Intensified Pharmacological Treatment for Schizophrenia, Major Depressive Disorder and Bipolar Depression After a First-time Treatment Failure

Rationale Schizophrenia (SZ), bipolar depression (BD) and major depressive disorders (MDD) collectively affect over 10 million people across the European Union (EU) and are associated with annual healthcare and societal costs in excess of 100 billion Euros. When diagnosed with one of these disorders, patients are prescribed psychotropic medication such as antidepressants, mood stabilisers and/or antipsychotics. The effectiveness of these treatments for individual patients cannot be predicted. After this first-line treatment fails, usually a second-line treatment is initiated; when this is not effective either, a third-line treatment is initiated. Third-line treatments are quite effective, for people not responding to the first two treatments lines. However, they are used late in the disease course and clear evidence from direct comparisons of treatment algorithms is lacking. The research question is whether the third-line treatments would be more efficacious than the current second-line treatments (treatment as usual) for schizophrenia, bipolar and major depressive disorders. Third-line treatment can then be regarded as 'early-intensified'. If this is indeed the case, this could lead to the prevention of unnecessary trials of ineffective treatments and recommendations for adaptations of worldwide guidelines as well as a reduction of healthcare and societal costs. Additionally, The INTENSIFY trial is part of the larger Horizon 2021 project, with the central goal of paving the way for a shift towards a treatment decision-making process tailored for the individual at risk for treatment resistance. To that end, we aim to establish evidence-based criteria to make decisions of early intense treatment in individuals at risk for treatment resistance across the major psychiatric disorders of schizophrenia, bipolar disorder and major depression. Objective The primary objective is to compare the treatment response, expressed as change in symptom severity as measured through the Positive And Negative Syndrome Scale (PANSS; SZ sample), and the Montgomery-Åsberg Depression Rating Scale (MADRS; MDD/BD samples) under an early-intensified pharmacological treatment to that under treatment as usual, in subjects who had a first-time treatment failure on their first-line treatment. Main trial endpoints Change in symptom severity total score from baseline (visit 2) to end of treatment (visit 4). For SZ, this is measured using PANSS. For MDD and BD, MADRS is applied. Secondary trial endpoints 1. All study samples: to compare changes in the severity and improvement sub-scores of the Clinical Global Impression Scale (CGI) between the two treatment arms over the six week treatment period (visit 2 versus visit 4). 2. All study samples: to compare changes in the levels of depression and anxiety as assessed with the Hospital Anxiety and Depression Scale (HADS) between the two treatment arms over the six week treatment period (visit 2 versus visit 4). 3. All study samples: to compare changes in cognitive performance as measured through the Trail Making Test, Digit Symbol Substitution Test, Rey Auditory Verbal Learning Test as well as the Perceived Deficits Questionnaire between the two treatment arms over the six week treatment period (visit 2 versus visit 4). 4. All study samples: to compare changes in quality of life and functioning measures (Q-LES-Q-SF, LAPS, QLS-100 and SDS between the two treatment arms over the six week treatment period (visit 2 versus visit 4). 5. All study samples: to compare presence of side effects as measured through General Assessment of Side Effects Scale (GASE) and reported spontaneously between the two treatment arms over the six week treatment period (visit 2 versus visit 4). 6. All study samples: to compare use of concomitant medication between the two treatment arms over the six week treatment period (visit 2 versus visit 4). 7. All study samples: to compare premature discontinuation (timing and reason)between the two treatment arms over the six week treatment period (visit 2 versus visit 4). 8. All study samples: comparison of the proportion of participants (EIPT vs. TAU) that is remission at visit 4. For SZ, remission is defined as meeting the PANSS modified Andreasen criteria (Low scores (≤3) P1. Delusions; P3. Hallucinatory behavior; P2. Conceptual disorganization; N1. Blunted affect; N4. Passive/apathetic social withdrawal; N6. Lack of spontaneity and flow of conversation; G5. Mannerisms/posturing; G9. Unusual thought content. For MDD/BD, remission is defined as a MADRS score ≤ 12 9. To compare changes in suicidal ideation between treatment arms. 10. SZ sample: to compare changes in PANSS subscale scores between the two treatment arms over the six-week treatment period (visit 2 versus visit 4). 