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Kitay BM, Murphy E, Macaluso M, Corlett PR, Hershenberg R, Joormann J, Martinez-Kaigi V, Nikayin S, Rhee TG, Sanacora G, Shelton RC, Thase ME, Wilkinson ST. Cognitive behavioral therapy following esketamine for major depression and suicidal ideation for relapse prevention: The CBT-ENDURE randomized clinical trial study protocol. Psychiatry Res 2023; 330:115585. [PMID: 37935086 DOI: 10.1016/j.psychres.2023.115585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/26/2023] [Accepted: 10/28/2023] [Indexed: 11/09/2023]
Abstract
In 2020, esketamine received a supplemental indication as a therapy for major depression with suicidal ideation (MDSI), based on protocols enrolling hospitalized patients. Given the high risk of suicide following hospital discharge and the high relapse rates following discontinuation of esketamine, the optimal long-term treatment approach remains unclear. Cognitive behavioral therapy (CBT) is highly effective in relapse prevention and has been shown to prevent suicide attempts in high-risk populations. Here we describe the study protocol for the CBT-ENDURE trial: Cognitive Behavioral Therapy Following Esketamine for Major Depression and SUicidal Ideation for RElapse Prevention. Patients with depression (N = 100) who are admitted to hospital or are outpatients with clinically significant suicidal ideation will be enrolled in the study. All patients will receive esketamine (twice weekly for four weeks) and will be randomly assigned (1:1 ratio) to receive a 16-week course of CBT plus treatment as usual (CBT group) or treatment as usual only (TAU only group). Patients are followed for a total of 6 months. Supported under a funding announcement from NIMH to conduct safety and feasibility trials for patients at high risk for suicide, the primary outcome of the CBT-ENDURE study is feasibility (as measured by recruitment and retention), with a key secondary outcome being relapse among those who experience substantial benefit following two weeks of esketamine.
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Affiliation(s)
- Brandon M Kitay
- Department of Psychiatry, Emory University School of Medicine, United States
| | - Eva Murphy
- Department of Psychiatry, Yale School of Medicine, United States
| | - Matthew Macaluso
- Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, University of Alabama at Birmingham, 100 York St, STE 2J, New Haven, CT 06511, United States
| | - Philip R Corlett
- Department of Psychiatry, Yale School of Medicine, United States
| | - Rachel Hershenberg
- Department of Psychiatry, Emory University School of Medicine, United States
| | - Jutta Joormann
- Department of Psychology, Yale University, United States
| | | | - Sina Nikayin
- Department of Psychiatry, Yale School of Medicine, United States
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, United States; Department of Public Health Science, School of Medicine, University of Connecticut, United States
| | - Gerard Sanacora
- Department of Psychiatry, Yale School of Medicine, United States
| | - Richard C Shelton
- Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, University of Alabama at Birmingham, 100 York St, STE 2J, New Haven, CT 06511, United States
| | - Michael E Thase
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, United States
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Tabrisi R, Harun-Rashid MD, Montero J, Venizelos N, Msghina M. Clozapine but not lithium reverses aberrant tyrosine uptake in patients with bipolar disorder. Psychopharmacology (Berl) 2023; 240:1667-1676. [PMID: 37318540 PMCID: PMC10349740 DOI: 10.1007/s00213-023-06397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
RATIONALE Availability of the dopamine and noradrenaline precursor tyrosine is critical for normal functioning, and deficit in tyrosine transport across cell membrane and the blood-brain barrier has been reported in bipolar disorder and schizophrenia. Clozapine and lithium are two psychoactive agents used to treat psychosis, mood disorders and suicidal behavior, but their mechanism of action remains largely unknown. OBJECTIVE To characterize immediate and delayed differences in tyrosine uptake between healthy controls (HC) and bipolar patients (BP) and see if these differences could be normalized by either clozapine, lithium or both. A second objective was to see if clozapine and lithium have additive, antagonistic or synergistic effects in this. METHOD Fibroblasts from five HC and five BP were incubated for 5 min or 6 h with clozapine, lithium, or combination of both. Radioactive labelled tyrosine was used to quantify tyrosine membrane transport. RESULTS There was significantly reduced tyrosine uptake at baseline in BP compared to HC, a deficit that grew with increasing incubation time. Clozapine selectively increased tyrosine uptake in BP and abolished the deficit seen under baseline conditions, while lithium had no such effect. Combination treatment with clozapine and lithium was less effective than when clozapine was used alone. CONCLUSIONS There was significant deficit in tyrosine transport in BP compared to HC that was reversed by clozapine but not lithium. Clozapine was more effective when used alone than when added together with lithium. Potential clinical implications of this will be discussed.
