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出境医 / 临床实验 / Combined Treatment of Prolonged Exposure and Pramipexole for Posttraumatic Stress Disorder and Depression

Combined Treatment of Prolonged Exposure and Pramipexole for Posttraumatic Stress Disorder and Depression

Study Description
Brief Summary:
This pilot study aims to test the safety, feasibility, and initial efficacy of combined 10 week treatment of prolonged exposure (PE) and Pramipexole in patients with comorbid posttraumatic stress disorder (PTSD) and depression (MDD). Resting state functional connectivity (rsFC) will be assessed at baseline and en of treatment.

Condition or disease Intervention/treatment Phase
PTSD MDD Combination Product: PE/Pramipexole Phase 3

Detailed Description:

Approximately half of the individuals with posttraumatic stress disorder (PTSD) present with major depressive disorder (MDD). Compared to PTSD alone, patients with comorbid PTSD-MDD demonstrate greater distress and poorer treatment outcome. Functional magnetic resonance imaging (fMRI) show that relative to PTSD alone, PTSD-MDD is associated with decreased resting state functional connectivity (rs-FC) in both fear- and reward-processing circuits. In addition, our data suggest that Prolonged Exposure (PE), first-line PTSD treatment, may successfully target impairments in the fear circuits, but not in the reward circuits, which may explain the treatment-refractory quality of PTSD-MDD.

The goal of this pilot study is to test the feasibility, safety and initial efficacy of an integrated therapeutic approach targeting both fear and reward impairments in PTSD-MDD patients. Specifically, the investigators will examine a combination treatment with PE, shown to effectively address fear circuitry deficits, and Pramipexole, a dopamine agonist, shown to increase reward circuit function and to have promise in treating depression but not previously studied in PTSD. The central hypothesis is that combined PE/Pramipexole will a) improve PTSD and depressive symptoms in PTSD-MDD patients, and b) increase functional connectivity of fear and reward pathways as measured by fMRI rs-FC. In this pilot study, 15 adults aged 18-60 years with PTSD-MDD will receive combined 10-week of PE and Pramipexole up to the maximum dose of 4mg a day. Clinical assessment will be conducted at baseline, week 5, post treatment and at 3-month follow up. Behaviorally assessments including the probabilistic reward task (PRT) and attention allocation tasks, and fMRI scans for resting state functional connectivity (rs-FC) will be conducted at baseline and end of treatment.

Study Design
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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 1 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Combined Prolonged Exposure and Pramipexole Treatment for Patients With PTSD and Depression
Actual Study Start Date : February 19, 2019
Actual Primary Completion Date : August 26, 2019
Actual Study Completion Date : August 26, 2019
Arms and Interventions
Arm Intervention/treatment
Experimental: PE/Pramipexole
Experimental: Prolonged Exposure/Pramipexole Prolonged Exposure (PE) Therapy consists of 10 sessions of 90-minute duration, normally conducted once a week. In addition to receiving PE as described above, patients will have Pramipexole treatment.
Combination Product: PE/Pramipexole

Experimental: PE/Pramipexole Prolonged Exposure (PE) Therapy consists of 10 sessions of 90-minute duration, normally conducted once a week. Elements of PE include imaginal and in vivo exposure to trauma reminders; breathing retraining; cognitive restructuring; and PTSD psychoeducation.

Pramipexole: In addition to receiving PE as described above, patients will have Pramipexole treatment. Daily dose will be started at 0.25 mg/day and increased by 0.25 mg/day every 3-4 days to a target of 2.5mg day by week 5. Beginning week 6 daily dose will be increased weekly by 0.5 mg/day to a maximum dose of 4mg. Dose will be increased as tolerated unless the patient has achieved remission and will be decreased in the event of intolerable adverse events.


