The study was a randomized, double-blind, placebo-controlled, multi-center, interventional, prospective clinical study conducted at two clinical sites in India, viz; KVTR Ayurvedic College, Boradi, Dhule and D.Y. Patil deemed to be University School of Ayurveda, Sector – 7, Nerul, Navi Mumbai, Maharashtra.
Ethical approvals from Institutional ethics committees of all study centers were obtained. The study was registered on Clinical Trials Registry India (CTRI) vide registration numberCTRI/2022/07/043753 registered on 6th July 2022.
- Enrolment of participants:
Participants having a history of stress and insomnia attending the outpatient department of the study centers were considered for the study. The study was carried out and reported adhering to CONSORT statement. (Figure 1)
The total duration of treatment was 1 month (30 days). Patients were asked to visit study site every 15thday for 1month (30 days).
- Primary and secondary Outcomes:
The primary Outcomes of the study were to assess the change in stress using the perceived stress scale (PSS) from baseline to end of the study visit and between the two groups and Change in Patient-reported total sleep time (as per Subject diary) from baseline to end of the study visit and between the two groups.
The secondary Outcomes of the study were to assess the change in general psychological health using Short General Health Questionnaire (GHQ-12) from baseline to end of the study visit and between the two groups, change in sleep efficiency (Total sleep time/ time in bed*100) derived from subject diary from baseline to end of the study visit and between the two groups, change in Patient-reported time to sleep onset (as per subject diary) from baseline to end of the study visit and between groups, change in Patient-reported number of awakenings (as per subject diary) from baseline to end of the study visit and between the two groups, change in Patient-reported wake time after sleep onset [Wake Time After Sleep Onset (WASO) is defined as the total awakening time from falling asleep to final awakening was subjectively determined based on the Subject diary)] from baseline to end of the study visit and between the two groups, change in the severity of insomnia using Insomnia Severity Index from baseline to end of the study visit and between the two study groups, post study change in serum cortisol (morning) level between the two study groups, change in daytime fatigue using Fatigue Severity Scale (FSS) from baseline to end of the study visit and between groups, change in daytime mood, ability to function at work, concentration and memory on a graded scale from baseline to end of the study visit and between the two study groups, change in quality of sleep using Pittsburgh Sleep Quality Index (PSQI) from baseline to end of the study visit and between the two study groups, assessment of requirement of rescue medications (sedatives) from baseline to end of the study and between the two study groups, assessment of adverse events and vitals including blood pressure, pulse rate, respiration rate and body temperature from baseline to end of the study visit and between the two study groups, assessment of safety by assessing safety lab parameters including CBC, Liver function tests,Renal function tests, Lipid Profile and Fasting Blood Sugar level, global assessment for overall change by participants and by physician at the end of the study and assessment of post study tolerability of study product by participants and physician.
Selection of Participants:
Inclusion criteria: Literate male & female subjects of age 18 to 55 years (both inclusive) who perceived themselves to be under stress and had a score between 14 - 24 on the Perceived Stress Scale (PSS) with an insomnia severity score of more than 7 and 21 on insomnia severity index and who were willing to follow the procedures as per the study protocol and voluntarily give informed consent were enrolled in the study.
Exclusion criteria: Subjects suffering from any chronic physical, hormonal, or psychiatric illness, using oral or systemic contraceptive medications, with uncontrolled diabetes and hypertension. subjects with substance dependence [taking prohibited medications like opium, cannabis methamphetamines, etc], chronic alcoholics, and habitual tobacco chewers, known cases of severe/chronic hepatic or renal disease, known subjects of any active malignancy, subjects giving a history of significant cardiovascular events <12 weeks prior to recruitment, subjects having known chronic, contagious infectious diseases, such as active tuberculosis, Hepatitis B or C, or HIV, known cases of active metabolic or gastrointestinal diseases that may interfere with nutrient absorption, metabolism, or excretion, excluding diabetes, subjects using any other investigational study product within 1 month prior to recruitment or subjects currentlyparticipatingin anyother clinical study, known hypersensitivity to any of the ingredients used in study products, pregnant and lactating females were excluded from the study. Other conditions, which in the opinion of the investigators, made subjects unsuitable for enrolment or could have interfered with his/her participation in, and completion of the study were also excluded from the study.
A total of 65 participants were screened in the study and all of them were recruited and randomized into two groups (32 in the Passiflora group and 33 in the Placebo group) as there were no screen failures. All 65 participants completed the study (32 in the Passiflora group and 33 in the Placebo group) as there were no dropouts.
As per the computer-generated randomization list, participants were randomized either to the Passiflora incarnata (Aerial Parts) Extract group or the Placebo group in a 1:1 ratio. Subjects were asked to take a given product in a dose of 600 mg at bedtime with water for 30 days
Product Name: Passiflora incarnata (Passion Flower) Extract Capsule
- a) Passiflora incarnata- Extract (Flower and aerial parts) - 600 mg each.
