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Confusing placebo effect with natural history in epilepsy: A big data approach
Author(s) -
Goldenholz Daniel M.,
Moss Robert,
Scott Jonathan,
Auh Sungyoung,
Theodore William H.
Publication year - 2015
Publication title -
annals of neurology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 4.764
H-Index - 296
eISSN - 1531-8249
pISSN - 0364-5134
DOI - 10.1002/ana.24470
Subject(s) - placebo , medicine , clinical trial , epilepsy , population , placebo response , regression toward the mean , psychiatry , alternative medicine , statistics , pathology , mathematics , environmental health
For unknown reasons, placebos reduce seizures in clinical trials in many patients. It is also unclear why some drugs showing statistical superiority to placebo in one trial may fail to do so in another. Using Seizuretracker.com , a patient‐centered database of 684,825 seizures, we simulated “placebo” and “drug” trials. These simulations were employed to clarify the sources of placebo effects in epilepsy, and to identify methods of diminishing placebo effects. Simulation 1 included 9 trials with a 6‐week baseline and 6‐week test period, starting at time 0, 3, 6…24 months. Here, “placebo” reduced seizures regardless of study start time. Regression‐to‐the‐mean persisted only for 3 to 6 months. Simulation 2 comprised a 6‐week baseline and then 2 years of follow‐up. Seizure frequencies continued to improve throughout follow‐up. Although the group improved, individuals switched from improvement to worsening and back. Simulation 3 involved a placebo‐controlled “drug” trial, to explore methods of placebo response reduction. An efficacious “drug” failed to demonstrate a significant effect compared with “placebo” ( p = 0.12), although modifications either in study start time ( p = 0.025) or baseline population reduction ( p = 0.0028) allowed the drug to achieve a statistically significant effect compared with placebo. In epilepsy clinical trials, some seizure reduction traditionally attributed to placebo effect may reflect the natural course of the disease itself. Understanding these dynamics will allow future investigations into optimal clinical trial design and may lead to identification of more effective therapies. Ann Neurol 2015;78:329–336