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Affiliation(s)
- R Tabrisi
- Department of Plastic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M D Harun-Rashid
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - J Montero
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - N Venizelos
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M Msghina
- Department of Psychiatry, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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Nguyen TML, Jollant F, Tritschler L, Colle R, Corruble E, Gardier AM. Pharmacological Mechanism of Ketamine in Suicidal Behavior Based on Animal Models of Aggressiveness and Impulsivity: A Narrative Review. Pharmaceuticals (Basel) 2023; 16:ph16040634. [PMID: 37111391 PMCID: PMC10146327 DOI: 10.3390/ph16040634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Around 700,000 people die from suicide each year in the world. Approximately 90% of suicides have a history of mental illness, and more than two-thirds occur during a major depressive episode. Specific therapeutic options to manage the suicidal crisis are limited and measures to prevent acting out also remain limited. Drugs shown to reduce the risk of suicide (antidepressants, lithium, or clozapine) necessitate a long delay of onset. To date, no treatment is indicated for the treatment of suicidality. Ketamine, a glutamate NMDA receptor antagonist, is a fast-acting antidepressant with significant effects on suicidal ideation in the short term, while its effects on suicidal acts still need to be demonstrated. In the present article, we reviewed the literature on preclinical studies in order to identify the potential anti-suicidal pharmacological targets of ketamine. Impulsive-aggressive traits are one of the vulnerability factors common to suicide in patients with unipolar and bipolar depression. Preclinical studies in rodent models with impulsivity, aggressiveness, and anhedonia may help to analyze, at least in part, suicide neurobiology, as well as the beneficial effects of ketamine/esketamine on reducing suicidal ideations and preventing suicidal acts. The present review focuses on disruptions in the serotonergic system (5-HTB receptor, MAO-A enzyme), neuroinflammation, and/or the HPA axis in rodent models with an impulsive/aggressive phenotype, because these traits are critical risk factors for suicide in humans. Ketamine can modulate these endophenotypes of suicide in human as well as in animal models. The main pharmacological properties of ketamine are then summarized. Finally, numerous questions arose regarding the mechanisms by which ketamine may prevent an impulsive-aggressive phenotype in rodents and suicidal ideations in humans. Animal models of anxiety/depression are important tools to better understand the pathophysiology of depressed patients, and in helping develop novel and fast antidepressant drugs with anti-suicidal properties and clinical utility.
