Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials

Novel mechanisms underlying rapid-acting antidepressants: ketamine-like compounds, neurosteroid GABAkines, and psychedelics

The discovery of the rapid antidepressant action of ketamine accelerated the identification of new molecules that are associated with fast and prolonged relief of depressive symptoms. As a result, a new group of antidepressants have emerged, some of them already approved for clinical use, classified as rapid-acting antidepressant drugs (RAADs). Potentiation of brain-derived neurotrophic factor (BDNF) or activation of the GABAA receptors are the main mechanisms behind the notable properties of RAADs, a mainstream topic in the field of pharmacology and drug discovery that deserves an updated review.

Unlocking the Potential of Wear Time of a Wearable Device to Enhance Postpartum Depression Screening and Detection: Cross-Sectional Study

BACKGROUND

Postpartum depression (PPD) is a mood disorder affecting 1 in 7 women after childbirth that is often underscreened and underdetected. If not diagnosed and treated, PPD is associated with long-term developmental challenges in the child and maternal morbidity. Wearable technologies, such as smartwatches and fitness trackers (eg, Fitbit), offer continuous and longitudinal digital phenotyping for mood disorder diagnosis and monitoring, with device wear time being an important yet understudied aspect.

OBJECTIVE

We aimed to suggest that wear time of a wearable device may provide additional information about perinatal mental health to facilitate screening and early detection of PPD. We proposed that wear time of a wearable device may also be valuable for managing other mental health disorders.

METHODS

Using the All of Us Research Program dataset, we identified females who experienced childbirth with and without PPD using computational phenotyping. We compared the percentage of days and number of hours per day females with and without PPD wore Fitbit devices during prepregnancy, pregnancy, postpartum, and PPD periods, determined by electronic health records. Comparisons between females with and without PPD were conducted using linear regression models. We also assessed the correlation between Fitbit wear time consistency (measured as the maximum number of consecutive days the Fitbit was worn) during prepregnancy and PPD periods in females with and without PPD using the Pearson correlation. All analyses were run with Bonferroni correction.

RESULTS

Our findings showed a strong trend, although nonsignificant after multiple testing correction, that females in the PPD cohort wore their Fitbits more than those in non-PPD cohort during the postpartum (PPD cohort: mean 69.9%, 95% CI 42.7%-97%; non-PPD cohort: mean 50%, 95% CI 25.5%-74.4%; P=.02) and PPD periods (PPD cohort: mean 66.6%, 95% CI 37.9%-95.3%; non-PPD cohort: mean 46.4%, 95% CI 20.5%-72.2%; P=.02). We found no difference in the number of hours per day females in the PPD and non-PPD cohorts wore their Fitbit during any period of pregnancy. Finally, there was no relationship between the consistency of Fitbit wear time during prepregnancy and PPD periods (r=-0.05, 95% CI -0.46 to 0.38; P=.84); however, there was a trend, though nonsignificant, in Fitbit wear time consistency among females without PPD (r=0.25, 95% CI -0.02 to 0.49; P=.07).

CONCLUSIONS

We hypothesize that increased Fitbit wear time among females with PPD may be attributed to hypervigilance, given the common co-occurrence of anxiety symptoms. Future studies should assess the link between PPD, hypervigilance, and wear time patterns. We envision that wear time patterns of a wearable device combined with digital biomarkers such as sleep and physical activity could enhance early PPD detection using machine learning by alerting clinicians to potential concerns and facilitating timely screenings, which may have implications for other mental health disorders.

Supplementary approaches to perinatal depression: a review of pathogenesis, herbal interventions, and dietary supplements

Although perinatal depression (PND) has garnered increasing attention, few specific pharmacological treatments exist, particularly for breastfeeding mothers concerned about antidepressant safety. The misconception that "natural is harmless" merits caution; herbal remedies and dietary supplements should be regarded as supplementary interventions pending robust safety evidence. This review summarizes recent advances in PND pathogenesis (neurotransmitter dysregulation, inflammation, hormonal imbalance, and microbiota alterations) and emerging drug development strategies, alongside clinical evidence for herbal and dietary supplements. Randomized controlled trial (RCT) findings reveal that while interventions like saffron and vitamin D show promise, significant limitations persist, including inconsistent efficacy, limited long-term safety data, and potential interactions with perinatal physiology. Caution is warranted until comprehensive studies validate the safety and reliability of natural interventions. This review underscores the need for rigorous trials to identify safe, effective PND treatments, particularly for vulnerable populations.

