Treatment-related improvement in neuropsychological functioning in suicidal depressed patients: paroxetine vs. bupropion

Alterations in orbitofrontal cortex communication relate to suicidal attempts in patients with major depressive disorder

BACKGROUND

Investigating how the interaction between the orbitofrontal cortex (OFC) and various brain regions/functional networks in major depressive disorder (MDD) patients with a history of suicide attempt (SA) holds importance for understanding the neurobiology of this population.

METHODS

We employed resting-state functional magnetic resonance imaging (rs-fMRI) to analyze the OFC's functional segregation in 586 healthy individuals. A network analysis framework was then applied to rs-fMRI data from 86 MDD-SA patients and 85 MDD-Control patients, utilizing seed mappings of OFC subregions and a multi-connectivity-indicator strategy involving cross-correlation, total interdependencies, Granger causality, and machine learning.

RESULTS

Four functional subregions of left and right OFC, were designated as seed regions of interest. Relative to the MDD-Control group, the MDD-SA group exhibited enhanced functional connectivity (FC) and attenuated interaction between the OFC and the sensorimotor network, imbalanced communication between the OFC and the default mode network, enhanced FC and interaction between the OFC and the ventral attention network, enhanced interaction between the OFC and the salience network, and attenuated FC between the OFC and the frontoparietal network.

LIMITATIONS

The medication and treatment condition of patients with MDD was not controlled, so the medication effect on the alteration model cannot be affirmed.

CONCLUSION

The findings suggest an imbalanced interaction pattern between the OFC subregions and a set of cognition- and emotion-related functional networks/regions in the MDD-SA group.

Standardized Treatment and Shortened Depression Course can Reduce Cognitive Impairment in Adolescents With Depression

Objectives

This study aimed to explore the influence of depression severity, disease course, treatment status, and other factors on cognitive function in adolescents with depressive disorders.

Methods

Participants who met the inclusion criteria were enrolled in the study. Sociodemographic data of each participant were recorded, including age, sex, and family history of mental disorders. Zung's Self-Rating Depression Scale was used to assess depression status in adolescents. Moreover, P300 and mismatch negativity (MMN) were used to objectively evaluate the participants' cognitive function.

Results

Only 26.8% of the adolescents with depression received standard antidepressant treatment. The latencies of N2 (267.80±23.34 ms), P3 (357.71±32.09 ms), and MMN (212.10±15.61 ms) in the adolescent depression group were longer than those in the healthy control group (p<0.01). Further analysis revealed that the latency of MMN was extended with increased levels of depression in adolescents. The MMN latency was short in participants with depression receiving standardized treatment. Furthermore, the latency of MMN was positively correlated with the severity and duration of depression (correlation coefficients were 0.465 and 0.479, respectively) (p<0.01).

Conclusion

Receiving standardized treatment and shortening the course of depression can reduce cognitive impairment in adolescents with depression.

Longitudinal associations between executive function impairments and suicide risk in patients with major depressive disorder: A 1-year follow-up study

Impaired executive function (EF) is a key feature of patients with major depressive disorder (MDD) that several studies have linked to suicidal ideation and suicide attempts. This is the first longitudinal study to examine the association between impaired EF and suicide risk in adult patients with MDD. Longitudinal prospective study with 3 assessment points: baseline, 6 and 12 months. The Columbia-Suicide Severity Rating Scale (C-SSRS) was used to assess suicidality. The Cambridge Neuropsychological Test Automated Battery (CANTAB) was used to assess EF. The association between EF impairments and suicidality was analyzed using mixed-effects models. Out of 167 eligible outpatients, 104 were included in the study. Of these, 72 were re-evaluated at 6 months and 60 at 12 months, obtaining 225 complete observations of the EF. Impaired decision-making and risk-taking behavior were associated with suicidal ideation. Difficulty in impulse control was related to suicidal ideation and to greater severity of suicidal ideation. Impaired spatial planning and working memory was linked to suicide attempts. Our results add to previous literature that the association between EF impairments and suicidality is maintained over the long term, supporting it as a longitudinal risk factor and a possible neurocognitive marker of suicide in patients with MDD.

Pharmacologic Approaches to Suicide Prevention

Suicide is a leading cause of death that is often preventable. This article reviews the role of medications in treating suicidal behavior and in preventing suicide. For an acute suicidal crisis, ketamine, and perhaps esketamine, are emerging as important tools. For patients with chronic suicidality, clozapine remains the only U.S. Food and Drug Administration (FDA) approved antisuicidal medication, and its use is predominantly for patients with schizophrenia and schizoaffective disorder. An abundance of literature supports the use of lithium among patients with mood disorders, including those with major depressive disorder. Despite the black box warning regarding antidepressants and suicide risk among children, adolescents, and young adults, antidepressants are widely used and remain helpful in reducing suicidal thoughts and behaviors, primarily among patients with mood disorders. Treatment guidelines focus on the importance of optimizing treatment of the psychiatric conditions known to be associated with suicide risk. For patients with these conditions, the authors recommend focusing on suicide as an independent treatment target and using an enhanced medication management strategy that includes maintaining a supportive, nonjudgmental therapeutic relationship; flexibility; collaboration; measurement-based care; consideration of combining medications with nonpharmacologic, evidence-based strategies; and ongoing safety planning.

Variability and concordance among indices of brain activity in major depressive disorder with suicidal ideation: A temporal dynamics resting-state fMRI analysis

OBJECTIVE

The resting-state functional magnetic resonance imaging (rs-fMRI) have been used to explore functional abnormality of the brain in MDD patients with suicidal ideation (SI). However, few studies reported the variability and concordance of alterations of rs-fMRI indices in MDD with SI. In this study, we aimed to explore the variability and concordance of alterations of rs-fMRI indices in MDD with SI.