Outcome Measures
Primary Outcome Measures :
  1. Change in PTSD Symptoms as Measured by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) [ Time Frame: Baseline, Week 5, Week 10, 3 month follow up ]
    The CAPS is the gold standard in PTSD assessment. It is a 30-item structured interview used for current (past week or month) and lifetime diagnosis of PTSD. The CAPS was designed to be administered by clinicians and clinical researchers who have a working knowledge of PTSD. The full interview takes 45-60 minutes to administer. Scores range from 0 to 80 with higher values represent a worse outcome.

  2. Change in Depressive Symptoms as Measured by the Hamilton Rating Scale for Depression (HRSD). [ Time Frame: Baseline, Week 5, Week 10, 3 month follow up ]
    The Hamilton Rating Scale for Depression is a 17-item instrument that was designed to measure frequency and intensity of depressive symptoms in individuals with major depressive disorder. Ratings are made using either a five- or a three-point scale, yielding total scores from 0 to 61, with higher values represent a worse outcome.


Secondary Outcome Measures :
  1. Changes in Functional Connectivity of Fear and Reward Pathways as Measured by Functional Magentic Resonance Imaging (fMRI) Resting State Functional Connectivity (Rs-FC). [ Time Frame: baseline and week 10. ]
    The investigators will use fMRI scans at baseline and posttreatment to assess connectivity in fear and reward circuits


Eligibility Criteria
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Ages Eligible for Study:   18 Years to 60 Years   (Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Males or females between the ages of 18 and 60
  2. Current DSM-V diagnosis of PTSD comorbid with MDD
  3. CAPS-5 ≥ 25, and 17-item HRSD ≥ 17
  4. Able to give consent, fluent in English

Exclusion Criteria:

  1. Prior or current diagnosis with traumatic brain injury, bipolar disorder, psychotic disorder, gambling or impulse control disorders, or dementia
  2. History of psychosis, psychotic disorder, mania or bipolar disorder
  3. Severe substance use disorder excluding nicotine (i.e., nicotine use disorder and mild-moderate alcohol/cannabis use disorder are accepted)
  4. Individuals at risk for suicide based on history and current mental state. BDI-II suicide item > 2 or CGI-Severity baseline score of 7.
  5. Treatment with antidepressants or other psychotropic medication in the past 4 weeks (or 6 weeks for fluoxetine; an exception will be made for zolpidem used intermittently for sleep).
  6. Pregnancy or plans to become pregnant during the period of the study.
  7. Current psychotherapy
  8. Current unstable or untreated medical illness
  9. Any condition that would exclude clinical MRI exam (e.g. pacemaker, paramagnetic metallic prosthesis, surgical clips, shrapnel, necessity for constant medicinal patch, some tattoos, severe obesity, claustrophobia)
  10. History of untoward reaction to pramipexole
Contacts and Locations

