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Pastis I, Santos MG, Paruchuri A. Exploring the role of inflammation in major depressive disorder: beyond the monoamine hypothesis. Front Behav Neurosci 2024; 17:1282242. [PMID: 38299049 PMCID: PMC10829100 DOI: 10.3389/fnbeh.2023.1282242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/04/2023] [Indexed: 02/02/2024] Open
Abstract
Major depressive disorder affects approximately 8.4% of the United States population. The World Health Organization estimates that 280 million adults worldwide are suffering from depression. They have estimated that by 2030 it will be the second most serious condition. Current treatment relies on the monoamine hypothesis, however, one-third of patients with MDD do not respond to monoamine-based antidepressants. For years, it was hypothesized that the primary pathway of MDD involved serotonin as the main neurotransmitter. The monoamine hypothesis, a widely accepted theory, sought to explain the biological basis of MDD as being caused by the depletion of monoamine neurotransmitters, namely norepinephrine and serotonin. This hypothesis regarding monoamines as the pathophysiological basis of MDD led to the design and widespread use of selective serotonin reuptake inhibitors. However, given that only one-third of patients improve with SSRI it is reasonable to infer that the pathway involved is more complex than once hypothesized and there are more neurotransmitters, receptors, and molecules involved. The monoamine hypothesis does not explain why there is a delay in the onset of effect and action of SSRIs. Several studies have demonstrated that chronic stress is a risk factor for the development of MDD. Thus the monoamine hypothesis alone is not enough to fully account for the pathophysiology of MDD highlighting the need for further research involving the pathways of MDD. In this paper, we review the role of inflammation and cytokines on MDD and discuss other pathways involved in the development and persistence of depressive symptoms.
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Affiliation(s)
- Irene Pastis
- Department of Psychiatry and Behavioral Medicine, East Carolina University, Greenville, NC, United States
| | - Melody G. Santos
- Internal Medicine and Psychiatry Combined Program, Department of Psychiatry and Behavioral Medicine, East Carolina University, Greenville, NC, United States
| | - Akshita Paruchuri
- East Carolina University Brody School of Medicine, Greenville, NC, United States
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Köhler-Forsberg O, Stiglbauer V, Brasanac J, Chae WR, Wagener F, Zimbalski K, Jefsen OH, Liu S, Seals MR, Gamradt S, Correll CU, Gold SM, Otte C. Efficacy and Safety of Antidepressants in Patients With Comorbid Depression and Medical Diseases: An Umbrella Systematic Review and Meta-Analysis. JAMA Psychiatry 2023; 80:1196-1207. [PMID: 37672261 PMCID: PMC10483387 DOI: 10.1001/jamapsychiatry.2023.2983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/21/2023] [Indexed: 09/07/2023]
Abstract
Importance Every third to sixth patient with medical diseases receives antidepressants, but regulatory trials typically exclude comorbid medical diseases. Meta-analyses of antidepressants have shown small to medium effect sizes, but generalizability to clinical settings is unclear, where medical comorbidity is highly prevalent. Objective To perform an umbrella systematic review of the meta-analytic evidence and meta-analysis of the efficacy and safety of antidepressant use in populations with medical diseases and comorbid depression. Data Sources PubMed and EMBASE were searched from inception until March 31, 2023, for systematic reviews with or without meta-analyses of randomized clinical trials (RCTs) examining the efficacy and safety of antidepressants for treatment or prevention of comorbid depression in any medical disease. Study Selection Meta-analyses of placebo- or active-controlled RCTs studying antidepressants for depression in individuals with medical diseases. Data Extraction and Synthesis Data extraction and quality assessment using A Measurement Tool for the Assessment of Multiple Systematic Reviews (AMSTAR-2 and AMSTAR-Content) were performed by pairs of independent reviewers following PRISMA guidelines. When several meta-analyses studied the same medical disease, the largest meta-analysis was included. Random-effects meta-analyses pooled data on the primary outcome (efficacy), key secondary outcomes (acceptability and tolerability), and additional secondary outcomes (response and remission). Main Outcomes and Measures Antidepressant efficacy presented as standardized mean differences (SMDs) and tolerability (discontinuation for adverse effects) and acceptability (all-cause discontinuation) presented as risk ratios (RRs). Results Of 6587 references, 176 systematic reviews were identified in 43 medical diseases. Altogether, 52 meta-analyses in 27 medical diseases were included in the evidence synthesis (mean [SD] AMSTAR-2 quality score, 9.3 [3.1], with a maximum possible of 16; mean [SD] AMSTAR-Content score, 2.4 [1.9], with a maximum possible of 9). Across medical diseases (23 meta-analyses), antidepressants improved depression vs placebo (SMD, 0.42 [95% CI, 0.30-0.54]; I2 = 76.5%), with the largest SMDs for myocardial infarction (SMD, 1.38 [95% CI, 0.82-1.93]), functional chest pain (SMD, 0.87 [95% CI, 0.08-1.67]), and coronary artery disease (SMD, 0.83 [95% CI, 0.32-1.33]) and the smallest for low back pain (SMD, 0.06 [95% CI, 0.17-0.39]) and traumatic brain injury (SMD, 0.08 [95% CI, -0.28 to 0.45]). Antidepressants showed worse acceptability (24 meta-analyses; RR, 1.17 [95% CI, 1.02-1.32]) and tolerability (18 meta-analyses; RR, 1.39 [95% CI, 1.13-1.64]) compared with placebo. Antidepressants led to higher rates of response (8 meta-analyses; RR, 1.54 [95% CI, 1.14-1.94]) and remission (6 meta-analyses; RR, 1.43 [95% CI, 1.25-1.61]) than placebo. Antidepressants more likely prevented depression than placebo (7 meta-analyses; RR, 0.43 [95% CI, 0.33-0.53]). Conclusions and Relevance The results of this umbrella systematic review of meta-analyses found that antidepressants are effective and safe in treating and preventing depression in patients with comorbid medical disease. However, few large, high-quality RCTs exist in most medical diseases.