METHODS

A sliding window analysis was performed among 36 MDD patients with SI, 66 MDD patients without SI (NSI), and 50 healthy controls (HCs). Furthermore, the correlation between voxel-wise concordance and cognitive function was examined in the SI group.

RESULTS

The SI group had a lower dynamics degree centrality (dDC) value than the NSI group in left inferior occipital gyrus, and a lower voxel mirrored homotopic connectivity (dVMHC) value than the NSI group in the right and left inferior occipital gyrus. The mean values of volume wise concordance of HCs group shown higher than SI group and NSI group. SI group revealed decreased voxel-wise concordance in right cerebellum, left fusiform gyrus, left lingual gyrus, right middle temporal gyrus, left postcentral gyrus, and right supplementary motor area compared to NSI group. Moreover, the voxel-wise concordance of left middle occipital gyrus was negatively correlated with verbal learning and memory and working memory in the SI group.

LIMITATION

This is a cross-sectional analysis, limiting causal inferences.

CONCLUSIONS

The abnormal voxel-wise concordance of left middle occipital gyrus could be useful in understanding the pathophysiology of MDD patients with SI.

Cognitive effort avoidance in veterans with suicide attempt histories

Suicide attempts (SA) are increasing in the United States, especially in veterans. Discovering individual cognitive features of the subset of suicide ideators who attempt suicide is critical. Cognitive theories attribute SA to facile schema-based negative interpretations of environmental events. Over-general autobiographical memory and facile solutions in problem solving tasks in SA survivors suggest that aversion to expending cognitive effort may be a neurobehavioral marker of SA risk. In veterans receiving care for mood disorder, we compared cognitive effort discounting and evidence-gathering in a beads task between veterans with (SAHx+; n = 26) versus without (SAHx-; n = 22) a history of SA. Groups did not differ in depressed mood or in a proxy metric of premorbid intelligence. Compared to SAHx- participants, SAHx+ participants self-reported significantly more severe cognitive problems in most domains, and also eschewed choice to earn higher monetary reward if earning it required a slightly increased working memory (WM) demand relative to an easy WM task. There was no group difference, however, in extent of evidence-gathering before declaring a conclusion in a beads task. These preliminary data suggest that aversion to expenditure of cognitive effort, potentially as a component of cognitive difficulties, may be a marker for SA risk.

The effect of second-generation antidepressant treatment on the attention and mental processing speed of patients with major depressive disorder: A meta-analysis study with structural equation models

Major depressive disorder (MDD) has been linked to attention and mental processing speed deficits that can be improved after pharmacological treatment. However, it is unclear whether a class of antidepressants is more effective than others to ameliorate these deficits in MDD. Additionally, the possible effects of clinical and demographic variables on improving MDD attention and processing speed deficits after antidepressant treatment are unknown. We aimed to study the possible neuropsychological effects of second-generation antidepressant classes on the attention and processing speed of MDD patients and the potential influences of clinical and demographic variables as moderators of these effects using a meta-analytic approach. Twenty-five papers were included in our study. A structural equation model meta-analysis was performed. The improvement of attention and processing speed after pharmacological treatment is clinically relevant but incomplete. Selective serotonin reuptake inhibitors (SSRIs) and dual inhibitors are the drugs causing the greatest improvement in the processing speed of MDD patients. Antidepressant class is an important variable linked to processing speed improvement after MDD treatment. However, the degree of improvement in both cognitive functions is strongly influenced by some clinical and demographic variables of depressed patients, such are age and education of the MDD patients, the duration of the antidepressant treatment, and the depression status of the patients.

Computerized Working Memory Training in Remission From Major Depressive Disorder: Effects on Emotional Working Memory, Processing Speed, Executive Functions, and Associations With Symptoms

Introduction

Remission from major depressive disorder (MDD) is associated with residual symptoms related to reduced functioning, quality of life, and relapse risk. Previous studies have raised questions about mechanisms involved-in and affected by cognitive training. This study investigated the associations and changes among depressive symptoms, rumination, processing speed (PS), executive functioning (EF), and emotional working memory (e-WM) pre- post computerized working memory training (CWMT).

Method

Twenty-nine remitted participants were included in a pre- post pilot study of within-subject effects of online CWMT. A total of 20 participants completed the intervention and pre- post tests of EF and PS, e-WM, in addition to symptom and rumination measures. Associations between changes in symptoms and cognition were investigated pre- post. Associations between improvements in CWMT, depression history, and changes in cognition were explored. Hypotheses and statistics were preregistered before data were analyzed.

Results

Manipulation of negatively valanced stimuli in e-WM showed an inverse association with rumination pre-intervention, but the association disappeared post-intervention. Cognitive functioning improved in most conditions with largest effects in EF. Symptoms did not change in the remitted sample. CWMT improvements were related to improvements in some aspects of EF and PS, but also to worse self-reported attention. Depression history was related to less improvement in EF.

Limitations

Sample size was small and there was dropout from the study. There was no control group, thus precluding practice and placebo effects and causal relationships.

Conclusions

Computerized WM training improves cognitive functions and could influence associations between e-WM and rumination. This could counteract functional impairment following MDD.

The Influence of Family-Related Factors on Suicide in Major Depression Patients

OBJECTIVE

To explore the influence of family-related factors on suicide-related behaviors of patients with major depression disorder, and to provide scientific evidence for effective preventive measures.

METHODS

A total of 852 outpatients at Renmin Hospital of Wuhan University were enrolled in this cross-sectional study from April 2019 to January 2021. The general demographic information and family-related information of the patients were collected via a general information questionnaire, the Family Assessment Device, the Egna Minnen av Barndoms Uppfostran, and the Childhood Trauma Questionnaire.

