Cornelsen K, Ferner U (1977) Evaluation of new drugs: clozapine as an example of an European multicenter study. Drugs under Res 1:404

    Google Scholar 

  11. Fritze J, Möller HJ (2001) Design of clinical trials of antidepressants: should a placebo control arm be included? CNS Drugs 15:755–764

    Article  CAS  PubMed  Google Scholar 

  12. Grohmann R, Engel RR, Geissler KH, Ruther E (2004) Psychotropic drug use in psychiatric inpatients: recent trends and changes over time-data from the AMSP study. Pharmacopsychiatry 37(Suppl 1):S27–S38

    PubMed  Google Scholar 

  13. Grohmann R, Engel RR, Ruther E, Hippius H (2004) The AMSP drug safety program: methods and global results. Pharmacopsychiatry 37(Suppl 1):S4–S11

    PubMed  Google Scholar 

  14. Grohmann R, Hippius H, Helmchen H, Ruther E, Schmidt LG (2004) The AMUP study for drug surveillance in psychiatry—a summary of inpatient data. Pharmacopsychiatry 37(Suppl 1):S16–S26

    PubMed  Google Scholar 

  15. Haro JM, Novick D, Suarez D, Alonso J, Lepine JP, Ratcliffe M (2006) Remission and relapse in the outpatient care of schizophrenia: three-year results from the schizophrenia outpatient health outcomes study. J Clin Psychopharmacol 26:571–578

    Article  PubMed  Google Scholar 

  16. Heres S, Davis J, Maino K, Jetzinger E, Kissling W, Leucht S (2006) Why olanzapine beats risperidone, risperidone beats quetiapine, and quetiapine beats olanzapine: an exploratory analysis of head-to-head comparison studies of second-generation antipsychotics. Am J Psychiatry 163:185–194

    Article  PubMed  Google Scholar 

  17. ICH International Conference of Harmonization (ICH) (2009) http://ich.org/cache/compo/276-254-1.html.Anonymous

  18. Khan A, Warner HA, Brown WA (2000) Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: an analysis of the Food and Drug Administration database. Arch Gen Psychiatry 57:311–317

    Article  CAS  PubMed  Google Scholar 

  19. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT (2008) Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 5:e45

    Article  PubMed  Google Scholar 

  20. Kirsch I, Moore TJ, Scoboria A, Nicholls SS (2002) The emperor’s new drugs: an analysis of antidepressant medication data submitted to the US Food and Drug Administration. Prevention and Treatment. Article 23. Posted 15 Jul 2002. http://www.journals.apa.org/prevention/volume5/pre0050023a.html.5.Anonymous

  21. Lane P (2007) Handling drop-out in longitudinal clinical trials: a comparison of the LOCF and MMRM approaches. Pharm Stat 7(2):93–106

    Article  Google Scholar 

  22. Laporte JR, Figueras A (1994) Placebo effects in psychiatry. Lancet 344:1206–1209

    Article  CAS  PubMed  Google Scholar 

  23. Lavin MR (1991) Placebo effects on mind and body. JAMA 265:1753–1754

    Article  CAS  PubMed  Google Scholar 

  24. Leucht S, Arbter D, Engel RR, Kissling W, Davis JM (2009) How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials. Mol Psychiatry 14(4):429–447

    Article  CAS  PubMed  Google Scholar 

  25. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD et al (2005) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 353:1209–1223

    Article  CAS  PubMed  Google Scholar 

  26. Lieberman JA, Tollefson G, Tohen M, Green AI, Gur RE, Kahn R, McEvoy J, Perkins D, Sharma T, Zipursky R et al (2003) Comparative efficacy and safety of atypical and conventional antipsychotic drugs in first-episode psychosis: a randomized, double-blind trial of olanzapine versus haloperidol. Am J Psychiatry 160:1396–1404