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Affiliation(s)
- Thi Mai Loan Nguyen
- Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, MOODS Team, F-91400 Orsay, France
| | - Fabrice Jollant
- Université Paris-Saclay, Faculté de Médecine, Inserm CESP/UMR 1018, MOODS Team, F-94270 Le Kremin-Bicêtre, France
- Service Hospitalo-Universitaire de Psychiatrie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, F-94275 Le Kremlin Bicêtre, France
- Pôle de Psychiatrie, CHU Nîmes, 30900 Nîmes, France
- Department of Psychiatry, McGill University and McGill Group for Suicide Studies, Montréal, QC H3A 0G4, Canada
| | - Laurent Tritschler
- Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, MOODS Team, F-91400 Orsay, France
| | - Romain Colle
- Université Paris-Saclay, Faculté de Médecine, Inserm CESP/UMR 1018, MOODS Team, F-94270 Le Kremin-Bicêtre, France
- Service Hospitalo-Universitaire de Psychiatrie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, F-94275 Le Kremlin Bicêtre, France
| | - Emmanuelle Corruble
- Université Paris-Saclay, Faculté de Médecine, Inserm CESP/UMR 1018, MOODS Team, F-94270 Le Kremin-Bicêtre, France
- Service Hospitalo-Universitaire de Psychiatrie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, F-94275 Le Kremlin Bicêtre, France
| | - Alain M Gardier
- Université Paris-Saclay, Faculté de Pharmacie, Inserm CESP/UMR 1018, MOODS Team, F-91400 Orsay, France
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The Downstaging Concept in Treatment-Resistant Depression: Spotlight on Ketamine. Int J Mol Sci 2022; 23:ijms232314605. [PMID: 36498934 PMCID: PMC9738502 DOI: 10.3390/ijms232314605] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022] Open
Abstract
Treatment-resistant depression is a pleomorphic phenomenon occurring in 30% of patients with depression. The chance to achieve remission decreases with every subsequent episode. It constitutes a significant part of the global disease burden, causes increased morbidity and mortality, and is associated with poor quality of life. It involves multiple difficult-to-treat episodes, with increasing resistance over time. The concept of staging captures the process of changes causing increasing treatment resistance and global worsening of functioning in all areas of life. Ketamine is a novel rapid-acting antidepressant with neuroplastic potential. Here, we argue that ketamine use as an add-on treatment of resistant major depressive disorder, based on its unique pharmacological properties, can reverse this process, give hope to patients, and prevent therapeutic nihilism.
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Hochschild A, Keilp JG, Madden SP, Burke AK, Mann JJ, Grunebaum MF. Ketamine vs midazolam: Mood improvement reduces suicidal ideation in depression. J Affect Disord 2022; 300:10-16. [PMID: 34953926 PMCID: PMC8828686 DOI: 10.1016/j.jad.2021.12.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/30/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Studies demonstrate rapid antidepressant and anti-suicidal ideation effects of subanesthetic ketamine. The specific subcomponents of depression that are most closely tied to reduction of suicidal ideation with ketamine treatment are less explored. METHODS Exploratory, post hoc analysis of data from a randomized clinical trial of ketamine vs midazolam in patients with major depressive disorder (MDD) and clinically significant suicidal ideation examined changes in factor analysis-derived symptom clusters from standard measures of depression (Hamilton Depression Rating Scale, HDRS; Beck Depression Inventory, BDI) and mood disturbance (Profile of Mood States, POMS), and their relationship to severity of suicidal ideation (Beck Scale for Suicidal Ideation; SSI). Ratings obtained before and one day after blinded intravenous infusion were decomposed into component factors or published subscales. Treatment effects on factors/subscales were compared between drugs, correlations with changes in suicidal ideation were tested, and stepwise regression was used to derive predictors of change in SSI. RESULTS Factor scores for HDRS Psychic Depression, HDRS Anxiety, BDI Subjective Depression, POMS Depression and POMS Fatigue improved more with ketamine than midazolam. Stepwise regression showed across both drugs that improvement in HDRS Psychic Depression, POMS Depression, and HDRS Anxiety predicted 51.6% of the variance in reduction of suicidal ideation. LIMITATIONS Secondary analysis of clinical trial data. CONCLUSIONS Ketamine's rapid effects on suicidal ideation appear to be mostly a function of its effects on core mood and anxiety symptoms of MDD, with comparatively little contribution from neurovegetative symptoms with the potential exception of vigor/fatigue. TRIAL REGISTRATION Data used in this secondary analysis came from ClinicalTrials.gov identifier: NCT01700829.