- b) Placebo Capsules were made using Microcrystalline Cellulose filled in similar looking capsules as Passiflora incarnata Capsules
- Dosage: As per computer generated randomization list, participants were randomized either to Passiflora incarnata (aerial parts) Extract group or placebo group in 1:1 ratio. Dose of Passiflora extract was 600 mg at bed time with water for 30 days.
Assessment Parameters:
- Efficacy Parameters: The study involved the use of laboratory parameters and various scales for the assessment of symptoms, overall change, and safety. The investigator assisted /explained /guided/helped the subject in filling up the scores in these scales wherever required.
1.1 Assessment of change in stress using the perceived stress scale (PSS):
The perceived Stress Scale (PSS) is the most widely used psychological instrument for measuring perception of stress. It is a measure of the degree to which situations in one’s life are appraised as stressful. Items are designed to tap into how unpredictable, uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about current levels of experienced stress.The questions in the PSS ask about feelings and thoughts during the last visit. In each case, respondents were asked how often they felt a certain way. PSS scores were obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1 & 4 = 0) to the four positively stated items (items 4, 5, 7, & 8) and then summing across all scale items.
1.2 Assessment of change in Subject-reported total sleep time (as per Subject diary):
A daily diary card was given to the subjects to record total sleep time. Subjects reported daily total sleep time (as per the Subject diary). Changes observed in the subject’s average reported total sleep time (as per patient diary) on daily basis over 15 days were compared to baseline visits and between the two groups.
1.3 Assessment of change in general psychological health using Short General Health Questionnaire (GHQ-12):
The General Health Questionnaire (GHQ-12) consists of 12 items, each assessing the severity of a mental problem over the past few weeks using a 4-point scale (from 0 to 3). The score is used to generate a total score ranging from 0 to 36, with higher scores indicating worse conditions. Assessment of general psychological health using Short General Health Questionnaire (GHQ-12) was done on baseline visit, visit 1 (day 15) and visit 2 (Day 30). Changes observed in general psychological health using Short General Health Questionnaire (GHQ-12) on Visit 1(Day 15) and Visit 2(Day 30) were compared to Baseline Visit and between the two groups.
1.4Assessment of change in sleep efficiency (Total sleep time/ time in bed*100):
Sleep efficiency was defined as total sleep time/ time in bed*100. Subjects were given daily diary card to record sleep efficiency on baseline visit, day 15 and day 30. Changes observed in average sleep efficiency on daily basis over 15 days were compared to baseline visit and between the two groups.
1.5 Assessment of change inpatient-reported time to sleep onset (as per subject diary): Daily diary cards were given to the subjects to record time to sleep onset on baseline visit, day 15 and day 30. Changes observed in average time to sleep onset on daily basis over 15 days was be compared to baseline visit and between the two groups.
1.6 Assessment of change in patient reported number of awakenings:
Subjects were given daily diary card to record number of awakenings on baseline visit, day 15 and day 30. Changes observed in patient reported average number of awakenings on daily basis over 15 days was compared to Baseline Visit and between the two groups.
1.7Assessment of change in patient -reported wake time after sleep onset:
Wake Time after Sleep Onset (WASO) is defined, as total awakening time from falling asleep to final awakening. This was determined based on Subject diary. Average WASO was evaluated on baseline visit and further on daily basis over 15 days. Changes observed in average WASO on daily basis over 15 days was compared to baseline visit and between the two groups.
1.8 Assessment of change in severity of insomnia using Insomnia Severity Index:
The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. Last 2 weeks severity of insomnia problem was evaluated using this index. The severity of insomnia is graded as 0–7 = No clinically significant insomnia, 8–14 = Sub threshold insomnia, 15–21 = Clinical insomnia (moderate severity) and 22–28 = Clinical insomnia (severe). Severity of Insomnia was evaluated on Baseline visit, visit 1 (day 15) and Visit 2 (day 30). Changes observed in Insomnia Severity Index on day 15 and day 30 was compared to baseline visit and between the two study groups.
1.9 Assessment of post study change in serum cortisol (morning) levels:
Morning Serum Cortisol level was checked on screening visit and at visit 2 i.e. end of study visit (Day 30). Changes observed in morning serum Cortisol level on visit 2 (Day 30) was compared to baseline visit and between the two study groups.
1.10 Assessment of change in daytime fatigue using Fatigue Severity Scale (FSS):
The fatigue severity scale (appendix F) is a method of evaluating the impact of fatigue. The FSS questionnaire contains nine statements that rate the severity of fatigue. Each question is given number from 1 to 7, subject needs to circle the number that reflects his/her condition during the past week and the extent to which he/she agree or disagree that the statement applies to him/her. Severity of fatigue was evaluated on baseline visit, visit 1 (day 15) and visit 2 (day 30). Changes observed in fatigue severity scale on day 15 and days 30 were compared to baseline visit and between the two study groups.