RESULTS

Participants without suicide-related behaviors accounted for 10.45% of the total sample, those with suicidal ideation accounted for 47.54%, those with suicidal plans accounted for 24.77% and with suicidal attempts for 17.25%. Patients with major depression disorder who have lower education level, who were separated from their parents, who have severely impaired family function, who experienced childhood abuse, and whose parents adopted apathetic and severe child-rearing styles had a higher risk of suicide-related behaviors. In the multivariate regression model, degree of major depression disorder, education and child-rearing style were independent risk factors for suicide-related behaviors.

CONCLUSION

Patients with major depression disorder who have been separated from their parents, have severely impaired family function, were abused in childhood or have been exposed to improper childrearing styles have a greater risk of suicide. Family-related factors play a predictive role in suicide in patients with major depression disorder. More attention should be paid to family-related factors to reduce the occurrence of suicidal ideation and attempt.

The rapid anti-suicidal ideation effect of ketamine: A systematic review

In many countries suicide rates have been trending upwards for close to twenty years-presenting a public health crisis. Most suicide attempts and deaths are associated with psychiatric illness, usually a depressive disorder. Subanesthetic ketamine is the only FDA-approved antidepressant that works in hours not weeks-thus potentially transforming treatment of suicidal patients. We reviewed all randomized controlled trials of the effect of ketamine on suicidal ideation to determine if ketamine rapidly reduces suicidal ideation [SI] in depressed patients and how long the benefit persists after one dose and if the route of administration or dose affects the outcome. A systematic review was conducted as per PRISMA [preferred reporting items for systematic reviews and meta-analyses] criteria. PubMed search inclusive of "ketamine" and "suicide" yielded 358 results. Papers (N = 354) were then read by at least two authors, identifying 12 meeting eligibility requirements and eleven RCTs examining whether ketamine treatment ameliorated SI. Four of five RCTs examined racemic ketamine (0.5 mg/kg) given intravenously and found an advantage for ketamine over control for rapid reduction in SI in acutely depressed patients. Two studies examined intranasal esketamine in depressed suicidal patients and found no advantage over saline. One study examined outcome six weeks after a single intravenous dose of ketamine and found benefit for SI sustained relative to 24 h post-dose. Further research is warranted into: optimal dosing strategy, including number and frequency; and long-term efficacy and safety. Ultimately, it remains to be shown that ketamine's benefit for SI translates into prevention of suicidal behavior.

Attentional control may be modifiable with Mindfulness-Based Cognitive Therapy to Prevent Suicide

OBJECTIVE

To test whether Mindfulness-Based Cognitive Therapy to Prevent Suicide (MBCT-S) is associated with improvement in attentional control, an objective marker of suicide attempt.

METHOD

In the context of a randomized clinical trial targeting suicide risk in Veterans, computerized Stroop and emotion Stroop (E-Stroop) tasks were administered 3 times over 6-months follow-up to 135 high suicide risk Veterans. Seventy were randomized to receive MBCT-S in addition to enhanced treatment as usual (eTAU), and 65 were randomized to eTAU only. E-Stroop word types included positively- and negatively-valenced emotion, suicide, and combat-related words. Interference scores and mixed effects linear regression analyses were used.

RESULTS

Veterans receiving MBCT-S showed a more favorable trajectory of attentional control over time, as indicated by performance on two E-Stroop tasks. Combat-stress interference scores improved over time among Veterans in MBCT-S. Interference processing time for negative affective words deteriorated over time among Veterans receiving eTAU only.

CONCLUSIONS

MBCT-S may effectively target attentional control, and in particular reduce processing time during affective interference, in high suicide risk Veterans. Future studies to replicate these findings are warranted.

Working memory associated with anti-suicidal ideation effect of repeated-dose intravenous ketamine in depressed patients

Suicide is a tremendous threat to global public health, and a large number of people who committed suicide suffered the pain of mental diseases, especially major depressive disorder (MDD). Previous study showed that ketamine could reduce suicidal ideation (SI), potentially by improving the impaired working memory (WM). The objective of current study was to illuminate the relationship between WM and SI in MDD with repeated ketamine treatment. MDD patients with SI (n = 59) and without SI (n = 37) completed six intravenous infusions of ketamine (0.5 mg/kg over 40 min) over 12 days (Day 1, 3, 5, 8, 10 and 12). The severity of depressive symptoms, SI and WM were assessed at baseline, day 13 and day 26. We found that WM was significantly improved after 6 ketamine infusions (F = 161.284, p = 0.009) in a linear mixed model. Correlation analysis showed that the improvement of depressive symptom was significantly associated with WM at baseline (r =  - 0.265, p = 0.042) and the reduction in SSI-part I was related to the change of WM (r = 0.276, p = 0.034) in the MDD patients with SI. Furthermore, Logistic regression analysis showed that improvement in WM might predict the anti-SI response of ketamine. Our findings suggest that the improvement of working memory may partly account for the anti-SI effect of ketamine, and intervention of improving working memory function may be capable of reducing suicidal ideation.

Educational attainment reduces the risk of suicide attempt among individuals with and without psychiatric disorders independent of cognition: a bidirectional and multivariable Mendelian randomization study with more than 815,000 participants

