Real-Time Evaluation of Emerging Treatments for Suicide Risk

减少自杀行为的风险是公共卫生的当务之急。有证据表明静脉注射氯胺酮 输液可迅速减轻抑郁症状和自杀意念导致的一系列小临床症状 试验，以及增加用于治疗严重抑郁症的非标签使用。关于以下影响的调查结果 氯胺酮输注治疗自杀念头激励了旨在模拟自杀念头的新药的开发 氯胺酮的谷氨酸受体调节剂活性。其中两种产品(鼻腔内注射埃斯氯胺酮和 氯胺酮输注后的顺序治疗(卢拉西酮加d-环丝氨酸)已被指定为 FDA作为潜在的突破性治疗方法，预计将迅速获得批准。在此之前完成的临床试验 许可很可能会证明这些新产品(以及随后的类似产品)迅速减少 抑郁和自杀意念的症状--导致对这些特定适应症的认可。预先审批 然而，试验不会解决患者、提供者和卫生系统最感兴趣的问题：将 短期内自杀意念的减少实际上会转化为自杀行为风险的降低？热情 对新的氯胺酮类药物潜在益处的担忧因对不良反应的担忧而有所缓和， 容忍度/反弹，以及误用的可能性。静脉输注氯胺酮可沉淀解离或 精神症状，氯胺酮有很长的娱乐性滥用历史。在与我们的讨论中 一位医学主任指出，卫生系统领导人对这项拟议研究的看法是，“埃斯氯胺酮可能 成为下一个格列卫或下一个奥施康定。我们最好找出是哪一家。 我们建议使用创新的方法来快速评估这些预期的新技术的效果 门诊难治性抑郁症患者自杀行为风险的治疗。这项工作将 充分利用我们网络的独特功能，包括全面的纵向数据基础设施、 患者报告结果数据的常规收集，可计算的EHR表型的广泛库 关于自杀行为的风险因素和结果，机器学习模型可以准确地预测自杀 行为，以及对罕见暴露和结果进行因果推断的分析方法。拟议的研究 将使用来自三个MHRN保健系统的数据： 1)快速评估新批准的治疗难治性抑郁症的使用模式 2)提取关于接受和不接受患者的综合预测因素和结果数据 可能降低自杀行为风险的新兴治疗方法 3)开发和实施用于加权倾向得分分析的变量选择方法 4)使用这些数据和方法来评估新兴治疗方法对自杀死亡、自杀风险的影响 在作出治疗决定后90天内尝试或精神科住院治疗。 5)根据治疗前自杀行为的风险检查治疗效果的异质性

Reducing risk of suicidal behavior is an urgent public health priority. Evidence that intravenous ketamine infusion could rapidly reduce symptoms of depression and suicidal ideation led to a series of small clinical trials, as well as increasing off-label use for treatment of severe depression. Findings regarding effects of ketamine infusion on suicidal ideation have inspired development of new medications designed to mimic ketamine's glutamate receptor modulator activity. Two of those products (intranasal esketamine and a sequential treatment of ketamine infusion followed by lurasidone plus d-cycloserine) have been designated by the FDA as potential breakthrough treatments, with rapid approval expected. Clinical trials completed prior to licensure will likely demonstrate that these new products (and similar products to follow) rapidly reduce symptoms of depression and suicidal ideation – leading to approval for those specific indications. Pre-approval trials, however, will not address questions of greatest interest to patients, providers, and health systems: Will short-term reductions in suicidal ideation actually translate to reduced risk of suicidal behavior? Enthusiasm regarding the potential benefits of new ketamine-like drugs is tempered by concerns regarding adverse effects, tolerance/rebound, and potential for misuse. Intravenous ketamine infusion can precipitate dissociative or psychotic symptoms, and ketamine has a long history of recreational misuse. During our discussions with health system leaders regarding this proposed research, one medical director pointed out, “Esketamine could be the next Gleevec or the next Oxycontin. We had better find out which.” We propose to use innovative methods to rapidly evaluate the effect of these anticipated new treatments on risk of suicidal behavior among outpatients with treatment-resistant depression. This work will take advantage of unique capabilities of our network, including comprehensive longitudinal data infrastructure, routine collection of patient-reported outcome data, an extensive library of computable EHR phenotypes regarding suicidal behavior risk factors and outcomes, machine-learning models to accurately predict suicidal behavior, and analytic methods for causal inference for rare exposures and outcomes. The proposed research will use data from three MHRN health systems to: 1) Rapidly evaluate patterns of use of newly approved therapies for treatment-resistant depression 2) Extract comprehensive predictor and outcome data regarding patients receiving and not receiving emerging treatments with potential to reduce risk of suicidal behavior 3) Develop and implement variable selection approaches for weighted propensity score analyses 4) Use these data and methods to evaluate impact of emerging treatments on risk of suicide death, suicide attempt, or psychiatric hospitalization within 90 days of a treatment decision. 5) Examine heterogeneity of treatment effects according to pre-treatment risk of suicidal behavior