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Affiliation(s)
| | - John G. Keilp
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - Sean P. Madden
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - Ainsley K. Burke
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - J. John Mann
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
| | - Michael F. Grunebaum
- Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute, and Columbia University Irving Medical Center, New York, NY
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Hippocampal neuropathology in suicide: Gaps in our knowledge and opportunities for a breakthrough. Neurosci Biobehav Rev 2021; 132:542-552. [PMID: 34906612 DOI: 10.1016/j.neubiorev.2021.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 12/03/2021] [Accepted: 12/10/2021] [Indexed: 01/27/2023]
Abstract
Suicide is a major global hazard. There is a need for increasing suicide awareness and effective and evidence-based interventions, targeting both suicidal ideation and conduct. However, anti-suicide pharmacological effects are unsatisfactory. The human hippocampus is vulnerable to neuropsychiatric damages and subsequently releases psychobiological signals. Human hippocampal studies of suicide completers have shown mechanistic changes in neurobiology, which, however, could not reflect the neuropathological 'fingerprints' of fatal suicide ideations and suicide attempts. In this review, we provide several leading theories of suicide, including the serotoninergic system, Wnt pathway and brain-derived neurotrophic factor/tropomyosin receptor kinase B signalling, and discuss the evidence for their roles in suicide and treatment. Moreover, the cognitive dysfunctions associated with suicide risk are discussed, as well as the novel evidence on cognitive therapies that decrease suicidal ideation. We highlight the need to apply multi-omics techniques (including single-nucleus RNA sequencing and mass spectrometry histochemistry) on hippocampal samples from donors who died by suicide or legal euthanasia, to clarify the aetiology of suicide and propose novel therapeutic strategies.
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7
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Zhang N, Yao L, Wang P, Liu Z. Immunoregulation and antidepressant effect of ketamine. Transl Neurosci 2021; 12:218-236. [PMID: 34079622 PMCID: PMC8155793 DOI: 10.1515/tnsci-2020-0167] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
Major depressive disorder (MDD) is a common mental health disorder that brings severe disease burden worldwide. Traditional antidepressants are mainly targeted at monoamine neurotransmitters, with low remission rates and high recurrence rates. Ketamine is a noncompetitive glutamate N-methyl-d-aspartate receptor (NMDAR) antagonist, and its rapid and powerful antidepressant effects have come to light. Its antidepressant mechanism is still unclarified. Research found that ketamine had not only antagonistic effect on NMDAR but also strong immunomodulatory effect, both of which were closely related to the pathophysiology of MDD. Although there are many related studies, they are relatively heterogeneous. Therefore, this review mainly describes the immune mechanisms involved in MDD and how ketamine plays an antidepressant role by regulating peripheral and central immune system, including peripheral inflammatory cytokines, central microglia, and astrocytes. This review summarizes the related research, finds out the deficiencies of current research, and provides ideas for future research and the development of novel antidepressants.
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Affiliation(s)
- Nan Zhang
- Department of Psychiatry, Renmin Hospital of Wuhan University, Jiefang Rd. 238, 430060, Wuhan, China
| | - Lihua Yao
- Department of Psychiatry, Renmin Hospital of Wuhan University, Jiefang Rd. 238, 430060, Wuhan, China
| | - Peilin Wang
- Department of Psychiatry, Renmin Hospital of Wuhan University, Jiefang Rd. 238, 430060, Wuhan, China
| | - Zhongchun Liu
- Department of Psychiatry, Renmin Hospital of Wuhan University, Jiefang Rd. 238, 430060, Wuhan, China
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Wasserman D, Iosue M, Wuestefeld A, Carli V. Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic. World Psychiatry 2020; 19:294-306. [PMID: 32931107 PMCID: PMC7491639 DOI: 10.1002/wps.20801] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.