Rates of suicidal behavior are increasing in the United States and identifying causal risk factors continues to be a public health priority. Observational literature has shown that educational attainment (EA) and cognitive performance (CP) influence suicide attempt risk; however, the causal nature of these relationships is unknown. Using summary statistics from genome-wide association studies (GWAS) of EA, CP, and suicide attempt risk with > 815,000 combined white participants of European ancestry, we performed multivariable Mendelian randomization (MR) to disentangle the effects of EA and CP on attempted suicide. In single-variable MR (SVMR), EA and CP appeared to reduce suicide attempt risk (EA odds ratio (OR) per standard deviation (SD) increase in EA (4.2 years), 0.524, 95% CI, 0.412-0.666, P = 1.07 × 10-7; CP OR per SD increase in standardized score, 0.714, 95% CI, 0.577-0.885, P = 0.002). Conversely, bidirectional analyses found no effect of a suicide attempt on EA or CP. Using various multivariable MR (MVMR) models, EA seems to be the predominant risk factor for suicide attempt risk with the independent effect (OR, 0.342, 95% CI, 0.206-0.568, P = 1.61 × 10-4), while CP had no effect (OR, 1.182, 95% CI, 0.842-1.659, P = 0.333). In additional MVMR analyses accounting simultaneously for potential behavioral and psychiatric mediators (tobacco smoking; alcohol consumption; and self-reported nerves, tension, anxiety, or depression), the effect of EA was little changed (OR, 0.541, 95% CI, 0.421-0.696, P = 3.33 × 10-6). Consistency of results across complementary MR methods accommodating different assumptions about genetic pleiotropy strengthened causal inference. Our results show that even after accounting for psychiatric disorders and behavioral mediators, EA, but not CP, may causally influence suicide attempt risk among white individuals of European ancestry, which could have important implications for health policy and programs aimed at reducing the increasing rates of suicide. Future work is necessary to examine the EA-suicide relationship populations of different ethnicities.

Association between cognition and suicidal ideation in patients with major depressive disorder: A longitudinal study

BACKGROUND

Suicidal ideation (SI) is common in patients with major depressive disorder (MDD) and often related to cognitive deficits. Limited longitudinal study has shown that cognitive improvement is associated with reduced SI. However, the comparatively study in Chinese depressed patients is still absent. The objective of this study was to explore the specific cognitive deficits in Chinese MDD with SI and investigate the relationship between changes in cognition and change in SI across antidepressant treatment.

METHODS

Three hundred and five patients with MDD received four weeks of antidepressant treatment. The 17-item Hamilton Depression Rating Scale (HAMD-17) and four domains of the MATRICS Consensus Cognitive Battery (MCCB), including speed of processing, working memory, visual learning and verbal learning were measured at baseline and four-week follow-up.

RESULTS

One hundred and thirty patients (42.6%) expressed suicidal ideation. Suicidal patients performed worse on verbal learning than non-suicidal patients. Change in speed of processing domain was negatively associated with change in suicidal scores over time. Logistic regression analysis showed that reduction of SI was associated with improvement of speed of processing.

LIMITATION

The major limitation was that there was no healthy control group in the current study, which might limit the interpretation of cognitive deficits in depressed patients with SI.

CONCLUSIONS

Our findings suggest that suicidal patients performed worse on verbal learning which can potentially serve as a cognitive biomarker of suicide risk in MDD. Moreover, reduced suicidal ideation was associated with improved speed of processing.

The Effect of Second-Generation Antidepressant Treatment on the Memory of Patients With Major Depressive Disorder: A Meta-analysis Study With Structural Equation Models

BACKGROUND

Major depressive disorder (MDD) has been linked to episodic memory deficits that may be improved after pharmacological treatment, but it is unclear whether there is a class of antidepressants that is more effective than others to ameliorate these deficits in MDD. In addition, the possible effects of clinical and sociodemographic variables on the improvement of MDD memory deficits after pharmacological treatment are currently unknown. Our aims are to study the possible neuropsychological effects of second-generation antidepressant classes on the episodic memory of MDD patients and to study the potential effects of clinical and demographic variables as moderators of the effects of antidepressants on the memory of depressed patients through a meta-analysis approach.

PROCEDURES

Nine articles were included in our study. A structural equation model meta-analysis was performed.

RESULTS

Our results suggest that selective serotonin reuptake inhibitors and serotonine-noradrenaline reuptake inhibitors would bring about a substantial improvement in the memory of depressed patients, whereas other antidepressant classes would cause rather modest effects. Our results also suggest that clinical and demographic variables play a very important role as mediators of memory improvement after MDD treatment. Thus, a relatively low level of symptom severity, a high degree of clinical improvement, a younger age, and more years of education were positively related to memory improvement after MDD treatment.

CONCLUSIONS

Although antidepressant class is an important variable linked to memory improvement in MDD, overall, the degree of memory amelioration in depression is very closely related to clinical and demographic variables of patients with depression.

Understanding the Complex of Suicide in Depression: from Research to Clinics

OBJECTIVE

Amongst psychiatric disorders, major depressive disorder (MDD) is the most prevalent, by affecting approximately 15-17% of the population and showing a high suicide risk rate equivalent to around 15%. The present comprehensive overview aims at evaluating main research studies in the field of MDD at suicide risk, by proposing as well as a schematic suicide risk stratification and useful flow-chart for planning suicide preventive and therapeutic interventions for clinicians.

METHODS

A broad and comprehensive overview has been here conducted by using PubMed/Medline, combining the search strategy of free text terms and exploded MESH headings for the topics of 'Major Depressive Disorder' and 'Suicide' as following: ((suicide [Title/Abstract]) AND (major depressive disorder [Title/Abstract])). All articles published in English through May 31, 2019 were summarized in a comprehensive way.

RESULTS

Despite possible pathophysiological factors which may explain the complexity of suicide in MDD, scientific evidence supposed the synergic role of genetics, exogenous and endogenous stressors (i.e., interpersonal, professional, financial, as well as psychiatric disorders), epigenetic, the hypothalamic-pituitary-adrenal stress-response system, the involvement of the monoaminergic neurotransmitter systems, particularly the serotonergic ones, the lipid profile, neuro-immunological biomarkers, the Brain-derived neurotrophic factor and other neuromodulators.

CONCLUSION

The present overview reported that suicide is a highly complex and multifaceted phenomenon in which a large plethora of mechanisms could be variable implicated, particularly amongst MDD subjects. Beyond these consideration, modern psychiatry needs a better interpretation of suicide risk with a more careful assessment of suicide risk stratification and planning of clinical and treatment interventions.