1.11 Assessment of requirement of rescue medications (sedatives):
As rescue medications, subjects were allowed to use sedatives during the study period if required. Record of number of sedatives and their dosage used by subject was recorded in the case record form. Number of subjects required rescue medication (sedatives) were calculated at the end of the study and were compared between the two groups.
1.12 Assessment of change in daytime mood, ability to function at work, concentration and memory on a graded scale:
Subjects were evaluated to check whether sleep problem interferes with his/her daily functioning such as daytime mood, ability to function at work, concentration, and memory on graded scale (0= Not at all Interfering, 1= A Little, 2= somewhat, 3= Much, 4= Very Much Interfering). Assessment of Daytime mood, ability to function at work, concentration and memory was done on baseline visit, visit 1 (day 15) and visit 2 (day 30). Changes observed in Daytime mood, ability to function at work, concentration, and memory on day 15 and day 30 was compared to baseline visit and between the two study groups.
1.13 Assessment of change in quality of sleep using Pittsburgh Sleep Quality Index (PSQI):
Pittsburgh Sleep Quality Index (PSQI) contains 19 self-rated questions and 5 questions rated by the bed partner or roommate. Only self-rated questions are included in the scoring. The 19 self- rated items are combined to form seven component scores each of which has a range of 0-3 points. In all cases, a score of 0 indicates no difficulty, while a score of 3 indicates severe difficulty. The seven component scores are then added to yield one global score with a range of 0- 21 points. O indicating no difficulty and 21 indicating severe difficulties in all areas. The Pittsburgh Sleep Quality Index (PSQI) (Appendix E) was evaluated on baseline visit, visit 1 (day 15) and visit 2 (day 30). Changes observed in quality of sleep using Pittsburgh Sleep Quality Index (PSQI) on day 15 and days 30 were compared to baseline visit and between the two study groups.
1.14 Global assessment for overall change by participants and by physician:
The CGI- I is a global assessment scale used by physician/investigator to provide a brief, stand- alone assessment of the Subject’s global functioning prior to and after initiating a study medication, including a knowledge of the Subject’s history, psychosocial circumstances, symptoms, behaviour, and the impact of the symptoms on the Subject’s ability to function. CGI-I was recorded/ filled at the end of the study. The CGI is rated on a 7-point scale, with the severity of illness scale using a range of responses from 1 (very much improved) to 7 (very much worse). Each component of the CGI is rated separately; the instrument does not yield a global score. At the End of Study, Investigator and participant rated the total change, whether or not, it is entirely due to product compared to participant’s condition at admission to the study and how much has he/she changed.
Table 1: Global assessment for overall change by participants and by physician at the end of the study
0 = Not assessed
|
4 = No change
|
1 = Very much improved
|
5 = Minimally worse
|
2 = Much improved
|
6 = Much worse
|
3 = Minimally improved
|
7= Very much worse
|
1.15 Assessment of tolerability of study products by investigator and participants: Evaluation of adverse events/adverse drug reactions at every follow up visit and establishment of their relationship with the study product was assessed. The tolerability of study productswas evaluated on following safety grades as; 1 = excellent overall safety (no adverse event/s reported); 2 = good overall safety (mild adverse events (s) reported which subside with or without medication); 3 = fair overall safety (moderate to severe adverse event(s) reported which subside with or without medication and do not necessitate stoppage of study products); and 4 = poor overall safety (severe or serious adverse event(s) which necessitate stoppage of study.
- Assessment of Safety
Safetywas assessed byclinical reviewof allsafetyparameters, includingthe following:
- Adverseevent reporting,as applicable
- Vital signs including allergicreactionse
- Lab parameters include CBC, Liver function tests, Renal function tests, Lipid Profile and Blood sugar fasting.
Safety variables were listed individually for detailed clinical review, when needed. Additional tables shall summarize adverse events by severity and relationship to study product as well as leading to SAEs and withdrawal of the subjects from the trial.
Plan for Statistical Analysis: The study data generated and collected was put to statistical analysis to reach to the final results and conclusions. The demographic data were presented in tables and graphs.The data obtained in the studies were subjected to tests of significance. The data on discrete variables has been represented as actual frequencies, i. e. n (%). The data on continuous variables has been represented as mean (± SD). GraphPad InStat Version 3.6 (www.graphpad.com) software was used for statistical analysis of data. P value < 0.05 was considered significant.
A total of 65 subjects were screened in the study of which 65 subjects were considered as completers. All cases that completed the study as per the protocol were considered as “Per Protocol Population”. Also, all the cases who took at least one dose of the study drug were considered as “Safety population” and were evaluated.