Study design
This is a multicentre, randomized and controlled trial to evaluate the efficacy and safety of JTW in patients with depression. A flowchart for the study is shown in Fig 1. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist is shown in Supplemental file 1.
Qualified patients were randomly divided into the treatment and control groups with a ratio of 1:1, respectively. Recruited patients received JTW plus fluoxetine or fluoxetine alone once per day for eight weeks. After the 8-week treatment period, the patients were then followed up for four weeks. The outcome measures included the Hamilton Depression (HAMD) Rating Scale scores, TCM syndrome integral scale scores, Wisconsin Card Sorting Test (WCST), blood metabonomics, urine metabonomics and brain structure and function on functional magnetic resonance imaging (fMRI).
Participants
Inclusion criteria
To participate in the study, patients should meet the following criteria:
(1) Conform to depression diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders’ American psychiatric diagnosis standard’, 4th Edition (DSM-IV);
(2) Conform to the diagnostic criteria of TCM syndrome of disharmony between the heart and kidney;
(3) HAMD 24-item score of ≥20 points and <35 points;
(4) Age, 18–65 years;
(5) Total HAMA score of ≤21 points, depressed mood (item 6) score ≥2 points and anxious mood (item 1) score <3 points;
(6) Those who have not taken antidepressants or have taken them but have stopped taking them for two weeks;
(7) Sign the informed consent form.
Exclusion criteria
Patients with the following criteria will be excluded:
(1) Secondary to other mental or physical illness and depression with severe psychotic symptoms;
(2) Severe anxiety (HAMA total score >21 points);
(3) Allergic constitution or previous research on drug allergy;
(4) Suicidal thoughts;
(5) Bipolar disorder, refractory depression;
(6) Intracranial cerebrovascular disease, neurodegenerative diseases, intracranial tumour, high blood pressure, or diabetes, leading to brain vascular distribution or abnormal blood flow of systemic disorders;
(7) Serious diseases of other systems or severe heart, liver and renal insufficiency;
(8) Glaucoma and epilepsy;
(9) Pregnancy or lactation or quasi-pregnancy;
(10) Positive urine pregnancy test in women of childbearing age;
(11) Contraindications on MR inspection and those who cannot complete MR scan or cannot adapt to the environment and noise of the MRI machine;
(12) Participation in or planning to participate in other observational drug studies within 30 days;
(13) Poor compliance or inability to be interviewed regularly.
Withdrawal and discontinuation
During the trial, if they had any adverse reactions, the participants could stop the trial at any time. No strategy was adopted to improve adherence to the study drug. During the trial, the drugs related to depression were banned, while those not related to depression could be used. Patients with severe illnesses could withdraw the trial and take the appropriate treatment.
Ethics and recruitment
All patients signed the informed consent forms prior to inclusion, which included the research protocols, the benefits and risks, confidentiality, costs, and voluntary principles. The study has been approved by the Ethics Committee of Tianjin University of Traditional Chinese Medicine. If the protocol requires modification, ethical approval will be reapplied. Any revisions in the study protocol will be submitted to the Ethics Committee and the National Natural Science Foundation of China.
Through advertisements and referrals, a total of 40 qualified patients were recruited from two research centres: the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine and the Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital.
Sample size
In reference to the relevant literature, the specific process to estimate the sample content of each group was as follows[17–19]. The sample size estimation formula for clinical trials is written as
where n is the number of cases required for each group, μ1 and μ2 are the expected averages of the treatment and control groups, respectively, and σ2 is the standard deviation of the control group, α = 0.05, β = 0.1, the output ƒ(α, β) of the look-up table is 10.5. Taking the score of HAMD scale after treatment as the main evaluation index, through consulting previous literatures [20–22] and taking the average, μ1 = 9.39, μ2 = 12.49, and σ2 of the control group is 2.97, the above research data were substituted into the above formula to calculate that n is 19.2, and the sample size of both the treatment and control groups was 20 cases with total 40 cases.
Randomization
Treatment allocation was done when participants met the inclusion criteria and signed the informed consent form. Patients were randomly divided into two groups, the treatment and control groups, with a 1:1 distribution ratio according to the random numbers generated by IBM SPSS Statistics software version 19.0. The recruiter obtained a sequence number from the distributor when a patient was eligible for the trial. The subjects’ allocation was concealed inside the sealed, opaque and serialized envelopes to avoid the influence from the biases of the researchers, who took responsibility of recruitment and treatment assessment. To ensure strict confidentiality, the envelopes were not transparent, even under intense light. The envelopes would be opened, and the assigned intervention type would be recognized only after each subject finished all baseline evaluations.
Blinding methods
This study was a single-blind trial. The evaluators knew the group allocations and the treatment protocol for better operation, while the subjects and statisticians were unaware of the group allocations in order not to be disturbed by subjective factors. The treatment assignments were also kept secret for the principal investigator, statistician and outcome evaluator throughout the trial before locking the database.
Interventions
Patients randomized to the treatment group were administered one bag of JTW granules (15 g C.chinensis Franch and 2g Ci.cassia Presl) dissolved in warm water plus fluoxetine 20 mg once daily for eight weeks. Patients in the control group received 20 mg fluoxetine once daily for eight weeks. JTW granules and fluoxetine were manufactured by Beijing Tcmages Pharmaceutical Co., Ltd and Eli Lilly Company, respectively.