Suicidal behavior in treatment resistant major depressive disorder patients treated with transmagnetic stimulation(TMS) and its relationship with cognitive functions

The aim of this study is to investigate the effects of rTMS treatment on suicidal thoughts/behaviors and to determine the cognitive mechanisms underlying the effects of rTMS treatment on suicidal thoughts/behaviors in treatment-resistant depression(TRD). Thirty patients with TRD received rTMS 5 sessions per week for 4-6 weeks. Montgomery-Asberg Depression Rating Scale(MADRS), Columbia Suicide Severity Rating Scale(C-SSRS), Suicidal Ideation Scale(SIS), Beck Hopelessness Scale(BHS) and Cambridge Neuropsychological Test Automated Battery(CANTAB) were administered before and after treatment. After rTMS treatment, there was a significant decrease in depressive complaints and suicidal thoughts and improvement in emotional recognition. However, there was no significant change in cognitive functions such as cognitive flexibility, motor response inhibition and decision making. Pre-treatment decision-making and flexible thinking skills were related to the change in suicidal ideation. In TRD patients, rTMS has a positive effect on depressive symptoms and suicidal thoughts/behaviors and emotion recognition abilities. Although there is no negative effect on other cognitive functions, the positive effect of rTMS on cognitive functions is limited. At this point, we think that the TRD would be treated more effectively with treatments targeting specific symptom clusters such as other cognitive functions and suicidal thoughts.

Ketamine for suicidal ideation in adults with psychiatric disorders: A systematic review and meta-analysis of treatment trials

OBJECTIVE

Ketamine may reduce suicidal ideation in treatment-resistant depression. But it is not known how quickly this occurs and how long it persists. We undertook a systematic review and meta-analysis to determine the short- and long-term effectiveness of ketamine for suicidality.

METHOD

CENTRAL, EMBASE, Medline, and PsycINFO were searched until 12 December 2018. Randomised controlled trials of ketamine or esketamine reporting data on suicidal ideation, self-harm, attempted or completed suicide in adults diagnosed with any psychiatric disorder were included. Two reviewers independently extracted data, and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Standardised mean difference was used for continuous outcomes.

RESULTS

Twenty-five reports from 15 independent trials, with a total of 572 participants diagnosed with predominately affective disorders, were included. The evidence was rated moderate to low. In most trials, ketamine was administered at 0.5 mg/kg via a single intravenous infusion over a 30- to 45-minute period. Only a single trial of intranasal esketamine was identified. At 4 hours post-infusion, treatment with ketamine was associated with a significant reduction in suicidal ideation scores (standardised mean difference = -0.51, 95% confidence interval = [-1.00, -0.03]), which persisted until 72 hours post-infusion (time points between 12 and 24 hours: standardised mean difference = -0.63, 95% confidence interval = [-0.99, -0.26]; between 24 and 72 hours: standardised mean difference = -0.57, 95% confidence interval = [-0.99, -0.14]), but not thereafter. However, there was marked heterogeneity of results. In a single trial of esketamine, marginal effects on suicidal ideation were observed. In terms of actual suicidal behaviour, there were virtually no data on effects of ketamine or esketamine.

CONCLUSION

A single infusion of ketamine may have a short-term (up to 72 hours) beneficial impact on suicidal thoughts. While confirmation of these results in further trials is needed, they suggest possible use of ketamine to treat acute suicidality. Means of sustaining any anti-suicidal effect need to be found.

Neurocognition in Post-Treatment Lyme Disease and Major Depressive Disorder

OBJECTIVE

Neurocognitive dysfunction in patients with residual or emergent symptoms after treatment for Lyme Disease is often attributed to comorbid depression. In this study, patients with Post-Treatment Lyme Disease Syndrome (PTLDS) were compared to patients with Major Depressive Disorder (MDD), as well as healthy comparison subjects (HC), on neurocognitive measures administered through the same laboratory, to determine if patterns of performance were similar.

METHODS

Two analyses were conducted. First, performance on the Wechsler Adult Intelligence Scale (WAIS-III) and on subtests from the Wechsler Memory Scale (WMS-III) was compared among the groups. Second, comparable subgroups of PTLDS and MDD patients with at least one low WMS-III score were compared on an additional set of measures assessing motor function, psychomotor performance, attention, memory, working memory, and language fluency, to determine if the overall profile of performance was similar in the two subgroups.

RESULTS

In the first analysis, PTLDS patients performed more poorly than both MDD and HC on tasks assessing verbal abilities, working memory, and paragraph learning. Processing speed in the two patient groups, however, was equally reduced. In the second analysis, MDD patients with low WMS-III exhibited concomitantly greater difficulties in psychomotor speed and attention, while low-WMS-III PTLDS patients exhibited greater difficulties in language fluency.

CONCLUSIONS

MDD and PTLDS can be confused neuropsychologically because both exhibit similar levels of psychomotor slowing. However, problems on memory-related tasks, though mild, are more pronounced in PTLDS. PTLDS patients with poorer memory also exhibit poorer language fluency, and less deficit in processing speed and attention compared to MDD.

Developing neurocognitive standard clinical care: A study of young adult inpatients

Neuropsychological assessments have provided the field of psychiatry with important information about patients. As an assessment tool, a neuropsychological battery can be useful in a clinical setting; however, implementation as standard clinical care in an inpatient unit has not been extensively evaluated. A computerized cognitive battery was administered to 103 current young adult inpatients (19.2 ± 3.1 years; 72% female) with affective disorder. Neurocognitive tasks included Verbal Recognition Memory (VRM), Attention Switching (AST), Paired Association Learning (PAL), and Rapid Visual Processing (RVP). Patients also completed a computerized self-report questionnaire evaluating subjective impressions of their cognition. Hierarchical cluster analysis determined three neurocognitive subgroups: cluster 1 (n = 17) showed a more impaired neurocognitive profile on three of the four variables compared to their peers in cluster 2 (n = 59), and cluster 3 (n = 27), who had the most impaired attentional shifting. Two of the four neurocognitive variables were significantly different between all three cluster groups (verbal learning and sustained attention). Overall group results showed an association between poorer sustained attention and increased suicidal ideation. These findings strengthen the idea that neurocognitive profiles may play an important role in better understanding the severity of illness in young inpatients with major psychiatric disorders.

