Publications

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment‐resistant anxiety disorders (TR‐AD) informing such trials is currently lacking. We used a Delphi method‐based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR‐AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free‐text responses to a 29‐item questionnaire on relevant aspects of TR‐AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR‐AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR‐AD vs. “difficult‐to‐treat” anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method‐based consensus on operational criteria for TR‐AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence‐based stepped‐care treatment algorithms for patients with anxiety disorders.

Introduction Given the high prevalence of mental health disorders and their significant socioeconomic burden, there is a need to develop improved treatments, and to evaluate them through placebo-controlled trials. However, the magnitude of the placebo response in randomised controlled trials to test medications may be substantial, affecting their interpretation. Therefore, improved understanding of the patient, trial and mental disorder factors that influence placebo responses would inform clinical trial design to better detect active treatment effects. There is a growing literature exploring the placebo response within specific mental health disorders, but no overarching synthesis of this research has been produced to date. We present a protocol for an umbrella review of systematic reviews and/or meta-analyses in which we aim to understand the effect size and potential predictors of placebo response within, and across, mental health disorders. Methods and analysis We will systematically search databases (Medline, PsycINFO, EMBASE+EMBASE Classic, Web of Knowledge) for systematic reviews and/or meta-analyses that report placebo effect size in clinical trials in patients with mental health disorders (initial search date 23 October 2022). Screening of abstracts and full texts will be done in pairs. We will extract data to qualitatively examine how placebo effect size varies across mental health disorders. We also plan to qualitatively summarise predictors of increased placebo response identified either quantitatively (eg, through meta-regression) or qualitatively. Risk of bias will be assessed using the AMSTAR-2 tool. We aim to not only summarise the current literature but also to identify gaps in knowledge and generate further hypotheses. Ethics and dissemination We do not believe there are any specific ethical considerations relevant to this study. We will publish the results in a peer-reviewed journal.

Anxiety disorders constitute the most common group of psychiatric disorders with a lifetime prevalence of 14.5–33.7%. Despite efficacious pharmacological and psychological treatments, first line treatment is often not effective, and development of new therapies is needed. One area of interest is the orexin system, a neurotransmitter system centred in the lateral hypothalamus with widespread projections throughout the brain, including to several key areas involved in the modulation of fear and anxiety. In this article, we summarise findings from pre-clinical and clinical investigations of the potential role of the orexin system in the neurobiology of fear and anxiety. Pre-clinical studies in rodents generally indicate that orexin signalling promotes fear and anxiety-related behaviour, particularly in response to aversive stimuli. Orexin signalling in the amygdala, bed nucleus of the stria terminalis, paraventricular nucleus of thalamus, locus coeruleus and prefrontal cortex has been specifically implicated. Human studies are limited, with some evidence that orexin receptor antagonists are anxiolytic in experimental medicine models of anxiety, some indications from clinical populations of altered orexin signalling, and a molecular genetic study associating a non-synonymous variant in the orexin 1 receptor (HCRTR1) with panic disorder and agoraphobia. Given this emerging body of evidence, further human studies are required to fully assess the orexin system as a potential novel anxiolytic target.

Anxiety is a normal phenomenon that represents an ‘alarm system’, which allows preparation of physical and psychological responses to a perceived threat or danger (the ‘fight-or-flight’ response). Anxiety is usually appropriate, short-lived and controllable. When anxiety is present inappropriately, and its symptoms are abnormally severe, persistent and impair physical, social or occupational functioning, an ‘anxiety disorder’ can be diagnosed. In this section, we summarise what is known about the aetiology and neurobiology of the anxiety disorders included in the International Classification of Diseases, 11th edition (ICD-11) classification of mental disorders: generalised anxiety disorder, panic disorder with or without agoraphobia, specific phobia, social anxiety disorder and separation anxiety disorder [1]. As there is significant overlap in the neurobiology of these disorders, we discuss the anxiety disorders as a whole, highlighting specific aspects where relevant. Characteristic features of the anxiety disorders are shown in Table 9.4.1.

Social anxiety disorder (SAD) is very common and can be significantly disabling. New treatments are needed as the remission rate for SAD is the lowest of all the anxiety disorders. Experimental medicine models, in which features resembling a clinical disorder are experimentally induced, are a cost-effective and timely approach to explore potential novel treatments for psychiatric disorders. Following the emergence of SARS-CoV-2, there is a need to develop experimental medicine models that can be carried out remotely. We developed a novel procedure to investigate SAD (the InterneT-based Stress test for Social Anxiety Disorder; ITSSAD) that can be carried out entirely online by a single investigator, potentially reducing costs and maximising internal reliability. The procedure involves an anticipatory period followed by a naturalistic social interaction task.