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital–Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Victoria Stiglbauer
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Jelena Brasanac
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Woo Ri Chae
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- BIH Charité Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Frederike Wagener
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Kim Zimbalski
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Oskar H. Jefsen
- Psychosis Research Unit, Aarhus University Hospital–Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Shuyan Liu
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Malik R. Seals
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Stefanie Gamradt
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph U. Correll
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, New York
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
| | - Stefan M. Gold
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
- Department of Psychosomatic Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Institute of Neuroimmunology and Multiple Sclerosis, Universitätsklinikum Hamburg–Eppendorf, Hamburg, Germany
| | - Christian Otte
- Department of Psychiatry and Neuroscience, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Berlin, Germany
- DZPG (German Center for Mental Health), partner site Berlin, Berlin, Germany
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Gutiérrez-Rojas L, de la Gándara Martín JJ, García Buey L, Uriz Otano JI, Mena Á, Roncero C. Patients with severe mental illness and hepatitis C virus infection benefit from new pangenotypic direct-acting antivirals: Results of a literature review. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:382-396. [PMID: 35718017 DOI: 10.1016/j.gastrohep.2022.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Hepatitis C virus (HCV) infection is a global health problem that can results in cirrhosis, hepatocellular carcinoma and even death. HCV infection is 3-20-fold more prevalent among patients with versus without severe mental illness (SMI), such as major depressive disorder, personality disorder, bipolar disorder and schizophrenia. Treatment options for HCV were formerly based on pegylated interferon alpha, which is associated with neuropsychiatric adverse events, and this contributed to the exclusion of patients with SMI from HCV treatment, elimination programmes, and clinical trials. Moreover, the assumption of poor adherence, scant access to healthcare and the stigma and vulnerability of this population emerged as barriers and contributed to the low rates of treatment and efficacy. METHODS This paper reviews the literature published between December 2010 and December 2020 exploring the epidemiology of HCV in patients with SMI, and vice versa, the effect of HCV infection, barriers to the management of illness in these patients, and benefits of new therapeutic options with pangenotypic direct antiviral agents (DAAs). RESULTS The approval of DAAs has changed the paradigm of HCV infection treatment. DAAs have proven to be an equally efficacious and safe option that improves quality of life (QoL) in patients SMI. CONCLUSIONS Knowledge of the consequences of the HCV infection and the benefits of treatment with new pangenotypic DAAs among psychiatrists can increase screening, referral and treatment of HCV infection in patients with SMI.
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Affiliation(s)
| | | | - Luisa García Buey
- Gastroenterology Department, Liver Unit, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Madrid, Spain
| | - Juan I Uriz Otano
- Gastroenterology Department, Liver Unit, Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Álvaro Mena
- Infectious Diseases Unit, Internal Medicine Service, Clinical Virology Group, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidade da Coruña, Coruña, Spain
| | - Carlos Roncero
- Psychiatry Service, University of Salamanca Health Care Complex and Psychiatric Unit, School of Medicine, Institute of Biomedicine, University of Salamanca, Salamanca, Spain
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Mednova IA, Levchuk LA, Boiko AS, Roschina OV, Simutkin GG, Bokhan NA, Loonen AJM, Ivanova SA. Cytokine level in patients with mood disorder, alcohol use disorder and their comorbidity. World J Biol Psychiatry 2023; 24:243-253. [PMID: 35818961 DOI: 10.1080/15622975.2022.2095439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Because alcohol use disorder (AUD) is often accompanied by mood disorder (MD) and both alcoholism and depression result in activation of the immune system, this study compares serum cytokine levels in the presence of co-morbidity with those in either AUD or MD alone. METHODS In this naturalistic prospective study the levels of 15 different cytokines were measured in serum samples of patients with MD (n = 43), participants with combined AUD-MD (n = 44) and AUD without MD (n = 42). The levels were compared cross-sectionally among themselves and with those in 50 healthy volunteers. RESULTS Pro-inflammatory IFN-2α levels were consistently significantly higher and anti-inflammatory IL-1RA significantly lower in all study groups in comparison to healthy volunteers. In the MD only group we found increased IL-6 (p = 0.001), IL-7 (p = 0.001) and IL-13 (p = 0.006) levels, and decreased TNFα (p = 0.0001), IL-1RA (p = 0.012), IL-10 (p = 0.002) compared with group MD + AUD. Patients with AUD only showed elevated levels of IL-1β (p = 0.046), IL-2 (p = 0.004), IL-7 (p = 0.0001), IL-4 (p = 0.049) and IL-13 (p = 0.015) in contrast with MD + AUD group. CONCLUSIONS Because the interactions of alcohol with peripheral and cerebral immune systems are multifaceted, the pertinent connection to the mechanism how alcohol consumption contributes to the development of mood disorders cannot be properly explored.
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Affiliation(s)
- Irina A Mednova
- Mental Health Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Lyudmila A Levchuk
- Mental Health Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Anastasiia S Boiko
- Mental Health Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Olga V Roschina
- Mental Health Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - German G Simutkin
- Mental Health Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Nikolay A Bokhan
- Mental Health Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation.,Psychiatry, Addictology and Psychotherapy Department, Siberian State Medical University, Tomsk, Russian Federation
| | - Anton J M Loonen
- PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Groningen, The Netherlands
| | - Svetlana A Ivanova
- Mental Health Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation.,Psychiatry, Addictology and Psychotherapy Department, Siberian State Medical University, Tomsk, Russian Federation
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McLauchlan DJ, Lancaster T, Craufurd D, Linden DEJ, Rosser AE. Different depression: motivational anhedonia governs antidepressant efficacy in Huntington's disease. Brain Commun 2022; 4:fcac278. [PMID: 36440100 PMCID: PMC9683390 DOI: 10.1093/braincomms/fcac278] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/13/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Depression is more common in neurodegenerative diseases such as Huntington's disease than the general population. Antidepressant efficacy is well-established for depression within the general population: a recent meta-analysis showed serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants and mirtazapine outperformed other antidepressants. Despite the severe morbidity, antidepressant choice in Huntington's disease is based on Class IV evidence. We used complementary approaches to determine treatment choice for depression in Huntington's disease: propensity score analyses of antidepressant treatment outcome using the ENROLL-HD data set, and a dissection of the cognitive mechanisms underlying depression in Huntington's disease using a cognitive battery based on the Research Domain Criteria for Depression. Study 1 included ENROLL-HD 5486 gene-positive adult patients started on an antidepressant medication for depression. Our outcome measures were depression (Hospital Anxiety and Depression Scale or Problem Behaviours Assessment 'Depressed Mood' item) at first follow-up (primary outcome) and all follow-ups (secondary outcome). The intervention was antidepressant class. We used Svyglm&Twang in R to perform propensity scoring, using known variables (disease progression, medical comorbidity, psychiatric morbidity, sedatives, number of antidepressants, demographics and antidepressant contraindications) to determine the probability of receiving different antidepressants (propensity score) and then included the propensity score in a model of treatment efficacy. Study 2 recruited 51 gene-positive adult patients and 26 controls from the South Wales Huntington's Disease Management Service. Participants completed a motor assessment, in addition to measures of depression and apathy, followed by tasks measuring consummatory anhedonia, motivational anhedonia, learning from reward and punishment and reaction to negative outcome. We used generalised linear models to determine the association between task performance and depression scores. Study 1 showed selective serotonin reuptake inhibitors outperformed serotonin norepinephrine reuptake inhibitors on the primary outcome (P = 0.048), whilst both selective serotonin reuptake inhibitors (P = 0.00069) and bupropion (P = 0.0045) were superior to serotonin norepinephrine reuptake inhibitors on the secondary outcome. Study 2 demonstrated an association between depression score and effort for reward that was not explained by apathy. No other mechanisms were associated with depression score. We found that selective serotonin reuptake inhibitors and bupropion outperform serotonin norepinephrine reuptake inhibitors at alleviating depression in Huntington's disease. Moreover, motivational anhedonia appears the most significant mechanism underlying depression in Huntington's disease. Bupropion is improves motivational anhedonia and has a synergistic effect with selective serotonin reuptake inhibitors. This work provides the first large-scale, objective evidence to determine treatment choice for depression in Huntington's disease, and provides a model for determining antidepressant efficacy in other neurodegenerative diseases.
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Affiliation(s)
- Duncan James McLauchlan
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff CF24 4HQ, UK.,Department of Neurology, Morriston Hospital, Swansea Bay University Health Board, Swansea SA6 6NL, UK
| | - Thomas Lancaster
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff CF24 4HQ, UK.,Cardiff University Brain Research Imaging Center, Cardiff University, Cardiff CF24 4HQ, UK.,Department of Psychology, University of Bath, Bath BA2 7AY, UK
| | - David Craufurd
- Manchester Center for Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Center, Manchester M13 9PL, UK.,St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Center, Manchester M13 9WL, UK
| | - David E J Linden
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff CF24 4HQ, UK.,Cardiff University Brain Research Imaging Center, Cardiff University, Cardiff CF24 4HQ, UK.,Department of Psychology, University of Bath, Bath BA2 7AY, UK.,School for Mental Health and Neuroscience, Fac. Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Anne E Rosser
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff CF24 4HQ, UK.,Department of Neurology, Morriston Hospital, Swansea Bay University Health Board, Swansea SA6 6NL, UK.,School of Biosciences, Cardiff University, Cardiff CF10 3AX, UK
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Influence of gender on cytokine induced depression and treatment: Gender aspects of IFN-α-induced depression. J Affect Disord 2021; 292:766-772. [PMID: 34171555 DOI: 10.1016/j.jad.2021.05.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 03/23/2021] [Accepted: 05/30/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cytokine treatment with Interferon-alpha (IFN-α) represents a clinical model of immune associated depression, but it remains unclear if it is of the same entity as major depressive disorder (MDD). The study focuses on possible gender differences in IFN-α induced depression and effects of a pre-emptive antidepressant treatment. METHODS Data from 181 patients with chronic hepatitis C infection (cHC) without history of mental illnesses undergoing treatment with IFN-α 2a and ribavirin were re-analyzed for gender effects. Patients with a pre-emptive antidepressant therapy with Escitalopram (n = 90, verum group) to prevent IFN-induced depression were compared to patients who received placebo (n = 91). Depressive symptoms before and during HCV-treatment were assessed using the Montgomery-Asberg Depression Rating Scale (MADRS), Beck's Depression Inventory (BDI) and the Hamilton Anxiety Rating Scale. RESULTS We found significant differences regarding the incidence and severity of depressive symptoms between men and women for patients without antidepressant pre-treatment (placebo group). Significantly more women without pre-emptive antidepressant therapy suffered from clinically relevant depression (MADRS values ≥ 13, p = 0.041) and self-rated depressive symptoms (BDI ≥ 17, p = 0.024). Antidepressant pre-treatment showed comparable effects regarding the reduction of incidence and severity of depression in both women and men. CONCLUSIONS Compared to MDD, IFN-alpha-induced depression in patients with cHC is also characterized by gender differences with an increased risk for women but no gender difference regarding the effects of an antidepressant pre-treatment is found. Our data strengthens the hypothesis that Interferon-induced depression serves as a clinical model for immune related depressive disorders.
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Roman M, Irwin MR. Novel neuroimmunologic therapeutics in depression: A clinical perspective on what we know so far. Brain Behav Immun 2020; 83:7-21. [PMID: 31550500 PMCID: PMC6940145 DOI: 10.1016/j.bbi.2019.09.016] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 09/11/2019] [Accepted: 09/20/2019] [Indexed: 12/27/2022] Open
Abstract
Depression, one of the most common mental health disorders, is among the leading causes of health-related disability worldwide. Although antidepressant treatment has been available for decades, depression remains largely refractory to the prevailing limited treatment approach of monoamine transmission modulation. Fortunately, recent evidence points to a link between depression and inflammatory factors within the innate and the adaptive immune system. The purpose of this review is to evaluate current and potential clinical immunotherapies for depression, as contextually focused by an immunologic lens of the pathophysiologic mechanisms of depression. The utility of pro-inflammatory cytokines (primarily interleukin-1β, interleukin -6 and tumor necrosis factor-α) is considered in their role as screening biomarkers in prediction of treatment response or nonresponse. The evidence base of numerous recent clinical studies is discussed as related to their antidepressant efficacy and favorable safety profile, with consideration of multiple agents that target inflammatory mechanisms linked to depression including nonsteroidal anti-inflammatory pathways (i.e., aspirin, celecoxib), cytokine antagonism (i.e., etanercept, infliximab), N-methyl-D-aspartate receptor (NMDA) receptor antagonism (i.e., ketamine), and modulation of kynurenine pathways (i.e., minocycline). Additionally, new and exciting directions in targeting inflammatory mechanisms in the treatment of depression are underway, and future investigation is also warranted to explore the utility of inflammation in diagnosing depression, guiding clinical treatment decision-making, and monitoring disease burden and relapse risk.
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Affiliation(s)
- Michael Roman
- University of Pennsylvania, Psychiatry Residency Program, Philadelphia, PA, United States
| | - Michael R Irwin
- Cousins Center for Psychoneuroimmunology, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, and Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Los Angeles, CA, United States.
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Do statins have an effect on depressive symptoms? A systematic review and meta-analysis. J Affect Disord 2019; 257:55-63. [PMID: 31299405 DOI: 10.1016/j.jad.2019.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Clinical trials of the effects of statins in people with and without depressive symptoms at baseline have yielded conflicting results with studies reporting both an increase and decrease in depressive symptoms. To address these inconsistences, a systematic review and meta-analysis has been conducted to determine the effects of statins on depression in those with or without clinical major depression. METHODS A comprehensive literature search was conducted in MEDLINE, EMBASE and PsychINFO to identify relevant articles that met predefined inclusion and exclusion criteria. The primary outcome measure was the mean difference in depression scores at endpoint between the statin and placebo groups which was computed using random effects model. RESULTS 10 articles were found and used to determine the effects of statins on depressive symptoms. Subgroup analyses were performed to determine the effects of statins in patients with and without depression at baseline. Overall, statin use was associated with significantly lower scores on depression rating scales compared with the placebo use (SMD: -0.309, CI: -0.525, -0.094; p = 0.005). The subgroup analysis showed significant effects in the depressed population (SMD: -0.796, CI: -1.107, -0.486, p = 0.001) but not in the non-depressed population (SMD: -0.153, CI: -0.353, 0.047, p = 0.113). LIMITATIONS There was high heterogeneity in the studies included and only two studies had low risk of bias. CONCLUSION The results suggest that statins are effective in improving depressive symptoms, particularly in those with clinical depression and that they do not worsen depression in non-depressed subjects.
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Liao Y, Xie B, Zhang H, He Q, Guo L, Subramanieapillai M, Fan B, Lu C, McIntyre RS. Efficacy of omega-3 PUFAs in depression: A meta-analysis. Transl Psychiatry 2019; 9:190. [PMID: 31383846 PMCID: PMC6683166 DOI: 10.1038/s41398-019-0515-5 10.1038/s41398-021-01582-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/29/2019] [Accepted: 06/01/2019] [Indexed: 08/13/2023] Open
Abstract
We conducted this meta-analysis of double-blind randomized placebo-controlled trials to estimate the efficacy of omega-3 polyunsaturated fatty acids (PUFAs), especially docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), in the improvement of depression. We applied a systematic bibliographic search in PubMed and EMBASE for articles published prior to 20 December 2017. This meta-analysis was performed using RevMan 5.3 and R 3.4.3, and means and standard deviations were calculated in fixed- or random-effects models based on the results of the Q-test. A sensitivity analysis was also conducted to evaluate the stability of the results, and publication bias was evaluated by a funnel plot and Egger's linear regression analysis. Our search resulted in 180 articles; we analyzed 26 studies, which included 2160 participants. The meta-analysis showed an overall beneficial effect of omega-3 polyunsaturated fatty acids on depression symptoms (SMD = -0.28, P = 0.004). Compared with placebo, EPA-pure (=100% EPA) and EPA-major formulations (≥60% EPA) demonstrated clinical benefits with an EPA dosage ≤1 g/d (SMD = -0.50, P = 0.003, and SMD = -1.03, P = 0.03, respectively), whereas DHA-pure and DHA-major formulations did not exhibit such benefits.Current evidence supports the finding that omega-3 PUFAs with EPA ≥ 60% at a dosage of ≤1 g/d would have beneficial effects on depression. Further studies are warranted to examine supplementation with omega-3 PUFAs for specific subgroups of subjects with inflammation, severity of depression, and the dose response for both EPA and DHA supplementation.
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Affiliation(s)
- Yuhua Liao
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, People's Republic of China
| | - Bo Xie
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, People's Republic of China
| | - Huimin Zhang
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, People's Republic of China
| | - Qian He
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, People's Republic of China
| | - Lan Guo
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Mehala Subramanieapillai
- Mood Disorders Psychopharmacology Unit, University Health Network; Department of Psychiatry, University of Toronto; Institute of Medical Science, University of Toronto; Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
| | - Beifang Fan
- Department of Psychiatry, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, People's Republic of China.
| | - Ciyong Lu
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, People's Republic of China.
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network; Department of Psychiatry, University of Toronto; Institute of Medical Science, University of Toronto; Department of Pharmacology, University of Toronto, Toronto, Ontario, Canada
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Efficacy of omega-3 PUFAs in depression: A meta-analysis. Transl Psychiatry 2019; 9:190. [PMID: 31383846 PMCID: PMC6683166 DOI: 10.1038/s41398-019-0515-5] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/29/2019] [Accepted: 06/01/2019] [Indexed: 01/05/2023] Open
Abstract
We conducted this meta-analysis of double-blind randomized placebo-controlled trials to estimate the efficacy of omega-3 polyunsaturated fatty acids (PUFAs), especially docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), in the improvement of depression. We applied a systematic bibliographic search in PubMed and EMBASE for articles published prior to 20 December 2017. This meta-analysis was performed using RevMan 5.3 and R 3.4.3, and means and standard deviations were calculated in fixed- or random-effects models based on the results of the Q-test. A sensitivity analysis was also conducted to evaluate the stability of the results, and publication bias was evaluated by a funnel plot and Egger's linear regression analysis. Our search resulted in 180 articles; we analyzed 26 studies, which included 2160 participants. The meta-analysis showed an overall beneficial effect of omega-3 polyunsaturated fatty acids on depression symptoms (SMD = -0.28, P = 0.004). Compared with placebo, EPA-pure (=100% EPA) and EPA-major formulations (≥60% EPA) demonstrated clinical benefits with an EPA dosage ≤1 g/d (SMD = -0.50, P = 0.003, and SMD = -1.03, P = 0.03, respectively), whereas DHA-pure and DHA-major formulations did not exhibit such benefits.Current evidence supports the finding that omega-3 PUFAs with EPA ≥ 60% at a dosage of ≤1 g/d would have beneficial effects on depression. Further studies are warranted to examine supplementation with omega-3 PUFAs for specific subgroups of subjects with inflammation, severity of depression, and the dose response for both EPA and DHA supplementation.
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Feng J, Wang M, Li M, Yang J, Jia J, Liu L, Zhou J, Zhang C, Wang X. Serum miR-221-3p as a new potential biomarker for depressed mood in perioperative patients. Brain Res 2019; 1720:146296. [PMID: 31211948 DOI: 10.1016/j.brainres.2019.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 01/04/2023]
Abstract
MicroRNAs (miRNAs) modulate various genes associated with brain disorders and circulating miRNAs may therefore serve as biomarkers for these neurological diseases. We previously found that the miRNA miR-221-3p was highly expressed in cerebrospinal fluid and the serum of major depressive disorder (MDD) patients. Here, we examined whether miR-221-3p could be used as a biomarker for depressed mood in perioperative patients. We first examined the relative expression of serum miR-221-3p by real-time quantitative PCR in perioperative patients with different degrees of depressive mood assessed by the Patient Health Questionnaire-9 (PHQ-9) diagnostic form. We found that miR-221-3p expression in the mild depressive mood group (PHQ-9 scores 5-9) was 2.21 fold that of the normal group (PHQ-9 scores 0-4) and the moderate&severe depressive mood group (PHQ-9 scores ≥ 10) showed miR-221-3p expression levels 3.66 fold that of the normal group. Then the absolute quantification of serum miR-221-3p was obtained using an miRNA standard curve. We found that the amount of serum miR-221-3p was positively correlated with depressed mood; when serum miR-221-3p > 1.7 × 107 copies/μg RNA, all indicated PHQ-9 scores were higher than 6. Subsequently, we found that miR-221-3p could indirectly increase the expression of IFN-α (Interferon alpha) in astrocytes by targeting IRF2 (Interferon Regulatory Factor 2) and that miR-221-3p participated in the anti-neuroinflammatory signaling cascades induced by ketamine and paroxetine via the IRF2/IFN-α pathway. Our results indicate that elevated serum miR-221-3p can be used as a biomarker for depressed mood in perioperative patients and that IFN-α-induced NF-κB activation in astrocytes mediated by miR-221-3p targeting of IRF2 may be one of the potential mechanisms.
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Affiliation(s)
- Jianguo Feng
- Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Maozhou Wang
- Department of Intensive Care Unit, The Affiliated Chaoyang Hospital of Capital Medical University, Beijing, China
| | - Mao Li
- Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Jimei Yang
- Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Jing Jia
- Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Jun Zhou
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Chunxiang Zhang
- Department of Biomedical Engineering, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Xiaobin Wang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China.
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Chen VCH, Lu ML, Yang YH, Weng JC, Chang CC. Antidepressant use and hepatocellular carcinoma in patients with hepatitis C who had received interferon therapy: A population-based cohort study. J Affect Disord 2019; 253:147-153. [PMID: 31035215 DOI: 10.1016/j.jad.2019.04.093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/24/2019] [Accepted: 04/21/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Using data from the National Health Insurance (NHI) of Taiwan, we conducted a nationwide population-based cohort study to investigate the association between antidepressant (ATD) use and the risk of hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV) who had received interferon (IFN) therapy. METHODS This study included a total of 274,952 HCV-infected patients without hepatitis B virus infection who were enrolled in the NHI program between January 1, 1997 and December 31, 2013. Among these patients, only 10,713 (age ≥18 years) had received IFN therapy between 2004 and 2008. Among the patients who had received IFN therapy, 2014 had received ATDs, and 8684 had not. A Cox proportional hazards regression model was applied after adjusting for age, sex, income, urbanization, medical comorbidity, and medication use. RESULTS Compared with non-ATD-treated patients, ATD-treated patients were more likely to receive a diagnosis of alcohol-related disease, diabetes mellitus (DM), hypertension, and hyperlipidemia. ATD-treated patients had a significantly lower incidence of HCC than non-ATD-treated patients (P = 0.0019). Female, older (age ≥50 years), and non-DM patients who had received cumulative high doses of ATDs had a significantly lower risk of HCC than non-ATD-treated patients. After adjustment, only high-dose selective serotonin reuptake inhibitor (SSRI) use was inversely associated with HCC risk (adjusted hazard ratio 0.37, 95% confidence interval 0.19-0.71, P = 0.0027). CONCLUSIONS Our study showed that ATD use, especially a relatively high cumulative dose of SSRIs, in HCV-infected patients who had received IFN was associated with reduced HCC risk. Future clinical studies are warranted to explore the underlying mechanisms and to apply them to newer direct-acting antiviral agent treatments.
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Affiliation(s)
- Vincent Chin-Hung Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Mong-Liang Lu
- Department of Psychiatry, Wan Fang Hospital & School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yao-Hsu Yang
- Center of Excellence for Chang Gung Research Datalink, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Jun-Cheng Weng
- Department of Psychiatry, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chen Chang
- Department of Psychiatry, Changhua Christian Hospital, No.135, Nanxiao Street, Changhua 50006, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Center of General Education, Tunghai University, Taichung, Taiwan.
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13
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Honko AN, Johnson JC, Marchand JS, Huzella L, Adams RD, Oberlander N, Torzewski LM, Bennett RS, Hensley LE, Jahrling PB, Olinger GG. High dose sertraline monotherapy fails to protect rhesus macaques from lethal challenge with Ebola virus Makona. Sci Rep 2017; 7:5886. [PMID: 28725019 PMCID: PMC5517626 DOI: 10.1038/s41598-017-06179-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/07/2017] [Indexed: 11/09/2022] Open
Abstract
The recent epidemic of Ebola virus disease in West Africa resulted in an unprecedented number of cases and deaths. Due to the scope of the outbreak combined with the lack of available approved treatment options, there was strong motivation to investigate any potential drug which had existing data reporting anti-Ebola activity. Drugs with demonstrated antiviral activity in the nonhuman primate models already approved for another indication or for which there was existing safety data were considered to be priorities for evaluation by the World Health Organization. Sertraline hydrochloride was reported to have anti-Ebola activity in vitro alone and in combination with other approved drugs. Although the efficacy was less than 100% in the murine model, the established safety profile of this product, the potential benefit alone and in combination, as well as the lack of other available options prioritized this compound for testing in the Ebola virus intramuscular rhesus macaque challenge model. Using a blinded dosing strategy, we demonstrated that high dose sertraline monotherapy provided no benefit for the prevention of Ebola virus disease in rhesus macaques with regards to reduction of viral load, morbidity, or survival highlighting the challenges of translating results between in vitro and in vivo models.
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Affiliation(s)
- Anna N Honko
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA.
| | - Joshua C Johnson
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Jonathan S Marchand
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Louis Huzella
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Ricky D Adams
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Nicholas Oberlander
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
- BD Technologies/Charles River Labs, Research Triangle Park, 27709, North Carolina, USA
| | - Lisa M Torzewski
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Richard S Bennett
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Lisa E Hensley
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Peter B Jahrling
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
| | - Gene G Olinger
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, 21702, Maryland, USA
- MRIGlobal-Global Health Surveillance and Diagnostics, Gaithersburg, Maryland, 20878, USA
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Abstract
Statins are used widely in primary and secondary prevention of cardiovascular disease; a treatment effect that has long been thought to be due to their cholesterol-lowering properties. However, statins also have a wide range of anti-inflammatory effects independent of their lipid-lowering mechanisms. In depression, low-grade inflammation is a replicated finding, and several studies have shown antidepressant properties of diverse anti-inflammatory drugs. Large observational studies have suggested reduced risks of depression amongst those taking statins, an effect that is thought to be explained by the anti-inflammatory properties of this class of drugs. Also, preliminary randomized controlled trials (RCTs) have indicated that statins may have adjunctive antidepressant effects when used as add-on treatment to selective serotonin reuptake inhibitors (SSRIs). However, the RCTs were small and limited by low generalizability, and some early observational studies have pointed towards potential neuropsychiatric adverse effects of statin treatment. Nevertheless, based on the good tolerability and general safety of the statins, researchers are currently investigating the potential antidepressant properties of these agents. The present review aims to give an overview on the potential antidepressant effects of statins based on their anti-inflammatory properties, covering topics such as safety versus treatment effects, potential mechanisms of action and the possibility of targeted treatment (precision medicine).
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital, Skovagervej 2, 8240, Risskov, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark. .,Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Christiane Gasse
- National Centre for Register-Based Research (NCRR), Aarhus University, Aarhus, Denmark.,iPSYCH, The Lundbeck Initiative for Integrated Research in Psychiatry, Aarhus, Denmark
| | - Michael Berk
- Deakin University, School of Medicine, IMPACT Strategic Research Centre, Geelong, VIC, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia.,The Florey Institute for Neuroscience and Mental Health, Parkville, VIC, Australia.,Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Søren Dinesen Østergaard
- Psychosis Research Unit, Aarhus University Hospital, Skovagervej 2, 8240, Risskov, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Nadeem A, Siddiqui N, Al-Harbi NO, Attia SM, AlSharari SD, Ahmad SF. Acute lung injury leads to depression-like symptoms through upregulation of neutrophilic and neuronal NADPH oxidase signaling in a murine model. Int Immunopharmacol 2017; 47:218-226. [PMID: 28433943 DOI: 10.1016/j.intimp.2017.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 02/07/2023]
Abstract
There is an increased prevalence of comorbid major depressive disorders with a number of inflammatory conditions which is thought to result from activation of the immune system. Acute lung injury (ALI) in humans has been also shown to be associated with depression previously. However, no study has explored the mechanism behind ALI-induced depression. NADPH oxidase (NOX-2) derived reactive oxygen species (ROS) are associated with neuropsychiatric disorders including depression. ROS generation via NOX-2 is also shown to be involved in the pathogenesis of ALI. Therefore, we hypothesized that ROS generation may be a common link between ALI and depression. The present study utilized LPS model of ALI in mice to explore the effect of lung inflammation on depression-like behavior and further delineate the role of NOX-2 signaling in it. ALI led to enhanced NOX-2 activation in neutrophils/brain and neuronal oxidative stress which was concurrent with depression-like symptoms as assessed by sucrose preference and tail suspension test. Role of neutrophilic NOX-2 in ALI-induced depression was confirmed by depletion of neutrophils as well NOX-2 inhibitor, apocynin. Both of these approaches led to reduction in depressive symptoms induced by ALI. The present study suggests that ALI-induced upregulation of neutrophilic NOX-2/ROS may contribute to depression-like symptoms in mice.
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Affiliation(s)
- Ahmed Nadeem
- Department of Pharmacology & Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
| | - Nahid Siddiqui
- Amity Institute of Biotechnology, Amity University, Noida, India
| | - Naif O Al-Harbi
- Department of Pharmacology & Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Sabry M Attia
- Department of Pharmacology & Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Shakir D AlSharari
- Department of Pharmacology & Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Sheikh F Ahmad
- Department of Pharmacology & Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Kohler O, Krogh J, Mors O, Benros ME. Inflammation in Depression and the Potential for Anti-Inflammatory Treatment. Curr Neuropharmacol 2017; 14:732-42. [PMID: 27640518 PMCID: PMC5050394 DOI: 10.2174/1570159x14666151208113700] [Citation(s) in RCA: 329] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/19/2015] [Accepted: 11/03/2015] [Indexed: 01/19/2023] Open
Abstract
Accumulating evidence supports an association between depression and inflammatory processes, a connection that seems to be bidirectional. Clinical trials have indicated antidepressant treatment effects for anti-inflammatory agents, both as add-on treatment and as monotherapy. In particular, nonsteroidal anti-inflammatory drugs (NSAIDs) and cytokine-inhibitors have shown antidepressant treatment effects compared to placebo, but also statins, poly-unsaturated fatty acids, pioglitazone, minocycline, modafinil, and corticosteroids may yield antidepressant treatment effects. However, the complexity of the inflammatory cascade, limited clinical evidence, and the risk for side effects stress cautiousness before clinical application. Thus, despite proof-of-concept studies of anti-inflammatory treatment effects in depression, important challenges remain to be investigated. Within this paper, we review the association between inflammation and depression together with the current evidence on use of anti-inflammatory treatment in depression. Based on this, we address the questions and challenges that seem most important and relevant to future studies, such as timing, most effective treatment lengths and identification of subgroups of patients potentially responding better to different anti-inflammatory treatment regimens.
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Affiliation(s)
- Ole Kohler
- Psychosis Research Unit, Aarhus University Hospital, Risskov, P.O. Box: Skovagervej 2, DK-8240, Risskov, Denmark
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Martin-Subero M, Diez-Quevedo C. Mental disorders in HIV/HCV coinfected patients under antiviral treatment for hepatitis C. Psychiatry Res 2016; 246:173-181. [PMID: 27718466 DOI: 10.1016/j.psychres.2016.09.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 07/27/2016] [Accepted: 09/24/2016] [Indexed: 12/14/2022]
Abstract
This paper aims to review the epidemiology and management of mental disorders in human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfected patients, the need for antiviral therapy in this specific population, and current treatment strategies for HIV/HCV patients with psychiatric and/or substance use disorders. This is a narrative review. Data was sourced from electronic databases and was not limited by language or date of publication. HIV infection has become a survivable chronic illness. Prevalence of HCV infection among HIV-infected patients is high ranging from 50% to 90%. Patients with psychiatric diseases have also an increased risk for HIV/HCV coinfection. The most effective strategy to decrease HCV-related morbidity and mortality in coinfection is to achieve viral eradication. Although psychiatric symptoms often appear during antiviral treatment and may be associated with the use of interferon-alpha (IFN-α), recent evidence suggests that many patients with comorbid mental and substance use disorders can be treated safely. Recent data indicate that IFNα-induced psychiatric side effects have a similar prevalence in HIV/HCV coinfected patients than in monoinfected patients and they can be managed and even prevented successfully with psychopharmacological strategies in the frame of a multidisciplinary team. New antivirals offer INF-free therapies for this specific population.
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Affiliation(s)
- Marta Martin-Subero
- FIDMAG Research Foundation, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Badalona, Spain.
| | - Crisanto Diez-Quevedo
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Badalona, Spain; Department of Psychiatry, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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Abstract
Severe, recalcitrant dermatologic conditions often require systemic treatment. Although efficacious, these medications have been associated with wide-ranging adverse reactions. Some are reversible, predictable, and either dose-dependent or treatment length-dependent, while others are unpredictable, irreversible, and potentially fatal. This review examines the neuropsychiatric adverse effects associated with US FDA-approved medications for treatment of the following dermatologic pathologies that typically require systemic therapy: autoimmune dermatoses, acne, psoriasis, and melanoma. A search of the literature was performed, with adverse effects ranging from mild headaches and neuropathy to severe encephalopathies. The medications associated with the most serious reactions were those used to treat psoriasis, especially the older non-biologic medications such as cyclosporine A and methotrexate. Given the importance of these systemic dermatologic therapies in treating severe, recalcitrant conditions, and the wide variety of potentially serious neuropsychiatric adverse effects of these medications, neurologists, psychiatrists, dermatologists, oncologists, and primary care providers must be aware of the potential for these neuropsychiatric adverse reactions to allow for appropriate counseling, management, and medication withdrawal.
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Hallahan B, Ryan T, Hibbeln JR, Murray IT, Glynn S, Ramsden CE, SanGiovanni JP, Davis JM. Efficacy of omega-3 highly unsaturated fatty acids in the treatment of depression. Br J Psychiatry 2016; 209:192-201. [PMID: 27103682 PMCID: PMC9406129 DOI: 10.1192/bjp.bp.114.160242] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 07/05/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Trials evaluating efficacy of omega-3 highly unsaturated fatty acids (HUFAs) in major depressive disorder report discrepant findings. AIMS To establish the reasons underlying inconsistent findings among randomised controlled trials (RCTs) of omega-3 HUFAs for depression and to assess implications for further trials. METHOD A systematic bibliographic search of double-blind RCTs was conducted between January 1980 and July 2014 and an exploratory hypothesis-testing meta-analysis performed in 35 RCTs including 6665 participants receiving omega-3 HUFAs and 4373 participants receiving placebo. RESULTS Among participants with diagnosed depression, eicosapentaenoic acid (EPA)-predominant formulations (>50% EPA) demonstrated clinical benefits compared with placebo (Hedge's G = 0.61, P<0.001) whereas docosahexaenoic acid (DHA)-predominant formulations (>50% DHA) did not. EPA failed to prevent depressive symptoms among populations not diagnosed for depression. CONCLUSIONS Further RCTs should be conducted on study populations with diagnosed or clinically significant depression of adequate duration using EPA-predominant omega-3 HUFA formulations.
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Affiliation(s)
- Brian Hallahan
- Brian Hallahan, MRCPsych, MD, Department of Psychiatry, Clinical Science Institute, National University of Ireland Galway, Galway, Ireland; Timothy Ryan, BA, Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois, USA; Joseph R. Hibbeln, MD, Section on Nutritional Neurosciences, Laboratory of Membrane Biochemistry & Biophysics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland, USA; Ivan T. Murray, MRCPsych, Department of Psychiatry, University Hospital Galway, Galway, Ireland; Shauna Glynn, MRCPsych, Child and Adolescent Mental Health Services, Castlebar, Mayo, Ireland; Christopher E. Ramsden, MD, John Paul SanGiovanni, ScD, Section on Nutritional Neurosciences, Laboratory of Membrane Biochemistry & Biophysics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland, USA; John M. Davis, MD, Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois, USA
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20
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Editorial overview: Immunomodulation: Exploiting the circle between emotions and immunity: impact on pharmacological treatments. Curr Opin Pharmacol 2016; 29:viii-xii. [DOI: 10.1016/j.coph.2016.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Kovacs D, Kovacs P, Eszlari N, Gonda X, Juhasz G. Psychological side effects of immune therapies: symptoms and pathomechanism. Curr Opin Pharmacol 2016; 29:97-103. [PMID: 27456240 DOI: 10.1016/j.coph.2016.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/22/2016] [Indexed: 01/09/2023]
Abstract
Immunotherapies revolutionised the treatment of several disorders but show specific side-effect profiles which frequently involve psychological symptoms. Long term interferon-alpha (IFN-alpha) therapy can cause wide-ranging psychiatric side-effects from fatigue, insomnia, anxiety to full-blown depression. This treatment-emergent depression shares several symptoms with major depressive disorder (MDD) with a predominance of somatic/neurovegetative symptoms, and can be treated with antidepressants. However, this experience directed research to inflammatory mechanisms in MDD. MDD has been confirmed as a heterogeneous disorder with a subgroup of patients suffering from low-grade chronic inflammation and frequently resistant to traditional antidepressant treatment. Thus future research should develop strategies to identify those MDD patients who could benefit from drugs acting through inflammatory pathways.
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Affiliation(s)
- David Kovacs
- MTA-SE Neuropsychopharmacology and Neurochemistry Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Peter Kovacs
- MTA-SE Neuropsychopharmacology and Neurochemistry Research Group, Hungarian Academy of Sciences, Budapest, Hungary; National Institute of Oncology, Budapest, Hungary
| | - Nora Eszlari
- MTA-SE Neuropsychopharmacology and Neurochemistry Research Group, Hungarian Academy of Sciences, Budapest, Hungary; Department of Pharmacodynamics, Semmelweis University, Budapest, Hungary
| | - Xenia Gonda
- MTA-SE Neuropsychopharmacology and Neurochemistry Research Group, Hungarian Academy of Sciences, Budapest, Hungary; Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Kútvölgyi u.4, Budapest, Hungary
| | - Gabriella Juhasz
- MTA-SE Neuropsychopharmacology and Neurochemistry Research Group, Hungarian Academy of Sciences, Budapest, Hungary; Department of Pharmacodynamics, Semmelweis University, Budapest, Hungary; Neuroscience and Psychiatry Unit, University Manchester, Manchester, UK; MTA-SE-NAP B Genetic Brain Imaging Migraine Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.
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Herold S, Freudenreich O. Hepatitis C Virus and Schizophrenia: Expanding the Role of the Community Psychiatrist. PSYCHOSOMATICS 2016; 57:634-637. [PMID: 27418108 DOI: 10.1016/j.psym.2016.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 01/21/2023]
Affiliation(s)
- Sarah Herold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Erich Lindemann Mental Health Center, Boston, MA.
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA; Erich Lindemann Mental Health Center, Boston, MA; Harvard Medical School, Boston, MA
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Norepinephrine-enhancing antidepressant exposure associated with reduced antiviral effect of interferon alpha on hepatitis C. Psychopharmacology (Berl) 2016; 233:1689-94. [PMID: 25971875 DOI: 10.1007/s00213-015-3956-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 05/05/2015] [Indexed: 01/31/2023]
Abstract
RATIONALE Major depressive disorder is a common consequence of exposure to the pro-inflammatory cytokine interferon alpha, which is treated effectively with antidepressant medication. Antidepressant mode of action may conflict with interferon alpha's mechanism in treating hepatitis C however. OBJECTIVES The purpose of this study is to prospectively explore, in a large naturalistic cohort, whether antidepressant exposure influenced end of treatment response of hepatitis C to interferon alpha. METHODS Two hundred thirty-nine patients infected with chronic hepatitis C and due to receive treatment were recruited. All participants initiated peg-interferon-2-alpha 180 μg weekly sub-cutaneously plus oral ribavirin 800-1200 mg daily. Participants were assessed for DSM-IV major depression at baseline and four weekly during treatment. RESULTS 32.6 % of the cohort was exposed to an antidepressant (serotonin-reuptake inhibitor: other categorised antidepressants 49:29). At baseline, 3.8 % had major depression and 55.2 % developed major depression during interferon alpha treatment. Exposure to an antidepressant not classified as a serotonin-reuptake inhibitor, of which all were norepinephrine-enhancing (OR 0.15, 95 % CI 0.04-0.60) and having a past history of psychiatric disorder (OR 4.41, 95 % CI 1.39-13.96) independently reduced the likelihood of end of treatment response. Serotonin-reuptake inhibitor exposure did not influence end of treatment response (OR 1.21, 95 % CI 0.35-4.19), neither did major depression at baseline (OR 2.31, 95 % CI 0.55-9.60) or during treatment (OR 0.69, 95 % CI 0.36-1.33). CONCLUSIONS Our findings support a lack of conflict of therapeutic mechanism of serotonin-reuptake inhibitor antidepressants with interferon alpha in treating hepatitis C, which may include inflammatory influence. This appears not to be true for norepinephrine-enhancing antidepressant types and warrants investigation using more direct methods.
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Dumitrescu AL. Depression and Inflammatory Periodontal Disease Considerations-An Interdisciplinary Approach. Front Psychol 2016; 7:347. [PMID: 27047405 PMCID: PMC4804721 DOI: 10.3389/fpsyg.2016.00347] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 02/25/2016] [Indexed: 12/18/2022] Open
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Whale R, Fialho R, Rolt M, Eccles J, Pereira M, Keller M, File A, Haq I, Tibble J. Psychomotor retardation and vulnerability to interferon alpha induced major depressive disorder: Prospective study of a chronic hepatitis C cohort. J Psychosom Res 2015; 79:640-5. [PMID: 26117091 DOI: 10.1016/j.jpsychores.2015.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 06/09/2015] [Accepted: 06/11/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) is a common consequence of interferon alpha (IFNα) treatment and important supporting evidence of a role of inflammation in the aetiology of depression. OBJECTIVE This study aimed to expand the knowledge of baseline clinical vulnerability characteristics to IFNα induced MDD, particularly exploring sub-threshold depressive symptoms. METHODS A prospective cohort of chronic HCV patients undergoing treatment with pegylated-IFNα and ribavirin was studied. MDD was assessed using the Structured Clinical Interview for DSM-IV (SCID-I). Depressive symptoms and severity were assessed at baseline and monthly with the Hamilton Depression Rating Scale (HAMD). Subjects with MDD or taking antidepressant treatment at baseline were excluded. RESULTS 278 patients were assessed for this cohort with a final study sample of 190. 94.2% had contracted HCV through intravenous drug use. During six months IFNα treatment, 53.2% of patients transitioned to DSM-IV threshold MDD. In the multivariate logistic analysis, independent factors significantly associated with development of MDD were younger age (OR 0.96, 95% CI 0.93-1.00, p=0.028), past history of MDD (OR 3.82, 95% CI 1.63-8.92, p=0.002), baseline HAMD items psychomotor retardation (OR 15.21, 95% CI 1.33-173.41, p=0.032) and somatic symptoms (general) (OR 2.96, 95% CI 1.44-6.08, p=0.003), and HCV genotype 2 (OR 2.27, 95% CI 1.07-4.78, p=0.032). CONCLUSIONS During IFNα treatment, the rate of transition to MDD was high in this cohort. Psychomotor retardation and somatic symptoms may represent a greater inflamed state pre-treatment. This iatrogenic model of MDD may offer important insights into wider depression aetiology.