Impact of Substance Use Disorder Pharmacotherapy on Executive Function: A Narrative Review

Substance use disorders are chronic, relapsing, and harmful conditions characterized by executive dysfunction. While there are currently no approved pharmacotherapy options for stimulant and cannabis use disorders, there are several evidence-based options available to help reduce symptoms during detoxification and aid long-term cessation for those with tobacco, alcohol and opioid use disorders. While these medication options have shown clinical efficacy, less is known regarding their potential to enhance executive function. This narrative review aims to provide a brief overview of research that has investigated whether commonly used pharmacotherapies for these substance use disorders (nicotine, bupropion, varenicline, disulfiram, acamprosate, nalmefene, naltrexone, methadone, buprenorphine, and lofexidine) effect three core executive function components (working memory, inhibitory control and cognitive flexibility). While pharmacotherapy-induced enhancement of executive function may improve cessation outcomes in dependent populations, there are limited and inconsistent findings regarding the effects of these medications on executive function. We discuss possible reasons for the mixed findings and suggest some future avenues of work that may enhance the understanding of addiction pharmacotherapy and cognitive training interventions and lead to improved patient outcomes.

Neurocognitive performance predicts treatment outcome with cognitive behavioral therapy for major depressive disorder

The current study examined the contribution of baseline neuropsychological functioning to the prediction of antidepressant outcome with cognitive behavioral therapy (CBT) for Major Depressive Disorder (MDD). We hypothesized that depressed participants who were more neurocognitively intact and had less rigid, negative thinking would respond better to CBT. Thirty-one MDD patients completed a comprehensive neuropsychological battery before initiation of CBT. A subgroup also completed a probabilistic reversal learning task. Depression severity was assessed with the Beck Depression Inventory (BDI); rigid, negative thinking was assessed with the Dysfunctional Attitudes Scale (DAS) and the Automatic Thoughts Questionnaire (ATQ) throughout treatment. Remitters were compared to non-remitters. Paradoxically, eventual remitters performed generally worse across the neuropsychological battery considered as a whole. Univariate testing showed a significant difference on only a single measure, the Continuous Performance Test d', when corrected for multiple comparisons. Baseline rigid, negative thinking did not predict treatment outcome. Results suggest that the structure of CBT may particularly benefit individuals with mild depression-related neurocognitive difficulties during a depressive episode. Further research is needed to examine these patient characteristics and their potential contribution to the mechanisms of CBT efficacy.

Treatment of neurocognitive symptoms in unipolar depression: A systematic review and future perspectives

BACKGROUND

Cognitive symptoms in Major Depressive Disorder (MDD) are persistent and commonly entail neurocognitive impairment and a decline in quality of life. This systematic review gathers the current scientific evidence on therapeutic strategies for neuropsychological impairment in MDD.

METHOD

A systematic search on PubMed, PsycINFO and Clinicaltrials.gov was carried out on December 2016 according to PRISMA using Boolean terms to identify interventions for the treatment of cognitive dysfunction in MDD. Only English-written articles providing original data and focusing in adults with MDD were included with no time restrictions.

RESULTS

A total of 95 studies reporting data on 40 pharmacological and non-pharmacological interventions were included. Interventions were grouped into the following categories: 1) Pharmacological Therapies (antidepressants, stimulants, compounds acting on NMDA receptors, compounds acting on the cholinergic system, compounds showing anti-inflammatory or antioxidant properties, other mechanisms of action), 2) Physical Therapies and 3) Psychological Therapies, 4) Exercise. There are some promising compounds showing a positive impact on cognitive symptoms including vortioxetine, lisdexamfetamine or erythropoietin.

LIMITATIONS

The studies included showed significant methodological differences in heterogeneous samples. The lack of a standardized neuropsychological battery makes comparisons between studies difficult.

CONCLUSION

Current evidence is not sufficient to widely recommend the use of procognitive treatments in MDD although promising results are coming to light.

Association between cognitive deficits and suicidal ideation in patients with major depressive disorder

The role of cognitive function in suicidal ideation in patients with major depressive disorder (MDD) has not been adequately explored. This research sought to measure the relationship between suicidal ideation and cognitive function. Therefore, in this study, the association between cognitive function and suicidal ideation in patients with MDD was assessed. Cognitive function was evaluated in 233 patients with MDD using the Japanese version of the Brief Assessment of Cognition in Schizophrenia (BACS). Suicidal ideation was assessed using item 3 of the Hamilton Depression Rating Scale. Approximately 59.2% of the patients (138/233) expressed suicidal ideation. Among the BACS subtests, only the executive function scores were significantly lower in patients with MDD with than in those without (p < 0.005). In addition, the executive function, motor speed function, and composite scores correlated negatively with the severity of suicidal ideation in these patients. These results suggest that executive function, motor speed function, and global neuropsychological function are associated with suicidal ideation in patients with MDD and that the BACS neuropsychological battery is an efficient instrument for monitoring these characteristics. Moreover, specific BACS scores can potentially serve as cognitive biomarkers of suicide risk in patients with MDD.

Cognitive performance in unipolar old-age depression: a longitudinal study

OBJECTIVE

Previous studies on cognitive deficits in acute and remitted states of old-age depression have shown mixed findings. The episodic nature of depression makes repeated assessment of cognitive performance important in order to address reversibility and stability of cognitive deficits.