Social anxiety disorder (SAD) is very common and can be significantly disabling. New treatments are needed as the remission rate for SAD is the lowest of all the anxiety disorders. Experimental medicine models, in which features resembling a clinical disorder are experimentally induced, are a cost-effective and timely approach to explore potential novel treatments for psychiatric disorders. Following the emergence of SARS-CoV-2, there is a need to develop experimental medicine models that can be carried out remotely. We developed a novel procedure to investigate SAD (the InterneT-based Stress test for Social Anxiety Disorder; ITSSAD) that can be carried out entirely online by a single investigator, potentially reducing costs and maximising internal reliability. The procedure involves an anticipatory period followed by a naturalistic social interaction task. In a sample of 20 non-treatment-seeking volunteers with symptoms of SAD, the ITSSAD induced significant subjective anxiety and reduced positive affect. Further, increased social anxiety symptoms at baseline predicted increased anxiety during the social interaction task. This protocol needs further validation with physiological measures. The ITSSAD is a new tool for researchers to investigate mechanisms underlying social anxiety disorder.

BACKGROUND: The mechanisms underlying placebo effects of psychotropic drugs remain poorly understood. We carried out the first systematic review of functional neuroimaging correlates of placebo response in adults with anxiety/depressive disorders. METHODS: We systematically searched a large set of databases up to February 2021 based on a pre-registered protocol (PROSPERO CRD42019156911). We extracted neuroimaging data related to clinical improvement following placebo or related to placebo mechanisms. We did not perform a meta-analysis due to the small number of included studies and significant heterogeneity in study design and outcome measures. RESULTS: We found 12 relevant studies for depressive disorders and four for anxiety disorders. Activity in the ventral striatum, rostral anterior cingulate cortex and other default mode network regions, orbitofrontal cortex, and dorsolateral prefrontal cortex correlated with placebo antidepressant responses. Activity in regions of the default mode network, including posterior cingulate cortex, was associated with placebo anxiolysis. There was also evidence for possible involvement of the endogenous opioid, dopamine and serotonin systems in placebo antidepressant and anxiolytic effects. CONCLUSIONS: Several brain regions and molecular systems may be involved in these placebo effects. Further adequately powered studies exploring causality and controlling for confounders are required.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder which often proves refractory to current treatment approaches. Transcranial direct current stimulation (tDCS), a noninvasive form of neurostimulation, with potential for development as a self-administered intervention, has shown potential as a safe and efficacious treatment for OCD in a small number of trials. The two most promising stimulation sites are located above the orbitofrontal cortex (OFC) and the supplementary motor area (SMA). METHODS: The aim of this feasibility study is to inform the development of a definitive trial, focussing on the acceptability, safety of the intervention, feasibility of recruitment, adherence and tolerability to tDCS and study assessments and the size of the treatment effect. To this end, we will deliver a double-blind, sham-controlled, crossover randomised multicentre study in 25 adults with OCD. Each participant will receive three courses of tDCS (SMA, OFC and sham), randomly allocated and given in counterbalanced order. Each course comprises four 20-min stimulations, delivered over two consecutive days, separated by at least 4 weeks' washout period. We will collect information about recruitment, study conduct and tDCS delivery. Blinded raters will assess clinical outcomes before, during and up to 4 weeks after stimulation using validated scales. We will include relevant objective neurocognitive tasks, testing cognitive flexibility, motor disinhibition, cooperation and habit learning. DISCUSSION: We will analyse the magnitude of the effect of the interventions on OCD symptoms alongside the standard deviation of the outcome measure, to estimate effect size and determine the optimal stimulation target. We will also measure the duration of the effect of stimulation, to provide information on spacing treatments efficiently. We will evaluate the usefulness and limitations of specific neurocognitive tests to determine a definitive test battery. Additionally, qualitative data will be collected from participants to better understand their experience of taking part in a tDCS intervention, as well as the impact on their overall quality of life. These clinical outcomes will enable the project team to further refine the methodology to ensure optimal efficiency in terms of both delivering and assessing the treatment in a full-scale trial. TRIAL REGISTRATION: ISRCTN17937049 . (date applied 08/07/2019). Recruitment (ongoing) began 23rd July 2019 and is anticipated to complete 30th April 2021.