11. BD study sample: To compare occurrence of (hypo)manic episode during the study between the treatment arms Trial design The clinical study is an international, multicenter controlled, randomised, open label trial, with a treatment duration of 6 weeks. Trial population The aim is to recruit 418 subjects into each of the study samples, leading to a total sample size of 1254 subjects. The study samples are: schizophrenia (schizophrenia, schizoaffective disorder or schizophreniform disorder), major depressive disorder and bipolar depressive disorder (bipolar I or II disorder currently in a depressive episode). Male and female subjects, in- and out-patients, within the age of at least 18 years old are eligible for participation. The main exclusion criteria to protect the subjects are subjects being pregnant or breastfeeding, subjects with previous failure on the early-intensified pharmacological treatments, known intolerance to any of the treatments or meeting any contraindications for the early-intensified pharmacological treatments. Interventions Per study sample (SZ, MDD, BD), subjects are randomised to treatment as usual (second-line treatment) or to the early-intensified pharmacological treatment (third-line treatment). Treatment per group per study sample can be found below: SZ sample: Treatment as Usual (TAU): Switch to second line antipsychotic Early-Intensified Pharmacological Treatment (EIPT): Switch to clozapine MDD sample: Treatment as Usual (TAU): Switch to second-line antidepressant Early-Intensified Pharmacological Treatment (EIPT): Oral antidepressant plus esketamine nasal spray or esketamine IV or ketamine IV BD sample: Treatment as Usual (TAU): Switch to quetiapine plus lithium or valproate acid Early-Intensified Pharmacological Treatment (EIPT): Switch to: 1. one of the following: escitalopram, sertraline, bupropion or venlafaxine plus 2. two of the following: lithium, valproate acid or quetiapine Ethical considerations relating to the clinical trial including the expected benefit to the individual subject or group of subjects represented by the trial subjects as well as the nature and extent of burden and risks All medications studied in the current trial are widely used (alone or in combination) in clinical practice and the risks for side effects are well established. In the current study, clinical practice is mimicked as much as possible to maximize generalizability and for feasibility purposes. To this end, Summaries of Product Characteristics (SmPCs) are followed with regards to contraindications (implemented as exclusion criterion), safety measures and allowed combinations with other medications. Site visits and assessments are kept to a minimum to keep subject burden at an acceptable level, while meeting the objectives of the study. Blood samples are only collected when subjects provide consent; safety measures are performed as part of clinical routine. Overall, the risks are similar to daily clinical practice; the only difference relative to clinical practice is the application of early-intensified pharmacological treatment earlier in the illness. However, these intense treatment options are also commonly prescribed by clinicians. There are no indications in existing literature that the earlier introduction of these medications poses a safety risk. A benefit of the study is that if it indeed turns out that the early-intensified pharmacological treatment is associated with more symptom improvement compared to treatment as usual, treatment guidelines may be changed accordingly and early-intensified pharmacological treatment becomes available earlier in the illness course, as second-line treatment. This would mean that future subjects have to go through less trial and error, which results in a reduced burden for subjects as well as lower societal and healthcare costs. IMPORTANT: the study was submitted to the European suthorities and they requested to split this study into 3 studies (1 for each diagnostic category). We have done this and created 3 new ClinicalTrials.gov studies as well. The numbers are NCT05958875 (SZ substudy), NCT05973786 (BD substudy) and NCT05973851 (MDD substudy). The site in the UK (London) followed the advice and will submit 3 separate protocols. However, Israel already submitted this as one protocol. Therefore, we keep this clinicaltrials.gov number for Israel.