METHODS

Dementia-free older participants (≥60 years) from the population-based Swedish National Study on Aging and Care in Kungsholmen who completed neuropsychological testing at baseline (T1) and follow-up (T2) formed the basis of the study sample. Participants were grouped according to depression status at T1 and T2: depressed-remitted (n = 32), remitted-depressed (n = 45), and nondepressed-depressed (n = 29). These groups were compared with a group of randomly selected and matched (age, gender, education, and follow-up time) healthy controls (n = 106) over a period of maximum 6 years.

RESULTS

Mixed ANCOVAs, controlling for age and gender, revealed depression-related deficits for processing speed, attention, executive function, and category fluency. In remitted states, only processing speed and attention were affected. However, these deficits were attenuated after exclusion of persons using benzodiazepine medications. A general pattern of cognitive decline was observed across all groups for processing speed, executive function, category fluency, and episodic and semantic memory; persons transitioning from a nondepressed to depressed state tended to show exacerbated cognitive decline.

CONCLUSIONS

The results support the notion that cognitive deficits in depression may be more transient than stable. Consequently, cognitive deficits in depression might be regarded as potential treatment targets rather than stable vulnerabilities. As such, repeated assessment of cognitive functioning may provide an additional marker of treatment response.

Evaluating the motor slowing hypothesis of depression

The purpose of this study was to evaluate the hypothesis that processing speed deficits are the primary cognitive deficits in those with depression, consistent with the motor slowing hypothesis. Participants (n=223) were research volunteers who served in the US military since September 11, 2001, and denied a history of significant brain injuries. Depression was measured using a structured interview, the Personality Assessment Inventory (PAI), and the Beck Depression Inventory-II (BDI-II). Outcomes included performance on 10 processing speed variables. Invalid performance/report accounted for significant variance for 8 of 10 processing speed measures. There was not a consistent pattern of slowed processing speed in those with current depressive diagnoses compared to those without. However, depression symptom burden per the PAI Depression scale was significant for 7 of 10 processing speed tests. Only non-dominant fine motor dexterity was significantly slower in those with high versus low burden using BDI-II quartiles. Thus, the motor slowing hypothesis was supported, but only for depression burden and not diagnostic status or high versus low categorical classification. These results underscore the importance of validity assessment and consideration of how one measures psychiatric constructs when evaluating relations among symptoms and cognition.

Ketamine versus midazolam in bipolar depression with suicidal thoughts: A pilot midazolam-controlled randomized clinical trial

OBJECTIVES

To evaluate feasibility and effects of a sub-anesthetic infusion dose of ketamine versus midazolam on suicidal ideation in bipolar depression. Neurocognitive, blood and saliva biomarkers were explored.

METHODS

Sixteen participants with bipolar depression and a Scale for Suicidal Ideation (SSI) score of ≥4 were randomized to ketamine (0.5 mg/kg) or midazolam (0.02 mg/kg). Current pharmacotherapy was maintained excluding benzodiazepines within 24 hours. The primary clinical outcome was SSI score on day 1 post-infusion.

RESULTS

Results supported feasibility. Mean reduction of SSI after ketamine infusion was almost 6 points greater than after midazolam, although this was not statistically significant (estimate=5.84, SE=3.01, t=1.94, P=.074, 95% confidence interval ([CI)]=-0.65 to 12.31). The number needed to treat for response (SSI <4 and at least 50% below baseline) was 2.2, and for remission (SSI=0) was 3.2. The strongest neurocognitive correlation was between memory improvement on the Selective Reminding Test (SRT) and reduction in SSI score on day 1 after ketamine (ρ=-.89, P=.007). Pre- to post-infusion decrease in serum brain derived neurotrophic factor (BDNF) correlated with reduction in SSI from baseline to day 1 after ketamine (n=5, ρ=0.90, P=.037) but not midazolam (P=.087).

CONCLUSIONS

The study demonstrated feasibility. Suicidal thoughts were lower after ketamine than after midazolam at a trend level of significance, likely due to the small pilot sample. Memory improvement and BDNF are promising biomarkers. Replication is needed in an adequately powered full-scale trial.

Sleep architecture parameters as a putative biomarker of suicidal ideation in treatment-resistant depression

BACKGROUND

Disturbed sleep may confer risk for suicidal behaviors. Polysomnographic (PSG) sleep parameters have not been systematically evaluated in association with suicidal ideation (SI) among individuals with treatment-resistant depression (TRD).

METHODS

This secondary data analysis included 54 TRD individuals (N=30 with major depressive disorder (MDD) and N=24 with bipolar depression (BD)). PSG sleep parameters included Sleep Efficiency (SE), Total Sleep Time (TST), Wakefulness After Sleep Onset (WASO), REM percent/latency, and non-REM (NREM) Sleep Stages 1-4. The Hamilton Depression Rating Scale (HAM-D) was used to group participants according to presence or absence of SI. Sleep abnormalities were hypothesized among those with current SI. ANOVA analyses were conducted before (Model 1) and after adjusting for depression (Model 2) and diagnostic variables (Model 3).

RESULTS

Significant differences in PSG parameters were observed in Model 1; those with SI had less NREM Stage 4 sleep (p<.05). After adjusting for central covariates, Models 2 and 3 revealed significantly less NREM Stage 4 sleep, lower SE (P<.05), and higher WASO (P<.05) among those with SI. BD participants with SI also had less NREM Stage 4 and more NREM Stage 1 sleep.

LIMITATIONS

1) a predominantly white sample; 2) exclusion of imminent suicide risk; 3) concomitant mood stabilizer use among BD patients; and 4) single-item SI assessment.

CONCLUSIONS

Independent of depression severity, SI was associated with less NREM Stage 4 sleep, and higher nocturnal wakefulness across diagnostic groups. Sleep may warrant further investigation in the pathogenesis of suicide risk, particularly in TRD, where risk may be heightened.