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Affiliation(s)
- Danuta Wasserman
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
| | - Miriam Iosue
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
| | - Anika Wuestefeld
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
| | - Vladimir Carli
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
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Schmaal L, van Harmelen AL, Chatzi V, Lippard ETC, Toenders YJ, Averill LA, Mazure CM, Blumberg HP. Imaging suicidal thoughts and behaviors: a comprehensive review of 2 decades of neuroimaging studies. Mol Psychiatry 2020; 25:408-427. [PMID: 31787757 PMCID: PMC6974434 DOI: 10.1038/s41380-019-0587-x] [Citation(s) in RCA: 177] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 10/21/2019] [Accepted: 10/29/2019] [Indexed: 01/06/2023]
Abstract
Identifying brain alterations that contribute to suicidal thoughts and behaviors (STBs) are important to develop more targeted and effective strategies to prevent suicide. In the last decade, and especially in the last 5 years, there has been exponential growth in the number of neuroimaging studies reporting structural and functional brain circuitry correlates of STBs. Within this narrative review, we conducted a comprehensive review of neuroimaging studies of STBs published to date and summarize the progress achieved on elucidating neurobiological substrates of STBs, with a focus on converging findings across studies. We review neuroimaging evidence across differing mental disorders for structural, functional, and molecular alterations in association with STBs, which converges particularly in regions of brain systems that subserve emotion and impulse regulation including the ventral prefrontal cortex (VPFC) and dorsal PFC (DPFC), insula and their mesial temporal, striatal and posterior connection sites, as well as in the connections between these brain areas. The reviewed literature suggests that impairments in medial and lateral VPFC regions and their connections may be important in the excessive negative and blunted positive internal states that can stimulate suicidal ideation, and that impairments in a DPFC and inferior frontal gyrus (IFG) system may be important in suicide attempt behaviors. A combination of VPFC and DPFC system disturbances may lead to very high risk circumstances in which suicidal ideation is converted to lethal actions via decreased top-down inhibition of behavior and/or maladaptive, inflexible decision-making and planning. The dorsal anterior cingulate cortex and insula may play important roles in switching between these VPFC and DPFC systems, which may contribute to the transition from suicide thoughts to behaviors. Future neuroimaging research of larger sample sizes, including global efforts, longitudinal designs, and careful consideration of developmental stages, and sex and gender, will facilitate more effectively targeted preventions and interventions to reduce loss of life to suicide.
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Affiliation(s)
- Lianne Schmaal
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | | | - Vasiliki Chatzi
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | - Yara J Toenders
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - Lynnette A Averill
- Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Veterans Affairs National Center for PTSD, Clinical Neurosciences Division, West Haven, CT, USA
| | - Carolyn M Mazure
- Psychiatry and Women's Health Research at Yale, Yale School of Medicine, New Haven, CT, USA
| | - Hilary P Blumberg
- Psychiatry, Radiology and Biomedical Imaging, Child Study Center, Yale School of Medicine, New Haven, CT, USA.
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Fehling KB, Selby EA. Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements. Front Psychiatry 2020; 11:499980. [PMID: 33613330 PMCID: PMC7891495 DOI: 10.3389/fpsyt.2020.499980] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/29/2020] [Indexed: 02/06/2023] Open
Abstract
Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.
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Affiliation(s)
| | - Edward A Selby
- Department of Psychology, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
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11
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Rengasamy M, Hsiung K, Price RB. Infusing hope into the treatment of suicidality: A review of ketamine's effects on suicidality. Curr Behav Neurosci Rep 2019; 6:166-176. [PMID: 33457182 PMCID: PMC7809881 DOI: 10.1007/s40473-019-00184-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Given recent increases in rates of suicide and lack of rapid treatments for suicidality, ketamine has been identified as a potential fast-acting anti-suicidal treatment. Our review seeks to describe the effects of ketamine on suicidality, given the growing literature on the use of ketamine in reducing suicidality. We examine open-label studies and randomized controlled trials evaluating treatment of suicidality with ketamine. Furthermore, our manuscript identifies potential mechanisms of ketamine's effects on suicidality. RECENT FINDINGS Based on existing RCTs, ketamine appears to have rapid anti-suicidal effects, with most literature studying such effects in timeframes less than one week. Although still in the early stages of research, mechanisms of ketamine include modulation of molecular, inflammatory, neural, cognitive, and behavioral processes. SUMMARY Thus, ketamine appears to be a promising treatment for suicidality, but requires larger scale and more robust RCTs to confirm the potential use of this agent in clinical settings.