Allopregnanolone Regulation of Phasic Dopamine Release and Motivated Behavior

Allopregnanolone, an endogenous neurosteroid that is a potent, positive allosteric modulator of γ-aminobutyric acid type A (GABAA) receptors, has emerged as a compound with considerable potential in the treatment of psychiatric disorders, including substance use disorders and postpartum depression. We previously demonstrated that allopregnanolone dose- and sex-dependently reduced electrically evoked dopamine release in the nucleus accumbens (NAc) of anesthetized male and female rats, which could indicate negative effects on motivation and reward processing. The present study investigated the effects of allopregnanolone on dopamine release and motivated behaviors in awake rats. Using fast-scan cyclic voltammetry, we found that 15 mg/kg allopregnanolone (IP) reduced the frequency of spontaneous dopamine transients in the NAc of freely moving male and female rats. Next, we observed that allopregnanolone (15 mg/kg, IP) produced a robust conditioned place preference in males and females, indicating that allopregnanolone's effects are not aversive despite fewer dopamine transients. Finally, using a sucrose self-administration task, we found that allopregnanolone (7.5 and 15 mg/kg, IP) did not significantly alter response rate, intertrial and interpress intervals, or trial latency in either sex, suggesting that allopregnanolone does not alter motivation or fast motor actions. These results clarify the regulation of dopamine neurotransmission and motivated behavior by allopregnanolone, which has clinical implications for its use as a therapeutic agent to treat various psychiatric disorders.

Levels of neuroactive steroids are elevated in those who develop first-onset depression early in pregnancy

Background

Allopregnanolone (ALLO) plays a key role in the pathogenesis of postpartum depression. However, ALLO levels have been variably associated with depression during pregnancy. It is unknown if a pre-pregnancy history of major depressive disorder (MDD), which is associated with blunted neurosteroidogenesis, and timing of perinatal depression (PND) may influence the association between neuroactive steroids (NAS) and PND.

Objective

To investigate differences in ALLO and other NAS levels during the first (T1) and second (T2) trimesters based on pre-pregnancy history of MDD and current PND.

Methods

Participants completed a diagnostic test of depression, blood samples and mental health history. Ninety-eight participants contributed data in T1 and 93 in T2. Levels of ALLO, pregnanolone (PA), isoallopregnanolone (ISO), epipregnanolone (EPI), and progesterone (P4) were quantified using gas chromatography-mass spectrometry. Analyses of covariance with pairwise comparisons predicted NAS levels from categorized groups of those with: 1) no history of MDD and no PND (never depressed), 2) a history of MDD but no PND (pre-pregnancy depression), 3) a history of MDD and current PND (recurrent depression), and 4) no history of MDD but current PND (perinatal-emergent depression).

Results

Across groups, there were marginally significant differences in T1 ALLO (p=.05) and ISO levels (p=.05). T1 ALLO levels were higher in the perinatal-emergent versus never depressed (p=.007) and recurrent depression (p=.05) groups. ISO levels were higher in the perinatal-emergent versus recurrent depression (p=.02) and never depressed (p=.03) groups. In T2, there were significant differences in PA levels (p=.04) and marginally significant differences in ALLO (p=.07) and ISO levels (p=.09). ALLO levels were higher in the perinatal-emergent versus recurrent depression group (p=.05), and in the never depressed (p=.05) and pre-pregnancy depression groups (p=.04) compared to recurrent depression. PA levels were higher in the perinatal-emergent depression versus never depressed (p=.02) and recurrent depression (p=.01) groups, and ISO levels were higher in the perinatal-emergent depression versus never depressed (p=.03) and recurrent depression (p=.07) groups.

Conclusions

These results suggest differing NAS-related mechanisms of pathogenesis across clinical phenotypes based on pre-pregnancy history of MDD and timing of PND onset. Future research should account for these factors when investigating NAS and PND.

A retrospective chart review study of patients treated in a hospital-based brexanolone program

PURPOSE

Postpartum depression (PPD), the most common childbirth complication in the United States, can be treated using brexanolone, an intravenous form of allopregnanolone.

METHODS

This retrospective chart review study evaluated clinical outcomes of 64 postpartum women who received brexanolone infusion for PPD in a real-world setting.

RESULTS

Treatment was associated with improved depression and anxiety symptoms, and 71% of patients reported significant improvement in their PPD.

CONCLUSIONS

While further research is needed, this study supports brexanolone as an efficacious treatment for PPD.