The impact of cognitive challenges in major depression: the role of the primary care physician

Nearly 1 in 5 Americans will struggle with major depression in their lives; some will have recurring bouts. Recent psychiatric research has given new attention to the prevalence of cognitive deficits in major depression and the impact such deficits have on remission and overall life functioning. When depression is partially treated i.e., leaving residual symptoms, patients have higher rates of relapse and lower functional outcomes. Impaired cognitive functioning is a frequent residual symptom, persisting in about 45% of patients even when emotional symptoms have improved, and results in a disproportionate share of the functional impairment, particularly in the workplace. Patients with depression have disrupted circuitry in brain regions responsible for cognition and it is therefore important to screen depressed patients for cognitive as well as emotional symptoms. Cognitive dysfunction should be evaluated in every mood disordered patient with validated self-report scales such as the Patient Health Questionnaire-9 or the Beck Depression Inventory and objective measures of cognitive function are also very very useful. Two easily administered tests are the Trails B Test and the Digit Symbol Substitution Test. Each take less than two minutes and measure working memory, executive function, and processing speed and can track cognitive improvement in depressed patients. Treatment of cognitive dysfunction in major depression is complicated by the 'serotonin conundrum': SSRI's frequently do not treat to full remission, and can cause cognitive blunting-actually adding to cognitive problems. Based on recent data including results from a recently completed meta-analysis by McIntyre and colleagues, an evidence-based algorithm for treating cognitive symptoms in depression is presented. A hierarchy of antidepressants and augmentation strategies based on the best available evidence is discussed. In conclusion, cognitive symptoms in major depressive disorder have been recognized as a target of therapeutic improvement by the FDA and have become a focus of clinical importance.

Cognitive Dysfunction in Major Depressive Disorder: Assessment, Impact, and Management

Cognitive dysfunction is increasingly being recognized as an important clinical dimension in major depressive disorder. This review summarizes the existing data on the epidemiology, assessment, and treatment of cognitive dysfunction among nonelderly adults with the disorder. Overall, cognitive dysfunction is prevalent, persists through periods of symptom remission, and may be independently associated with functional outcomes. However, although the evidence increasingly suggests that clinicians should be heedful of their patients' cognitive functioning, there is as yet no consensus on how best to monitor cognition clinically. In addition, although most studies have reported improved cognition with antidepressant medications, psychotherapy, and neuromodulation, the clinical significance of these improvements is unclear, and high-level evidence to guide decision making is limited. Nonetheless, given the important functional implications, clinicians should assess and monitor cognition and optimize both medication and psychological treatments to mitigate cognitive dysfunction among patients with major depressive disorder.

Differential effects of bupropion on acquisition and performance of an active avoidance task in male mice

Bupropion is an antidepressant drug that is known to aid smoking cessation, although little experimental evidence exists about its actions on active avoidance learning tasks. Our aim was to evaluate the effects of this drug on two-way active avoidance conditioning. In this study, NMRI mice received bupropion (10, 20 and 40mg/kg) or saline before a daily training session (learning phase, days 1-4) in the active avoidance task. Performance was evaluated on the fifth day (retention phase): in each bupropion-treated group half of the mice continued with the same dose of bupropion, and the other half received saline. Among the vehicle-treated mice, different sub-groups were challenged with different doses of bupropion. Results indicated that mice treated with 10 and 20mg/kg bupropion exhibited more number of avoidances during acquisition. The response latency confirmed this learning improvement, since this parameter decreased after bupropion administration. No differences between groups were observed in the retention phase. In conclusion, our data show that bupropion influences the learning process during active avoidance conditioning, suggesting that this drug can improve the control of emotional responses.

The Cognitive Effects of Antidepressants in Major Depressive Disorder: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Cognitive dysfunction is often present in major depressive disorder (MDD). Several clinical trials have noted a pro-cognitive effect of antidepressants in MDD. The objective of the current systematic review and meta-analysis was to assess the pooled efficacy of antidepressants on various domains of cognition in MDD.

METHODS

Trials published prior to April 15, 2015, were identified through searching the Cochrane Central Register of Controlled Trials, PubMed, Embase, PsychINFO, Clinicaltrials.gov, and relevant review articles. Data from randomized clinical trials assessing the cognitive effects of antidepressants were pooled to determine standard mean differences (SMD) using a random-effects model.

RESULTS

Nine placebo-controlled randomized trials (2 550 participants) evaluating the cognitive effects of vortioxetine (n = 728), duloxetine (n = 714), paroxetine (n = 23), citalopram (n = 84), phenelzine (n = 28), nortryptiline (n = 32), and sertraline (n = 49) were identified. Antidepressants had a positive effect on psychomotor speed (SMD 0.16; 95% confidence interval [CI] 0.05-0.27; I(2) = 46%) and delayed recall (SMD 0.24; 95% CI 0.15-0.34; I(2) = 0%). The effect on cognitive control and executive function did not reach statistical significance. Of note, after removal of vortioxetine from the analysis, statistical significance was lost for psychomotor speed. Eight head-to-head randomized trials comparing the effects of selective serotonin reuptake inhibitors (SSRIs; n = 371), selective serotonin and norepinephrine reuptake inhibitors (SNRIs; n = 25), tricyclic antidepressants (TCAs; n = 138), and norepinephrine and dopamine reuptake inhibitors (NDRIs; n = 46) were identified. No statistically significant difference in cognitive effects was found when pooling results from head-to-head trials of SSRIs, SNRIs, TCAs, and NDRIs. Significant limitations were the heterogeneity of results, limited number of studies, and small sample sizes.

CONCLUSIONS

Available evidence suggests that antidepressants have a significant positive effect on psychomotor speed and delayed recall.