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Affiliation(s)
- Manivel Rengasamy
- Department of Psychiatry, University of Pittsburgh School
of Medicine, Pittsburgh, PA
| | | | - Rebecca B. Price
- Department of Psychiatry, University of Pittsburgh School
of Medicine, Pittsburgh, PA
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12
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Croarkin PE, Nakonezny PA, Deng ZD, Romanowicz M, Vande Voort JL, Camsari DD, Schak KM, Port JD, Lewis CP. High-frequency repetitive TMS for suicidal ideation in adolescents with depression. J Affect Disord 2018; 239:282-290. [PMID: 30031247 PMCID: PMC6431788 DOI: 10.1016/j.jad.2018.06.048] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/27/2018] [Accepted: 06/26/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND This exploratory study sought to examine the effect of an acute course of high-frequency repetitive TMS on suicidal ideation in adolescents. METHODS Data were pooled from 3 prior protocols providing a 30-session course of open-label TMS treatment for adolescents with treatment-resistant depression. All participants (n = 19) were outpatients taking antidepressant medication, with TMS provided as adjunctive treatment. Suicidality was assessed at baseline, after 10 treatments, after 20 treatments, and after 30 treatments. Outcome measures of suicidal ideation included the Columbia Suicide Severity Rating Scale (C-SSRS) "Intensity of Ideation" subscale and Item 13 "Suicidality" on the Children's Depression Rating Scale, Revised (CDRS-R). RESULTS The predicted odds of suicidal ideation (CDRS-R Item 13 and C-SSRS Intensity of Ideation subscale) significantly decreased over 6 weeks of acute TMS treatment without adjustments for illness (depression) severity. However, the magnitude of the decrease in the predicted odds of suicidal ideation across 6 weeks of treatment was attenuated and rendered non-significant in subsequent analyses that adjusted for illness (depression) severity. LIMITATIONS This was an exploratory study with a small sample size and no sham control. Regulatory and ethical barriers constrained enrollment of adolescents with severe suicidality. CONCLUSIONS The present findings suggest that open-label TMS mitigated suicidal ideation in adolescents through the treatment and improvement of depressive symptom severity. Although caution is warranted in the interpretation of these results, the findings can inform the design and execution of future interventional trials targeting suicidal ideation in adolescents.
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Affiliation(s)
- Paul E. Croarkin
- Mayo Clinic Depression Center, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA,Corresponding Author: Paul E. Croarkin DO, MS, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, Tel: (507) 293-2557, Fax: (507) 284-3933,
| | - Paul A. Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA,Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zhi-De Deng
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Magdalena Romanowicz
- Mayo Clinic Depression Center, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Jennifer L. Vande Voort
- Mayo Clinic Depression Center, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Deniz Doruk Camsari
- Mayo Clinic Depression Center, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Kathryn M. Schak
- Mayo Clinic Depression Center, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - John D. Port
- Mayo Clinic Depression Center, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA,Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Charles P. Lewis
- Mayo Clinic Depression Center, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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General Psychiatric Management for Suicidal Patients, With Remarks on Chronicity: Contending With the Angel of Death. J Nerv Ment Dis 2017; 205:419-426. [PMID: 28557882 DOI: 10.1097/nmd.0000000000000701] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Assessing, managing, and treating suicidal patients, particularly those with chronic suicidality, challenge clinical decision making and emotional self-management in trainees and seasoned practitioners. Educators and trainees have noted needs for additional teaching materials in these areas. This article assists in addressing these gaps. We reviewed diagnostic and phenomenological characteristics encountered in acutely and chronically suicidal patients, their comprehensive assessment, general approaches to management, risk mitigation and safety planning, and psychological and biological interventions. Integrating information from research and clinical experience-based literature, we offer concise guidance on comprehensive psychiatric management for the varieties of acutely and chronically suicidal patients encountered in practice. By actively engaging suicidal patients and their families, systematically attending to warning signs, conducting risk mitigation and safety planning, and using psychological and biological treatments as indicated, clinicians are likely to reduce suicidal ideation, plans, and attempts in patients and might reduce completed suicides.