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Affiliation(s)
- Richard Whale
- Brighton and Sussex Medical School, United Kingdom; Sussex Partnership NHS Foundation Trust, United Kingdom.
| | - Renata Fialho
- Sussex Partnership NHS Foundation Trust, United Kingdom; School of Psychology, University of Sussex, United Kingdom.
| | - Michael Rolt
- Sussex Partnership NHS Foundation Trust, United Kingdom; School of Psychology, University of Sussex, United Kingdom.
| | - Jessica Eccles
- Brighton and Sussex Medical School, United Kingdom; Sussex Partnership NHS Foundation Trust, United Kingdom.
| | - Marco Pereira
- Faculty of Psychology and Educational Sciences, University of Coimbra, Portugal.
| | - Majella Keller
- Digestive Diseases Centre, Brighton and Sussex University Hospitals NHS Trust, United Kingdom.
| | - Alexandra File
- Digestive Diseases Centre, Brighton and Sussex University Hospitals NHS Trust, United Kingdom.
| | - Inam Haq
- Digestive Diseases Centre, Brighton and Sussex University Hospitals NHS Trust, United Kingdom.
| | - Jeremy Tibble
- Digestive Diseases Centre, Brighton and Sussex University Hospitals NHS Trust, United Kingdom.
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Staufer K, Scherzer TM, Miehsler W, Reichhold D, Kienbacher C, Ferenci-Förster D, Hagmann M, Ferenci P, Moser G. Self-reported need for psychotherapy predicts interferon-induced depression in hepatitis C: stratification for interferon-free treatment. Antivir Ther 2015; 20:501-6. [PMID: 25573901 DOI: 10.3851/imp2931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Interferon (IFN)-induced depression occurs in approximately 30% of chronic hepatitis C (CHC) patients undergoing pegylated (PEG)-IFN-based antiviral therapy. While IFN-free therapy has been developed, it is not accessible to all CHC patients due to the high costs of treatment. This study evaluated the Assessment of Demand for Additional Psychological Treatment (ADAPT) questionnaire as a screening tool for patients at risk of IFN-induced depression, in order to identify patients who may uniquely benefit from IFN-free regimens. METHODS In this prospective study, consecutive patients being treated for CHC with PEG-IFN-based antiviral therapy were examined for the occurrence of depression during a 12-week treatment period. Using univariate and multivariate regression models, the value of the ADAPT questionnaire, in comparison to the Hospital Anxiety and Depression Scale (HADS), and the patients' psychiatric history was analysed. RESULTS A total of 103 patients (59% male; median age 42) were included, of whom 25% (26/103) developed IFN-induced depression during the study period. HADS-Depression (D) subscale (OR=1.187, P=0.003; area under the curve [AUC]=0.690) and ADAPT-Psychotherapy (PT) subscale (OR=1.020, P=0.006; AUC=0.695) showed the highest accuracy for identification of patients at risk for depression. A HADS-D score of ≥7 and an ADAPT-PT score of ≥37.8 showed a similar sensitivity (61.5% versus 57.7%), whereas ADAPT-PT showed a more favourable specificity (68.9% versus 77.4%). CONCLUSIONS The ADAPT-PT subscale effectively identifies patients at risk for IFN-induced depression and should therefore be taken into account when allocating patients to IFN-free antiviral treatment regimens.
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Affiliation(s)
- Katharina Staufer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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Sarkar S, Sarkar R, Berg T, Schaefer M. Sadness and mild cognitive impairment as predictors for interferon-alpha-induced depression in patients with hepatitis C. Br J Psychiatry 2015; 206:45-51. [PMID: 25359924 DOI: 10.1192/bjp.bp.113.141770] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antiviral therapy with interferon-alpha (IFN-α) for hepatitis C virus (HCV) infection is associated with increased risk for depression. AIMS To identify clinical predictors for IFN-α-induced depression during antiviral therapy for HCV infection. METHOD Depression (defined with the Montgomery-Åsberg Depression Rating Scale (MADRS)) was evaluated before and during antiviral treatment in 91 people with chronic HCV infection without a history of psychiatric disorders. Cognitive function was evaluated using the Trail Making Test A/B (TMT A/B). (Trial registration at ClinicalTrials.gov: NCT00136318.) RESULTS Depression during antiviral therapy was significantly associated with a baseline MADRS score of 3 or higher (P = 0.006). In total, 89% (n = 16) of patients who had a baseline score >0 for the single item sadness developed depression. Poor baseline performance in the TMT A (P = 0.027) and TMT B (P = 0.033) was predictive for severe depression. CONCLUSIONS Pre-treatment screening for subthreshold depressive and cognitive symptoms will help to identify those at risk for IFN-α-associated depression among patients with chronic hepatitis C.
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Affiliation(s)
- Susanne Sarkar
- Susanne Sarkar, PhD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department and Outpatient Clinic of Medical Psychology, Center of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg; Rahul Sarkar, MD, Department of Psychiatry and Psychotherapy, Asklepios Westklinikum Hamburg-Klinikum, Hamburg; Thomas Berg, MD, Department of Gastroenterology und Rheumatology, Section of Hepatology, Universitätsklinikum, Leipzig; Martin Schaefer, MD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany
| | - Rahul Sarkar
- Susanne Sarkar, PhD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department and Outpatient Clinic of Medical Psychology, Center of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg; Rahul Sarkar, MD, Department of Psychiatry and Psychotherapy, Asklepios Westklinikum Hamburg-Klinikum, Hamburg; Thomas Berg, MD, Department of Gastroenterology und Rheumatology, Section of Hepatology, Universitätsklinikum, Leipzig; Martin Schaefer, MD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany
| | - Thomas Berg
- Susanne Sarkar, PhD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department and Outpatient Clinic of Medical Psychology, Center of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg; Rahul Sarkar, MD, Department of Psychiatry and Psychotherapy, Asklepios Westklinikum Hamburg-Klinikum, Hamburg; Thomas Berg, MD, Department of Gastroenterology und Rheumatology, Section of Hepatology, Universitätsklinikum, Leipzig; Martin Schaefer, MD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany
| | - Martin Schaefer
- Susanne Sarkar, PhD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department and Outpatient Clinic of Medical Psychology, Center of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg; Rahul Sarkar, MD, Department of Psychiatry and Psychotherapy, Asklepios Westklinikum Hamburg-Klinikum, Hamburg; Thomas Berg, MD, Department of Gastroenterology und Rheumatology, Section of Hepatology, Universitätsklinikum, Leipzig; Martin Schaefer, MD, Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité, Mitte, Berlin, and Department of Psychiatry, Psychotherapy and Addiction Medicine, Kliniken Essen-Mitte, Essen, Germany
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