    Article  PubMed  Google Scholar 

  27. Linden M (1997) Phase IV research and drug utilization observation studies. Pharmacopsychiatry 30:1–3

    Article  CAS  PubMed  Google Scholar 

  28. Linden M, Baier D, Beitinger H, Kohnen R, Osterheider M, Philipp M, Reimitz DE, Schaaf B, Weber HJ (1997) Guidelines for the implementation of drug utilization observation (DUO) studies in psychopharmacological therapy. The “Phase IV Research” Task-Force of the Association for Neuropsychopharmacology and Pharmacopsychiatry (AGNP). Pharmacopsychiatry 30:65–70

    Article  CAS  PubMed  Google Scholar 

  29. Miller FG, Rosenstein DL (2006) The nature and power of the placebo effect. J Clin Epidemiol 59:331–335

    Article  PubMed  Google Scholar 

  30. Möller H-J, Steinmeyer EM (1990) Mood curves of neurotic-depressive patients undergoing treatment with antidepressants: time-series analyses of experience with HTAKA model. Pharmacopsychiatry 23:215–221

    Article  PubMed  Google Scholar 

  31. Möller HJ (1991) Outcome criteria in antidepressant drug trials: self-rating versus observer-rating scales. Pharmacopsychiatry 24:71–75

    Article  PubMed  Google Scholar 

  32. Möller HJ (2000) Rating depressed patients: observer- vs self-assessment. Eur Psychiatry 15:160–172

    Article  PubMed  Google Scholar 

  33. Möller HJ (2001) Methodological issues in psychiatry: psychiatry as an empirical science. World J Biol Psychiatry 2:38–47

    Article  PubMed  Google Scholar 

  34. Möller HJ (2005) Are the new antipsychotics no better than the classical neuroleptics? The problematic answer from the CATIE study. Eur Arch Psychiatry Clin Neurosci 255:371–372

    Article  PubMed  Google Scholar 

  35. Möller HJ (2005) Problems associated with the classification and diagnosis of psychiatric disorders. World J Biol Psychiatry 6:45–56

    Article  PubMed  Google Scholar 

  36. Möller HJ (2008) Do effectiveness (“real world”) studies on antipsychotics tell us the real truth? Eur Arch Psychiatry Clin Neurosci 258:257–270

    Article  PubMed  Google Scholar 

  37. Möller HJ (2008) Is there a need for a new psychiatric classification at the current state of knowledge? World J Biol Psychiatry 9:82–85

    Article  PubMed  Google Scholar 

  38. Möller HJ (2008) Isn’t the efficacy of antidepressants clinically relevant? A critical comment on the results of the metaanalysis by Kirsch et al. 2008. Eur Arch Psychiatry Clin Neurosci 258:451–455

    Article  PubMed  Google Scholar 

  39. Möller HJ (2009) Standardised rating scales in Psychiatry: methodological basis, their possibilities and limitations and descriptions of important rating scales. World J Biol Psychaitry 10:6–26

    Article  Google Scholar 

  40. Möller HJ, Bottlender R, Grunze H, Strauss A, Wittmann J (2001) Are antidepressants less effective in the acute treatment of bipolar I compared to unipolar depression? J Affect Disord 67:141–146

    Article  PubMed  Google Scholar 

  41. Möller HJ, Fischer G, von Zerssen D (1987) Prediction of therapeutic response in acute treatment with antidepressants. Results of an empirical study involving 159 endogenous depressive inpatients. Eur Arch Psychiatry Neurol Sci 236:349–357

    Article  PubMed  Google Scholar 

  42. Möller HJ, Grunze H (2000) Have some guidelines for the treatment of acute bipolar depression gone too far in the restriction of antidepressants? Eur Arch Psychiatry Clin Neurosci 250:57–68

    Article  PubMed  Google Scholar 

  43. Möller HJ, Maier W (2009) Evidence-based medicine in psychotherapy: possibilities, problems and limitations. Eur Arch Psychiatry Clin Neurosci (submitted)

  44. Nies AS (1990) Principle of therapeutics. In: Goodman Gilman A (ed) The pharmacological basis of therapeutics. Pergamon, New York, pp 62–83

