There is increasing interest in discovering individualized treatment rules (ITRs) for patients who have heterogeneous responses to treatment. In particular, one aims to find an optimal ITR that is a ...deterministic function of patient-specific characteristics maximizing expected clinical outcome. In this article, we first show that estimating such an optimal treatment rule is equivalent to a classification problem where each subject is weighted proportional to his or her clinical outcome. We then propose an outcome weighted learning approach based on the support vector machine framework. We show that the resulting estimator of the treatment rule is consistent. We further obtain a finite sample bound for the difference between the expected outcome using the estimated ITR and that of the optimal treatment rule. The performance of the proposed approach is demonstrated via simulation studies and an analysis of chronic depression data.
In a randomized trial involving participants with methamphetamine use disorder, the response among those who received bupropion and naltrexone was 11 percentage points higher than that among ...participants who received placebo. Adverse events included gastrointestinal disorders.
Based on two decades of data, Tadmon and Olfson have identified clear and growing trends that fewer psychiatrists are providing less psychotherapy to fewer patients, regardless of the disorder being ...treated, sociodemographic features, or prescribed medication. There were only two exceptions: patients over age 65, who continued to receive psychotherapy by psychiatrists in about 30% of the visits, and patients with schizophrenia, who continued to received psychotherapy by psychiatrists about 10% of the time. While psychiatrists are doing less and less therapy (50% of the psychiatrists reported doing no psychotherapy at all), other less expensive therapists-sans medical training and the associated debt-are being used as replacements. However, about 10% of the sampled psychiatrists still do regularly provide therapy along with medications-a practice that is most typical for self-pay patients-and it seems to be holding.
Future reports will 1 compare longer-term outcomes of the various randomized treatments (e.g., does cognitive therapy prevent relapse better than medication as either a switch or augmentation ...strategy?); 2 identify which patients benefit from which treatments (e.g., do different patients defined by different clinical features or genetic polymorphisms respond differently to different treatments?); and 3 determine whether different treatment sequences (in steps 1 to 4) are preferred for some but not other patients (1). Two-thirds of patients had at least one concurrent general medical condition; two-thirds had at least one other psychiatric disorder; nearly 40% had their first depressive episode before age 18; over half reported a mood disorder in at least one first-degree relative; and over half met criteria for anxious features (2, 3).
Rush et al wish to respond to a reanalysis of their original STAR*D data. This re-analysis concluded that the cumulative remission rate of depressed outpatients undergoing four to five sequential ...antidepressant therapies across approximately 12 months in the study was 35%, instead of the 67% rate reported by them. The analytic approach taken by Pigott et al has significant methodological flaws. Pigott et al selectively eliminated the data from 561 (15%) of the 3,671 patients reported by Rush et al. (1) who enrolled into Level 1 of STAR*D, 297 (21%) of the 1,439 patients reported by them.
In 2008 the National Institutes of Health established the Research, Condition and Disease Categorization Database (RCDC) that reports the amount spent by NIH institutes for each disease. Its goal is ...to allow the public "to know how the NIH spends their tax dollars," but it has been little used. The RCDC for 2018 was used to assess 428 schizophrenia-related research projects funded by the National Institute of Mental Health. Three senior psychiatrists independently rated each on its likelihood ("likely", "possible", "very unlikely") of improving the symptoms and/or quality of life for individuals with schizophrenia within 20 years. At least one reviewer rated 386 (90%), and all three reviewers rated 302 (71%), of the research projects as very unlikely to provide clinical improvement within 20 years. Reviewer agreement for the "very unlikely" category was good; for the "possible" category was intermediate; and for the "likely" category was poor. At least one reviewer rated 30 (7%) of the research projects as likely to provide clinical improvement within 20 years. The cost of the 30 projects was 5.5% of the total NIMH schizophrenia-related portfolio or 0.6% of the total NIMH budget. Study results confirm previous 2016 criticisms that the NIMH schizophrenia-related research portfolio disproportionately underfunds clinical research that might help people currently affected. Although the results are preliminary, since the RCDC database has not previously been used in this manner and because of the subjective nature of the assessment, the database would appear to be a useful tool for disease advocates who wish to ascertain how NIH spends its public funds.
Context and Purpose
Measurement‐based care (MBC) is an evidence‐based health‐care practice in which indicators of disease are tracked to inform clinical actions, provide feedback to patients and ...improve outcomes. The current opioid crisis in multiple countries provides a pressing rationale for adopting a basic MBC approach for opioid use disorder (OUD) using DSM‐5 to increase treatment retention and effectiveness.
Proposal
To stimulate debate, we propose a basic MBC approach using the 11 symptoms of OUD (DSM‐5) to inform the delivery of medications for opioid use disorder (MOUD; including methadone, buprenorphine and naltrexone) and their evaluation in office‐based primary care and specialist clinics. Key features of a basic MBC approach for OUD using DSM‐5 are described, with an illustration of how clinical actions are guided and outcomes communicated. For core treatment tasks, we propose that craving and drug use response to MOUD should be assessed after 2 weeks, and OUD remission status should be evaluated at 3, 6 and 12 months (and exit from MOUD treatment) and beyond. Each of the 11 DSM‐5 symptoms of OUD should be discussed with the patient to develop a case formulation and guide selection of adjunctive psychological interventions, supplemented with information on substance use, and optionally extended with information from other clinical instruments. A patient‐reported outcome measure should be recorded and discussed at each remission assessment.
Conclusions
MBC can be used to tailor and adapt MOUD treatment to increase engagement, retention and effectiveness. MBC practice principles can help promote patient‐centred care in OUD, personalized addiction therapeutics and facilitate communication of outcomes.
A recent individual patient data meta‐analysis showed that antidepressant medication is slightly more efficacious than cognitive behavioral therapy (CBT) in reducing overall depression severity in ...patients with a DSM‐defined depressive disorder. We used an update of that dataset, based on seventeen randomized clinical trials, to examine the comparative efficacy of antidepressant medication vs. CBT in more detail by focusing on individual depressive symptoms as assessed with the 17‐item Hamilton Rating Scale for Depression. Five symptoms (i.e., “depressed mood” , “feelings of guilt” , “suicidal thoughts” , “psychic anxiety” and “general somatic symptoms”) showed larger improvements in the medication compared to the CBT condition (effect sizes ranging from .13 to .16), whereas no differences were found for the twelve other symptoms. In addition, network estimation techniques revealed that all effects, except that on “depressed mood” , were direct and could not be explained by any of the other direct or indirect treatment effects. Exploratory analyses showed that information about the symptom‐specific efficacy could help in identifying those patients who, based on their pre‐treatment symptomatology, are likely to benefit more from antidepressant medication than from CBT (effect size of .30) versus those for whom both treatments are likely to be equally efficacious. Overall, our symptom‐oriented approach results in a more thorough evaluation of the efficacy of antidepressant medication over CBT and shows potential in “precision psychiatry” .
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