Gambling disorder creates a significant public health burden. Despite decades of clinical trials, there are no licensed pharmacological treatments for gambling disorder. Contributing factors to this are the high placebo response rates seen in clinical trials, the heterogeneity of the disorder and high rates of psychiatric comorbidities. Indeed, a number of demographic and clinical variables have previously been associated with altered responses to pharmacotherapy, psychotherapy and placebo. Which variables are likely to predict response to one modality over another remains uncertain. We carried out multiple linear regression analyses in a pooled dataset from six treatment studies in gambling disorder with the aim of identifying predictors of treatment response. Potential predictors were identified a priori through hypothesis and entered into models including all patients, and subsequently for those randomized to active medication or placebo separately. We found that baseline severity of gambling symptoms and number of weeks completed in a trial were predictors of active medication response, while decreased baseline symptoms of anxiety, increased baseline symptoms of depression, and non-Caucasian ethnicity were associated with placebo response. Sensitivity analyses showed that these associations were robust to choices made during the analysis. Further research is required to understand whether controlling for these variables, or using enriched samples, improves assay sensitivity in placebo-controlled clinical trials for gambling disorder.

Placebos are not inert, but exert measurable biological effects. The placebo response in psychiatric illness is important and clinically relevant, but remains poorly understood. In this paper, we review current knowledge about the placebo response in psychiatric medicine and identify research directions for the future. We argue that more research is needed into the placebo response in psychiatric medicine for three broad reasons. First, awareness of factors that cause placebo response, for whom, and when, within clinical trials will allow us to better evidence efficacy of new treatments. Second, by understanding how placebo mechanisms operate in the clinic, we can take advantage of these to optimise the effects of current treatments. Finally, exploring the biological mechanisms of placebo effects might reveal tractable targets for novel treatment development.

BACKGROUND: The 7.5% CO2 inhalational model can be used to explore potential treatments for generalized anxiety disorder. However, it is unknown how inter-individual variability in the functional architecture of negative affective valence systems might relate to anxiogenic response in this model. METHODS: A total of 13 healthy volunteers underwent functional magnetic resonance imaging during a passive emotional face perception task. We explored task-evoked functional connectivity in the potential threat system through generalized psychophysiological interaction analysis. Within 7 days, these participants underwent prolonged 7.5% CO2 inhalation, and results from the generalized psychophysiological interaction analysis were correlated with CO2 outcome measures. RESULTS: Functional connectivity between ventromedial prefrontal cortex and right amygdala positively correlated with heart rate and subjective anxiety, while connectivity between midcingulate cortex and left amygdala negatively correlated with anxiety during CO2 challenge. CONCLUSIONS: Response to CO2 challenge correlated with task-evoked functional connectivity in the potential threat system. Further studies should assess whether this translates into clinical populations.

Background: Previous research indicates that antidepressants can restore the balance between negative and positive emotional processing early in treatment, indicating a role of this effect in later mood improvement. However, less is known about the effect of antidepressants on reward processing despite the potential relevance to the treatment of anhedonia. In this study, we investigated the effects of an acute dose of the atypical antidepressant (dual dopamine and noradrenaline reuptake inhibitor) bupropion on behavioral measures of emotional and reward processing in healthy volunteers. Methods: Forty healthy participants were randomly allocated to double-blind intervention with either an acute dose of bupropion or placebo prior to performing the Emotional Test Battery (ETB) and a probabilistic instrumental learning task. Results: Acute bupropion significantly increased the recognition of ambiguous faces as happy, decreased response bias toward sad faces and reduced attentional vigilance for fearful faces compared to placebo. Bupropion also reduced negative bias compared to placebo in the emotional recognition memory task (EMEM). There was no evidence that bupropion enhanced reward processing or learning. Instead, bupropion was associated with reduced likelihood to choose high-probability wins and increased score on a subjective measure of anhedonia. Conclusions: Whilst acute bupropion decreases negative and increases positive emotional processing, it has an adverse effect on reward processing. There seems to be a dissociation of the acute effects of bupropion on positive emotional processing and reward processing, which may have clinical implications for anhedonia early in treatment.

Many pharmacological and psychological approaches have been found efficacious in patients with generalized anxiety disorder (GAD), but many treatment-seeking patients will not respond and others will relapse despite continuing with interventions that initially had beneficial effects. Other patients will respond but then stop treatment early because of untoward effects such as sexual dysfunction, drowsiness, and weight gain. There is much scope for the development of novel approaches that could have greater overall effectiveness or acceptability than currently available interventions or that have particular effectiveness in specific clinical subgroups. ‘Experimental medicine’ studies in healthy volunteers model disease states and represent a proof-of-concept approach for the development of novel therapeutic interventions: they determine whether to proceed to pivotal efficacy studies and so can reduce delays in translating innovations into clinical practice. Investigations in healthy volunteers challenged with the inhalation of air ‘enriched’ with 7.5% carbon dioxide (CO2) indicate this technique provides a validated and robust experimental medicine model, mirroring the subjective, autonomic, and cognitive features of GAD. The anxiety response during CO2 challenge probably involves both central noradrenergic neurotransmission and effects on acid-base sensitive receptors and so may stimulate development of novel agents targeted at central chemosensors. Increasing awareness of the potential role of altered cytokine balance in anxiety and the interplay of cytokines with monoaminergic mechanisms may also encourage the investigation of novel agents with modulating effects on immunological profiles. Although seemingly disparate, these two approaches to treatment development may pivot on a shared mechanism in exerting anxiolytic-like effects through pharmacological effects on acid-sensing ion channels.

Placebo-controlled trials are the gold standard measure of efficacy in the development of new treatments for depression. However, the large placebo effects associated with standard measures of subjective symptoms reduce the sensitivity of such trials to detect antidepressant effects. There is a need to develop novel efficacy markers that are resistant to placebo effects. Measures of emotional processing, known to be sensitive to antidepressant treatment, may be such a marker, although the effect of an acute placebo treatment on these measures remains unclear. We assessed the influence of placebo on a validated battery of emotional processing tasks, the Emotional Test Battery (ETB), in healthy participants. Participants were informed they might receive the antidepressant drug bupropion, placebo or no treatment, with placebo effect being estimated as the difference between the placebo and no treatment groups. We found no significant difference between these groups on measures of emotional processing. There was also no effect of subjective treatment expectancy on performance in the tasks. This suggests that the ETB might be a useful tool for Phase I trials assessing novel antidepressant agents against placebo.

The lack of clear understanding of the pathophysiology of chronic pain could explain why we currently have only a few effective treatments. Understanding how pain relief is realised during placebo analgesia could help develop improved treatments for chronic pain. Here, we tested whether experimental placebo analgesia was associated with altered resting-state cortical activity in the alpha frequency band of the electroencephalogram (EEG). Alpha oscillations have been shown to be influenced by top-down processes, which are thought to underpin the placebo response. Seventy-three healthy volunteers, split into placebo or control groups, took part in a well-established experimental placebo procedure involving treatment with a sham analgesic cream. We recorded ongoing (resting) EEG activity before, during, and after the sham treatment. We show that resting alpha activity is modified by placebo analgesia. Post-treatment, alpha activity increased significantly in the placebo group only (p $<$ 0.001). Source analysis suggested that this alpha activity might have been generated in medial components of the pain network, including dorsal anterior cingulate cortex, medial prefrontal cortex, and left insula. These changes are consistent with a cognitive state of pain expectancy, a key driver of the placebo analgesic response. The manipulation of alpha activity may therefore present an exciting avenue for the development of treatments that directly alter endogenous processes to better control pain.

Rheumatic pain and, in particular, rheumatoid arthritis, osteoarthritis and fibromyalgia, are common and debilitating chronic pain syndromes. Recently, human functional neuroimaging, for example EEG, fMRI, and PET has begun to reveal some of the crucial central nervous system mechanisms underlying these diseases. The purpose of this review is to summarise current knowledge on the brain mechanisms of rheumatic pain revealed by functional neuroimaging techniques. The evidence suggests that two mechanisms may be largely responsible for the clinical pain associated with these rheumatic diseases: abnormalities in the medial pain system and/or central nervous system sensitisation and inhibition. If we can understand how functioning of the central nociceptive system becomes altered, even in the absence of peripheral nociceptive input, by using functional neuroimaging techniques, in the future we may be able to develop improved, more effective treatments for patients with chronic rheumatic pain.

Patients with learning disabilities are not always involved in decision-making about their medications. This may mean that some patients are unfairly denied of their autonomy. We carried out an audit of current practice concerning consent to treatment in patients with learning disabilities against best practice guidelines. Data were collected via a questionnaire given to a sample of 70 patients with learning disabilities within the Salford catchment area. This questionnaire assessed whether patients were involved in decision-making regarding their medications and whether they were being given enough information to give informed consent. A total of 45 patients completed questionnaires. Overall, the patients’ knowledge of their medications was poor, particularly of the proposed duration, possible disadvantages and name of the treatment. It appears that doctors are engaging these patients during consultations and discussing their medications. However, the delivery of this information needs to be improved, and patients’ understanding and recall need to be checked more thoroughly.