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Schmidt FM, Kirkby KC, Lichtblau N. Inflammation and Immune Regulation as Potential Drug Targets in Antidepressant Treatment. Curr Neuropharmacol 2017; 14:674-87. [PMID: 26769225 PMCID: PMC5050395 DOI: 10.2174/1570159x14666160115130414] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 10/20/2015] [Accepted: 11/04/2015] [Indexed: 12/21/2022] Open
Abstract
Growing evidence supports a mutual relationship between inflammation and major depression. A variety of mechanisms are outlined, indicating how inflammation may be involved in the pathogenesis, course and treatment of major depression. In particular, this review addresses 1) inflammatory cytokines as markers of depression and potential predictors of treatment response, 2) findings that cytokines interact with antidepressants and non-pharmacological antidepressive therapies, such as electroconvulsive therapy, deep brain stimulation and physical activity, 3) the influence of cytokines on the cytochrome (CYP) p450-system and drug efflux transporters, and 4) how cascades of inflammation might serve as antidepressant drug targets. A number of clinical trials have focused on agents with immunmodulatory properties in the treatment of depression, of which this review covers nonsteroidal anti-inflammatory drugs (NSAIDs), cytokine inhibitors, ketamine, polyunsaturated fatty acids, statins and curcumin. A perspective is also provided on possible future immune targets for antidepressant therapy, such as toll-like receptor-inhibitors, glycogen synthase kinase-3 inhibitors, oleanolic acid analogs and minocycline. Concluding from the available data, markers of inflammation may become relevant factors for more personalised planning and prediction of response of antidepressant treatment strategies. Agents with anti-inflammatory properties have the potential to serve as clinically relevant antidepressants. Further studies are required to better define and identify subgroups of patients responsive to inflammatory agents as well as to define optimal time points for treatment onset and duration.
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Affiliation(s)
- Frank M Schmidt
- Department of Psychiatry and Psychotherapy, University Hospital Leipzig, Semmelweisstraße 10, D-04103 Leipzig, Germany
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15
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Wilkinson ST, Sanacora G. KETAMINE: A POTENTIAL RAPID-ACTING ANTISUICIDAL AGENT? Depress Anxiety 2016; 33:711-7. [PMID: 27082101 PMCID: PMC6676475 DOI: 10.1002/da.22498] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/03/2016] [Accepted: 03/04/2016] [Indexed: 01/20/2023] Open
Abstract
Ketamine has attracted widespread attention as a potential rapid-acting antidepressant. There is also considerable interest in its use for the rapid treatment of patients deemed at risk for suicide. Here, we review the available evidence (open-label and randomized controlled trials) that examine the effects of ketamine on suicidal ideation (SI). Overall, data suggest that ketamine has a rapid albeit transient effect in reducing SI, though some studies had mixed results at different time points or using different assessments. Weaknesses to the existing literature include the small sample sizes of the studies, the exclusion of patients with significant SI at baseline from many of the studies, and the potential functional unblinding when participants are randomized to saline as placebo. The evidence supporting the clinical use of ketamine for SI is very preliminary. Although ketamine appears to a promising therapeutic option in a context where there is a great unmet need (i.e., patients at imminent risk of suicide), further controlled trials are needed to allow for meaningful clinical recommendations.
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Affiliation(s)
| | - Gerard Sanacora
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
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Abstract
Ketamine, a widely used anesthetic agent, is currently being investigated as a novel therapeutic for depression and suicidality. Ketamine has garnered substantial attention from researchers, clinicians, media outlets, and patients alike, but numerous questions remain. One of the compelling features of ketamine is the rapidity of its antidepressant effects, which peak just 24 h after infusion, setting it apart from other existing treatments. Ketamine's rapid time course has inspired research efforts to explore its potential as a life-saving therapy for patients at imminent risk of suicide. In this article, we review current evidence supporting the rapid effects of ketamine on suicidal ideation in the context of unipolar and bipolar depression. We then discuss several future directions that are necessary before ketamine can be considered a viable treatment option for suicidality in clinical settings. These include: testing for a specific anti-suicidal effect-separate from overall antidepressant effects-to ascertain whether ketamine might hold promise for a broader class of suicidal patients; ensuring that acute benefits of ketamine can be prolonged over a clinically meaningful timeframe; and developing a better understanding of the mechanisms by which ketamine might reduce suicide risk. Such efforts will enable the field to more accurately assess the potential of ketamine, as well as its limitations, allowing for appropriate placement within the context of comprehensive clinical care for suicide prevention.
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Affiliation(s)
- Rebecca B. Price
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sanjay J. Mathew
- Michael E. DeBakey VA Medical Center, Houston, TX, USA,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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