Locations
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United States, New York
New York State Psychiatric Institute
New York, New York, United States, 10032
Sponsors and Collaborators
Research Foundation for Mental Hygiene, Inc.
Investigators
Layout table for investigator information
Principal Investigator: Yuval Neria, PhD Columbia Psyhciatry and New York State Psychiatric Institute
Tracking Information
First Submitted Date  ICMJE December 2, 2018
First Posted Date  ICMJE December 5, 2018
Results First Submitted Date  ICMJE September 19, 2019
Results First Posted Date  ICMJE November 26, 2019
Last Update Posted Date November 26, 2019
Actual Study Start Date  ICMJE February 19, 2019
Actual Primary Completion Date August 26, 2019   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: December 4, 2018)
  • Change in PTSD Symptoms as Measured by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) [ Time Frame: Baseline, Week 5, Week 10, 3 month follow up ]
    The CAPS is the gold standard in PTSD assessment. It is a 30-item structured interview used for current (past week or month) and lifetime diagnosis of PTSD. The CAPS was designed to be administered by clinicians and clinical researchers who have a working knowledge of PTSD. The full interview takes 45-60 minutes to administer. Scores range from 0 to 80 with higher values represent a worse outcome.
  • Change in Depressive Symptoms as Measured by the Hamilton Rating Scale for Depression (HRSD). [ Time Frame: Baseline, Week 5, Week 10, 3 month follow up ]
    The Hamilton Rating Scale for Depression is a 17-item instrument that was designed to measure frequency and intensity of depressive symptoms in individuals with major depressive disorder. Ratings are made using either a five- or a three-point scale, yielding total scores from 0 to 61, with higher values represent a worse outcome.
Original Primary Outcome Measures  ICMJE
 (submitted: December 3, 2018)
  • Change from baseline to post treatment and 3 month follow up on severity of PTSD symptoms [ Time Frame: Baseline, Week 5, Week 10, 3 month follow up ]
    We will use the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). The CAPS-5 is a 30-item structured interview that can be used to determine current (past month) diagnosis of PTSD, to make lifetime diagnosis of PTSD, and to assess PTSD symptoms over the past wee
  • Change from baseline to post treatment and 3 month follow up on severity of depressive symptoms [ Time Frame: Baseline, Week 5, Week 10, 3 month follow up ]
    We will use the The Hamilton Rating Scale for Depression (HRSD),[1] also called the Hamilton Depression Rating Scale (HDRS), abbreviated HAM-D, is a multiple item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery. The patient is rated by a clinician on 17 to 29 items (depending on version) scored either on a 3-point or 5-point Likert-type scale.
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: December 4, 2018)
Changes in Functional Connectivity of Fear and Reward Pathways as Measured by Functional Magentic Resonance Imaging (fMRI) Resting State Functional Connectivity (Rs-FC). [ Time Frame: baseline and week 10. ]
The investigators will use fMRI scans at baseline and posttreatment to assess connectivity in fear and reward circuits
Original Secondary Outcome Measures  ICMJE
 (submitted: December 3, 2018)
Changes in functional connectivity of fear and reward pathways as measured by fMRI rs-FC. [ Time Frame: baseline and week 10. ]
We will use fMRI scans at baseline and posttreatment to assess connectivity in fear and reward circuits
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Combined Treatment of Prolonged Exposure and Pramipexole for Posttraumatic Stress Disorder and Depression
Official Title  ICMJE Combined Prolonged Exposure and Pramipexole Treatment for Patients With PTSD and Depression
Brief Summary This pilot study aims to test the safety, feasibility, and initial efficacy of combined 10 week treatment of prolonged exposure (PE) and Pramipexole in patients with comorbid posttraumatic stress disorder (PTSD) and depression (MDD). Resting state functional connectivity (rsFC) will be assessed at baseline and en of treatment.
Detailed Description

Approximately half of the individuals with posttraumatic stress disorder (PTSD) present with major depressive disorder (MDD). Compared to PTSD alone, patients with comorbid PTSD-MDD demonstrate greater distress and poorer treatment outcome. Functional magnetic resonance imaging (fMRI) show that relative to PTSD alone, PTSD-MDD is associated with decreased resting state functional connectivity (rs-FC) in both fear- and reward-processing circuits. In addition, our data suggest that Prolonged Exposure (PE), first-line PTSD treatment, may successfully target impairments in the fear circuits, but not in the reward circuits, which may explain the treatment-refractory quality of PTSD-MDD.

The goal of this pilot study is to test the feasibility, safety and initial efficacy of an integrated therapeutic approach targeting both fear and reward impairments in PTSD-MDD patients. Specifically, the investigators will examine a combination treatment with PE, shown to effectively address fear circuitry deficits, and Pramipexole, a dopamine agonist, shown to increase reward circuit function and to have promise in treating depression but not previously studied in PTSD. The central hypothesis is that combined PE/Pramipexole will a) improve PTSD and depressive symptoms in PTSD-MDD patients, and b) increase functional connectivity of fear and reward pathways as measured by fMRI rs-FC. In this pilot study, 15 adults aged 18-60 years with PTSD-MDD will receive combined 10-week of PE and Pramipexole up to the maximum dose of 4mg a day. Clinical assessment will be conducted at baseline, week 5, post treatment and at 3-month follow up. Behaviorally assessments including the probabilistic reward task (PRT) and attention allocation tasks, and fMRI scans for resting state functional connectivity (rs-FC) will be conducted at baseline and end of treatment.