Understanding and treating postpartum depression: a narrative review

Postpartum depression (PPD) is an increasingly prevalent but still poorly characterized disorder. Causal and modulating factors include hormones fluctuations, such as estrogen, progesterone, and allopregnolone, pathways imbalances, such as oxytocin and kynurenine, chronobiological factors, and brain imaging alterations. Treatment may differ from the traditional major depression management, while selective serotonin reuptake inhibitors such as sertraline are commonly used and suggested by guidelines, neurosteroids such as brexanolone and the more convenient zuranolone have been recently approved. Newer neurosteroids such as ganaxolone, valaxanolone, and lysaxanolone are currently under development, but also esketamine and psychedelics are promising potential treatments. Other somatic treatments including brain stimulation techniques and light therapy also showed benefit. PPD is therefore increasingly understood as, at least partially, independent from major depressive disorder. Specific and individualized treatments including pharmacological and non-pharmacological therapies are progressively being introduced in the routine clinical practice.

Neuroactive steroid biosynthesis during pregnancy predicts future postpartum depression: a role for the 3α and/or 3β-HSD neurosteroidogenic enzymes?

Postpartum depression (PPD) affects ~10-15% of childbearing individuals, with deleterious consequences for two generations. Recent research has explored the biological mechanisms of PPD, particularly neuroactive steroids (NAS). We sought here to investigate associations between NAS levels and ratios during pregnancy and the subsequent development of depressive symptoms with postpartum onset. NAS levels and psychological scales were measured in individuals with and without mood disorders at up to eight visits across pregnancy and postpartum. Generalized linear mixed-effects regression models were used to assess relationships in euthymic pregnant individuals between each of the NAS biomarkers and ratios and subsequent PPD. Participants with a one-unit increase in the log isoallopregnanolone/pregnanolone ratio at the third trimester (T3) had higher odds (OR = 1.64, 95% CI: 1.13-2.37, FDR adjusted p = 0.038, C-index = 0.82), and those with a one-unit increase in the log pregnanolone/progesterone ratio at T3 had lower odds (OR = 0.64, 95% CI: 0.47-0.88, FDR adjusted p = 0.036, C-index = 0.82) of developing PPD; those with a one-unit increase in the log progesterone level at T3 had higher odds of developing PPD (OR = 4.00, 95% CI: 1.54-10.37, FDR adjusted p = 0.035, C-index = 0.80). We found key differences in the progesterone metabolic pathway at the third trimester, indicating likely decreased activity/expression of the 3α-HSD enzyme and/or increased activity/expression of 3β-HSD.

New directions in neurosteroid therapeutics in neuropsychiatry

In recent years three neuroactive steroids (NAS), brexanolone (allopregnanolone, AlloP), ganaxolone and zuranolone, have been approved for the treatment of neuropsychiatric illnesses including postpartum depression and seizures in a neurodevelopmental syndrome. The approved agents are pregnane steroids and strong positive allosteric modulators (PAMs) of gamma-aminobutyric acid type A receptors (GABAARs). Broad effects on GABAARs play important roles in therapeutic benefits. However, these NAS also have actions on non-GABAR targets that could be important for clinical outcomes. Thus, understanding the broader effects of NAS is potentially important for expanding the therapeutic landscape of these important modulators. The approved NAS as well as other structurally distinct NAS and oxysterols have effects on non-GABAAR receptors and ion channels, along with intracellular actions that could have therapeutic importance, including modulation of cellular stress mechanisms, neuroinflammation, mitochondrial function and autophagy, among others. In this review, we explore GABAergic and other cellular effects of pregnane steroids including novel molecules that have potential therapeutic importance. This work discusses the complex chemical nature of NAS and what is being learned at cellular, molecular, synaptic and brain network levels about key sites of action including GABAARs and other targets.

New Agents in the Treatment of Psychiatric Disorders: What Innovations and in What Areas of Psychopathology?