    Google Scholar 

  45. Novick D, Haro JM, Suarez D, Lambert M, Lepine JP, Naber D (2007) Symptomatic remission in previously untreated patients with schizophrenia: 2-year results from the SOHO study. Psychopharmacology (Berl) 191:1015–1022

    Article  CAS  Google Scholar 

  46. Plutchik R, Platman SR, Fieve RR (1969) Three alternatives to the double-blind. Arch Gen Psychiatry 20:428–432

    CAS  PubMed  Google Scholar 

  47. Quitkin FM, McGrath PJ, Rabkin JG, Stewart JW, Harrison W, Ross DC, Tricamo E, Fleiss J, Markowitz J, Klein DF (1991) Different types of placebo response in patients receiving antidepressants. Am J Psychiatry 148:197–203

    CAS  PubMed  Google Scholar 

  48. Rickels K (1986) Non-specific factors in drug therapy. Thomas, Springfield

    Google Scholar 

  49. Rickels K, Lipman RS, Fisher S, Park LC, Uhlenhuth EH (1970) Is a double-blind clinical trial really double-blind? A report of doctors’ medication guesses. Psychopharmacologia 16:329–336

    Article  CAS  PubMed  Google Scholar 

  50. Riedel M, Strassnig M, Müller N, Zwack P, Möller HJ (2005) How representative of everyday clinical populations are schizophrenia patients enrolled in clinical trials? Eur Arch Psychiatry Clin Neurosci 255:143–148

    Article  CAS  PubMed  Google Scholar 

  51. Rothman KJ, Michels KB (1994) The continuing unethical use of placebo controls. N Engl J Med 331:394–398

    Article  CAS  PubMed  Google Scholar 

  52. Seemüller F, Möller HJ, Obermeier M, Bauer M, Adli M, Kronmüllert K, Holsboer F, Brieger P, Laux G, Bender W et al (2009) Do efficacy and effectiveness samples differ in antidepressant treatment outcome? Am J Psychiatry (in press)

  53. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC (1998) The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59(Suppl 20):22–33 quiz 34–57, 22–33

    PubMed  Google Scholar 

  54. Sneed JR, Rutherford BR, Rindskopf D, Lane DT, Sackeim HA, Roose SP (2008) Design makes a difference: a meta-analysis of antidepressant response rates in placebo-controlled versus comparator trials in late-life depression. Am J Geriatr Psychiatry 16:65–73

    Article  PubMed  Google Scholar 

  55. Storosum JG, van Zwieten BJ, van den BW, Gersons BP, Broekmans AW (2001) Suicide risk in placebo-controlled studies of major depression. Am J Psychiatry 158(8):1271–1275

    Article  CAS  PubMed  Google Scholar 

  56. Taves DR (1974) Minimization: a new method of assigning patients to treatment and control groups. Clin Pharmacol Ther 15:443–453

    CAS  PubMed  Google Scholar 

  57. Versavel M, Leonard JP, Herrmann WM (1995) Standard operating procedure for the registration and computer-supported evaluation of pharmaco-EEG data. ‘EEG in Phase I’ of the Collegium Internationale Psychiatriae Scalarum (CIPS). Neuropsychobiology 32:166–170

    Article  CAS  PubMed  Google Scholar 

  58. Walsh BT, Seidman SN, Sysko R, Gould M (2002) Placebo response in studies of major depression: variable, substantial, and growing. JAMA 287:1840–1847

    Article  PubMed  Google Scholar 

  59. Wittenborn JR (1977) Guidelines for clinical trials of psychotropic drugs. Pharmakopsychiatr Neuropsychopharmacol 10:205–231

    Google Scholar 

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Möller, HJ., Broich, K. Principle standards and problems regarding proof of efficacy in clinical psychopharmacology. Eur Arch Psychiatry Clin Neurosci 260, 3–16 (2010). https://doi.org/10.1007/s00406-009-0071-8

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