Study Type  ICMJE Interventional
Study Phase  ICMJE Phase 3
Study Design  ICMJE Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Condition  ICMJE
  • PTSD
  • MDD
Intervention  ICMJE Combination Product: PE/Pramipexole

Experimental: PE/Pramipexole Prolonged Exposure (PE) Therapy consists of 10 sessions of 90-minute duration, normally conducted once a week. Elements of PE include imaginal and in vivo exposure to trauma reminders; breathing retraining; cognitive restructuring; and PTSD psychoeducation.

Pramipexole: In addition to receiving PE as described above, patients will have Pramipexole treatment. Daily dose will be started at 0.25 mg/day and increased by 0.25 mg/day every 3-4 days to a target of 2.5mg day by week 5. Beginning week 6 daily dose will be increased weekly by 0.5 mg/day to a maximum dose of 4mg. Dose will be increased as tolerated unless the patient has achieved remission and will be decreased in the event of intolerable adverse events.

Study Arms  ICMJE Experimental: PE/Pramipexole
Experimental: Prolonged Exposure/Pramipexole Prolonged Exposure (PE) Therapy consists of 10 sessions of 90-minute duration, normally conducted once a week. In addition to receiving PE as described above, patients will have Pramipexole treatment.
Intervention: Combination Product: PE/Pramipexole
Publications * Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Terminated
Actual Enrollment  ICMJE
 (submitted: November 7, 2019)
1
Original Estimated Enrollment  ICMJE
 (submitted: December 3, 2018)
15
Actual Study Completion Date  ICMJE August 26, 2019
Actual Primary Completion Date August 26, 2019   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  1. Males or females between the ages of 18 and 60
  2. Current DSM-V diagnosis of PTSD comorbid with MDD
  3. CAPS-5 ≥ 25, and 17-item HRSD ≥ 17
  4. Able to give consent, fluent in English

Exclusion Criteria:

  1. Prior or current diagnosis with traumatic brain injury, bipolar disorder, psychotic disorder, gambling or impulse control disorders, or dementia
  2. History of psychosis, psychotic disorder, mania or bipolar disorder
  3. Severe substance use disorder excluding nicotine (i.e., nicotine use disorder and mild-moderate alcohol/cannabis use disorder are accepted)
  4. Individuals at risk for suicide based on history and current mental state. BDI-II suicide item > 2 or CGI-Severity baseline score of 7.
  5. Treatment with antidepressants or other psychotropic medication in the past 4 weeks (or 6 weeks for fluoxetine; an exception will be made for zolpidem used intermittently for sleep).
  6. Pregnancy or plans to become pregnant during the period of the study.
  7. Current psychotherapy
  8. Current unstable or untreated medical illness
  9. Any condition that would exclude clinical MRI exam (e.g. pacemaker, paramagnetic metallic prosthesis, surgical clips, shrapnel, necessity for constant medicinal patch, some tattoos, severe obesity, claustrophobia)
  10. History of untoward reaction to pramipexole
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 18 Years to 60 Years   (Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE Contact information is only displayed when the study is recruiting subjects
Listed Location Countries  ICMJE United States
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT03765138
Other Study ID Numbers  ICMJE Research Foundation for Mental
Has Data Monitoring Committee No
U.S. FDA-regulated Product
Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
IPD Sharing Statement  ICMJE
Plan to Share IPD: No
Responsible Party Yuval Y Neria, Research Foundation for Mental Hygiene, Inc.
Study Sponsor  ICMJE Research Foundation for Mental Hygiene, Inc.
Collaborators  ICMJE Not Provided
Investigators  ICMJE
Principal Investigator: Yuval Neria, PhD Columbia Psyhciatry and New York State Psychiatric Institute
PRS Account Research Foundation for Mental Hygiene, Inc.
Verification Date November 2019

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP