April 15, 2009

Leading Psychiatrist Unimpressed By Seroquel As Add-On Depression Treatment

I've been holding off writing much about the efficacy and safety data that emerged in connection with last week's FDA psychopharmacology advisory committee hearing as to whether the committee would recommend to the FDA approval of Seroquel XR for a range of indications. The committee said "No" to approval for Seroquel as a treatment for generalized anxiety and as a treatment for depression as a monotherapy and as a maintenance therapy. The committee did recommend approval of AstraZeneca's atypical antipsychotic as an add-on, or adjunctive, treatment for depression. I've held off writing until now because Seroquel is a drug that harmed me and I wanted others to take the lead in examining safety and efficacy data.

Now Tufts University psychiatrist Danny Carlat casts a cold eye on the add-on treatment data submitted to the FDA at his blog.

"While I agree with the committee's rejection of two indications, I'm concerned that they were inappropriately impressed by the Seroquel augmentation data. As far as I know, the augmentation studies have not been published, but a summary can be found on page 27 of AZ's briefing document [found here]. It looks like they used the same research design as BMS did in their Abilify augmentation studies, and that the Seroquel results were equally unimpressive (see this article at Clin Psych for a slam of the Abilify data). Seroquel reduced the MADRS depression score by about 15 points, while placebo decreased it by about 12 points. This 3 point advantage is tiny, considering that the MADRS is a 60 point scale. Personally, I don't think that this 5% advantage (3 divided by 60 possible points) is worth Seroquel's side effects."

That's pretty damn indicting and absolutely limited efficacy--a 5 percent advantage? Oh, boy--although it's not possible to calculate the effect size of the drug yet, as the full dat sets have not been published. But I bet it's small.

The two add-on studies of Seroquel are called Study 6 and Study 7, respectively, and were six-week trials.

A summary of Study 6, conducted in the US, can be found in this FDA briefing document, given to members of the committee and also made publicly available (starts on page 29). In it, the FDA lays out clinical improvement in patients in AZ's study who took an anti-depressant plus placebo, an anti-depressant plus 150 mgs. a day of Seroquel or an anti-depressant plus 300 mgs. a day of Seroquel.

On the Montgomery-Åsberg Depression Rating Scale (the primary outcome measure) in Study 6, patients in the placebo/anti-depressant group saw an average reduction (meaning improvement) in their MADRS score of 11.70 points, the anti-depressant/Seroquel 150 mgs. group saw a reduction of 13.60 points while the anti-depressant/Seroquel 300 mgs. group saw a reduction of 14.70 points. So that's a 3.16 percent advantage over placebo for the 150 mgs. group and a 5 percent advantage for the 300 mgs a day group.

Study 7 begins on page 33 of the same document and was a similarly constructed six-week trial of patients in South Africa, Europe, North America and Australia.

On the Montgomery-Åsberg Depression Rating Scale in Study 7, patients in the placebo/anti-depressant group saw an average reduction in their MADRS score of 12.21 points, the anti-depressant/Seroquel 150 mgs. group saw a reduction of 15.26 points while the anti-depressant/Seroquel 300 mgs. group saw a reduction of 14.94 points. So that's a 5.08 percent advantage over placebo for the 150 mgs. group and a 4.55 percent advantage over placebo for the 300 mgs. group.

I'm not even sure how the advisory committee arrived at a determination that Seroquel XR had demonstrated efficacy in these six weeks studies, since the drug is barely efficacious. It literally must have just squeaked by the committee.

Carlat also delivers a bit of a coup de grace by noting that in a:

"[R]ecently published randomized trial showed that when Seroquel was added to Prozac, it yielded no advantages over placebo, aside from helping patients sleep better over the first few weeks. This was not a study of treatment-resistant patients (unlike the FDA data) but it nonetheless shakes my confidence in the potency of the medication."

That study is right here. Read the abstract for yourself.

Like Carlat, I worry that FDA approval of Seroquel XR as an add-on depression treatment will lead to a huge direct-to-consumer marketing campaign and plenty of patients gaining weight and developing diabetes. The FDA should not follow the advisory committee's recommendation. The agency may just be doing millions of Americans a favor.

Posted by Philip Dawdy at April 15, 2009 12:01 AM
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Comments

I was put on Seroquel, Risperdal and Abilify for generalized anxiety disorder as a teenager as add ons and now they don't recommend it. I wish my old psychiatrists could have seen this years ago. Instead they put me on Seroquel, Risperdal and Abilify and didn't give a damn about whether it would really work. As long as your on as many psyche meds as possible. I've been off my medication for over a year and there isn't much difference off medication as their was when I was put on cocktails antidepressants, antipsychotics, stimulants, mood stabolixers and benzodiazepines. I wish I could ask my old psychiatrists why they kept putting me on this stuff. It doesn't matter whether or not the FDA approves it, they are going to keep givign out antipsychotics for generalized anxiety disorder and various other anxiety disorders and to kids, adolescents and teenagers. Psychiatrists just don't care. They just get off to prescribing this stuff, no matter whether or not it works at all.