Psychiatric disorders are a major cause of illness in the world. Unfortunately, many patients are resistant to treatment and present serious complications. Schizophrenia is refractory to treatment in about one-third of patients. Antidepressants are effective in about half of patients. Suicidal ideation is an increasing issue in patients with mixed features in bipolar disorder (BD). Therefore, there is a need to develop and test new drugs or new indications of available medications for the treatment of psychiatric disorders through evidence-based investigations. This narrative review aims to present the molecules approved by the main drug agencies, the Food and Drug Administration (FDA) and the European Medicines Agency (EMA), from 2018 to date, along with new indications and new formulations of existing medications. We searched PubMed for new drugs approved for schizophrenia, BD, major depressive disorder (MDD), anxiety disorders, and obsessive-compulsive disorder (OCD). We evaluated their clinical benefits, safety, and tolerability profiles. Finally, we considered studies on the main molecules that have shown initial evidence of efficacy and are in the process of obtaining approval. Our search suggested that a new antipsychotic, lumateperone, and two drug combinations, olanzapine/samidorphan (OLZ/SAM) and xanomeline/trospium (KarXT), were approved for schizophrenia. In addition, some new methods of administration-monthly risperidone administration, subcutaneous risperidone administration, and transdermal asenapine administration-obtained approval from the main drug agencies. Lumateperone and OLZ/SAM were also approved in BD. Esketamine, a compound that modulates glutamatergic transmission, was approved to treat treatment-resistant depression and acute suicidal ideation. The dextromethorphan/bupropion combination was approved for MDD. Two new agents, brexanolone and zuranolone, were approved for treatment of postpartum depression. On the other hand, no new drugs received approval for anxiety disorders or OCD. In summary, some new psychotropic medications have been developed, in particular with the aim to improve the symptoms of resistant patients and to decrease the incidence of adverse effects. It is necessary to continue testing the effectiveness of new compounds in methodologically rigorous studies.

Association between dietary flavonoid intake and anxiety: data from NHANES 2017-2018

BACKGROUND

Anxiety disorders are among the most prevalent mental health conditions, characterized by excessive fear, tension, avoidance behaviors, and heightened threat perception. Approximately 1 in 14 individuals meets the diagnostic criteria for an anxiety disorder. Flavonoids, bioactive compounds found in fruits, vegetables, and tea, possess antioxidant, anti-inflammatory, and neuroprotective properties. However, evidence on the relationship between flavonoid intake and anxiety risk remains limited. This study examines the association between flavonoid intake and anxiety risk and explores the effects of specific flavonoid subclasses.

METHODS

This study utilized data from the National Health and Nutrition Examination Survey (NHANES). Individual flavonoid intake was assessed using two-day 24-hour dietary recalls, and anxiety status was evaluated through a standardized anxiety questionnaire. To assess the relationship between flavonoid intake and anxiety risk, weighted logistic regression analysis was performed. Additionally, restricted cubic spline (RCS) analysis was employed to evaluate potential nonlinear associations. We conducted subgroup analyses for flavonoids that showed significant associations in the logistic regression, including theaflavin-3-gallate, total flavones, total flavanones, total isoflavones, and naringenin. These analyses aimed to explore the moderating effects of demographic characteristics such as sex, age, marital status, smoking status, and body mass index (BMI).

RESULTS

We analyzed data from 1,637 participants in the NHANES. Significant differences were observed between the anxious and non-anxious groups in age, poverty-income ratio (PIR), BMI, smoking status, marital status, education level, and flavonoid intake. The anxious group had higher age (47.12 vs. 42.81 years, P < 0.0001), PIR (P < 0.0001), and BMI (P = 0.01). They also had a higher proportion of females, unmarried individuals, and current smokers (P < 0.0001). Logistic regression analysis showed that genistein, petunidin, naringenin, apigenin, and total flavones were significantly associated with reduced anxiety risk (P < 0.05). Subgroup analysis confirmed protective effects in males, married individuals, participants with General Educational Development (GED)-level education, and specific ethnic groups. RCS analysis suggested nonlinear relationships, with total flavones, total flavanones, and naringenin showing protective effects at low intake levels (P < 0.05). All models demonstrated good fit (P < 0.001).

CONCLUSION

Flavonoid intake is inversely associated with anxiety risk, particularly Theaflavin-3-gallate, Total Flavones, Total Flavanones, Total Isoflavones, and Naringenin. Further studies are needed to confirm optimal intake levels and underlying mechanisms.

Profiling neuroactive steroids in pregnancy. A non-derivatised liquid chromatography tandem mass spectrometry method for the quantitation of allopregnanolone and four related isomers in maternal serum