Posted by: Princess at April 15, 2009 06:40 AM

In the beginning, SSRI Stories found the going pretty clear cut and straightforward in regard to the medications taken by those who committed murders, murder-suicides, rampage shootings and other acts of violence. For instance, Eric Harris [Columbine] was taking only one psychiatric med, the SSRI antidepressant Luvox, as were about 95% of the earlier cases.

Since the introduction of the atypical antipsychotics, however, there are more cases where the perpetrator was taking an SSRI/SNRI and an atypical antipsychotic. Since these atypical antipsychotics are half antidepressant, it confounds the statistics on SSRI Stories as to exactly which medication, the antidepressant or the antipsychotic [or a combo], was the main cause of the violence.

Docs are already using Seroquel for 'add-on' and, of course, Abilify is approved for this use. So to now have a marketing ad for Seroquel as an add-on is really bad news both for the patients and for their victims.

In all nine of the women school teacher cases [molestation of young male students] on SSRI Stories, the only precription drug was an SSRI or SNRI. But I am sure the waters are going to begin to get muddled.

In the case of the 28 year old woman Sunday school teacher who murdered 8 year old Sandra Cantu in California, there are pictures of the teacher taken several years ago which show her to be of normal weight. In her arraignment pictures she is at least 40 pounds overweight.
Was this a natural weight gain or was it an SSRI or even an atypical antipsychotic weight gain. The newspapers this week-end had reported that she was being treated the last several years at a community mental health clinic in regard to a petty theft.

The Sunday school teacher's defense attorney, Ellen Schwarzenberg, had this to say [in the second sentence posted here] : "We'll have no comment with regard to the evidence obtained," Willett said. He noted that Huckaby is ALREADY [emphasis mine] undergoing mental evaluation for a petty theft conviction this year, and "obviously any mental issues will have an effect on this case."

Schwarzenberg asked during Tuesday's hearing for "further medication evaluation" of Huckaby, but the defense attorney did not explain her request."

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/04/14/MNG91728G7.DTL


04-15) 04:00 PDT Stockton - --

Softly crying, her feet chained and her hands shackled to her waist, Melissa Huckaby was arraigned Tuesday on charges that she kidnapped, raped and murdered 8-year-old Sandra Cantu of Tracy - allegations that could send her to the death chamber.

Posted by: Rosie at April 15, 2009 07:24 AM

I have to believe that this data was never presented to the committee in this explicit way or it would not have been approved as an adjunct therapy. I guess there was a lot of hand wringing and chest beating over the dangers of "treatment resistant depression" and the horrors of "untreated depression" (while brushing over the depression and illness exacerbating effects of treatment). The way fear mongering works its way into these advisory hearings is quite predictable; it happens every time and that's pharma doing their thing. Anyway for the most part the committee did listen to reason but even this one lapse is going to lead to skyrocketing advertising and sales unless the FDA does the right thing ultimately by rejecting Seroquel as an adjunct therapy.

Posted by: Sara at April 15, 2009 08:29 AM

Google the Baltimore, MD Dept of Public Health, to the Commissioner , who will soon be number 2 at FDA once vetted....Dr. Joshua Sharfstein.

Tell him what the Advisory Committee recommended. And tell him to use his powers to stop it.

Posted by: sorrowful at April 15, 2009 11:45 AM

Philip, I agree that it was correct for you, as manager and major domo of this blog, to wait for the best data analysis you can get before commenting on the Psychopharm. vote on extending the use of Seroquel at the 4/8/09 FDA meeting held in Silver Spring.

However, Sara is really getting closer to the truth in her statement ...re, HOW clearly the data was presented. We got two sets of slides ...the official ones and then another set done the night before the meeting; date stamped 10 p.m. April 7. All the Astras (guessing twenty of them) sat directly behind the U-shaped Advisory Com. Table. Many on the Committee were last-minute subs who knew no controversy in the literature,or the history of the law suits, or the controversy over the "clinical trials." They were from other fields drawn in at the eleventh hour. The questions posed to the Committee for vote were changed and manipulated several times, orchestrated by FDA staff. Under the circumstances, and constant bunny-hops up to the mike by Astras "making clarifications", it was extremely hard to follow as an "informed lay person", let alone an ethical biostatitician from out of his/her field....I wonder if they even had a quorum if one is required....and I wonder what is actually on the "tape" that may soon become available.

I advise that Philip send the contents of the Seroquel threads found here on furious seasons to Senator Charles Grassley as potential EVIDENCE of FDA and Astra manipulation and propose that the Senator get a copy of the tape...will there be a tape? An edited tape? We shall see.

Meanwhile, there are eye witnesses to the Hearing. Informed, knowledgable eye witnesses. Who will not lie if put under oath.

This is a story that is not over.

Posted by: steamin' returns at April 15, 2009 06:45 PM
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