Neuroactive steroids are metabolites of progesterone, synthesised during pregnancy by the placenta. Here, we describe development of a novel liquid chromatography tandem mass spectrometry (LC-MS/MS) assay for quantitation of allopregnanolone, pregnanolone, isopregnanolone, epipregnanolone and allopregnan-20α-ol-3-one in maternal serum. Following addition of deuterated internal standards, 200 μL of serum was subjected to solid phase extraction. Chromatography was performed using a pentafluorophenyl column, and LC-MS/MS on a Sciex 6500+. Sample injection volume was 20 μL, and injection-to-injection time 10.0 min. The assay was validated according to published guidelines; assay linearity and lower limit of quantification were suitable for analysis of each steroid in maternal serum, for all analytes mean recoveries were 100 % ± 15 %, intra- and inter-assay imprecision <15 %, and matrix effects negligible, and specificity experiments confirmed nil interference from a wide range of endogenous metabolites of progesterone. The method was applied to human serum samples obtained from a large cohort of third trimester pregnancies which were subsequently characterised by normal fetal and maternal outcomes, and relationships between maternal neuroactive steroid concentrations and fetal gestational age assessed. Positive correlations between maternal serum concentration and fetal gestational age were observed for isopregnanolone, allopregnanolone and allopregnan-20α-ol-3-one. The LC-MS/MS method offers significant advantages over previously published approaches for quantitation of neuroactive steroids in human maternal serum, notably obviating the need for derivatisation, whilst achieving exceptional specificity. Characterisation of normal maternal neuroactive steroid concentrations will aid future research as dysregulated placental progesterone metabolism is observed in pregnancies with poor outcomes.

Pharmacological Monotherapy for Depressive Disorders: Current and Future-A Narrative Review

Objective: To narratively review currently available antidepressants and future potential antidepressants as monotherapy for the treatment of depressive disorders. Methods: Selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), dopamine reuptake inhibitor (bupropion), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs) were reviewed according to the results from Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study and systematic reviews. For the rest of the antidepressants, a PubMed/Medline search was conducted with priority for systematic reviews. For drugs in development for depressive disorders, PubMed, Google, and Clinicaltrials.gov databases were used. Results: The STAR*D Study demonstrated that sertraline, venlafaxine, and bupropion monotherapy had similar efficacy in patients with major depressive disorder (MDD) who failed citalopram. A network meta-analyses of randomized, placebo-controlled trials found that SSRIs, SNRIs, bupropion, TCAs, mirtazapine, and agomelatine had similar relative efficacy compared to placebo, but had different acceptability. Gepirone had more failed/negative studies and smaller effect size relative to placebo compared to other antidepressants. The combination of dextromethorphan and bupropion, ketamine infusion, and intranasal esketamine had faster onset of action but similar effect size compared to monoamine-based antidepressants as monotherapy. Brexanolone and zuranolone are effective in postpartum depression (PPD), but the effect size of zuranolone in MDD as monotherapy or adjunctive therapy was very small. Psychedelics, glutamate receptor-related agents, kappa opioid receptor antagonists, orexin receptor antagonists, new anti-inflammatory agents, and biomarker-based antidepressant therapy have been under investigation for depressive disorders. Psychedelics showed faster onset of action, large effect size, and long durability. Conclusions: Monoamine-based antidepressants likely continue to be the mainstream antidepressants for depressive disorder. NMDA receptor antagonists and neurosteroid antidepressants will play a bigger role with the improvement of accessibility. Psychedelics may become a game changer if phase III studies validate their efficacy and safety in depressive disorders.

The translocator protein 18 kDa (TSPO) ligand etifoxine in an animal model of anxiety: Line- and sex-dependent effects on emotionality, stress reactivity, spine density, oxytocin receptors, steroids, and microbiome composition

The treatment of stress-related disorders such as anxiety and depression is still challenging. One potential therapeutical option are neurosteroids. Their synthesis is promoted by ligands of the mitochondrial translocator protein 18 kDa (TSPO). We tested the TSPO ligand etifoxine (ETX) in a rat model of hyper-anxiety and depression-like behavior, i.e., in female and male HAB (high anxiety-related behavior) rats, as well as in respective low anxiety (LAB) and non-selected control (NAB) rats for behavioral, molecular, cellular, and physiological parameters. Daily acute i.p. treatment with ETX or vehicle over 5 or 9 days revealed that ETX was most effective in female HAB rats; it reduced anxiety levels (5 days) and OXT-R binding brain site-specifically (5 and 9 days), and increased spine density (5 days). The behavioral ETX effect exclusively found in female HABs was accompanied by increased 3β5α-THDOC levels, without any effect in female LABs and NABs and on other neurosteroids. In males of all breeding lines, ETX changed a total of 10 out of 23 brain steroids. Passive stress-coping during 10-min forced swimming was not affected by 9-day treatment with ETX, the resulting stress-induced plasma corticosterone levels were higher in ETX-treated NAB rats of both sexes compared with their VEH-treated groups. The fecal bacterial composition was similar but beta diversity differed between HABs and LABs and from NABs independent of sex; ETX treatment had no effect. Therefore, we propose considering the aspect of sex in treatment strategies for anxiety disorders. This is particularly important to establish better treatment regimens for women.

Cyclodextrin-based delivery systems for chemical and genetic drugs: Current status and future

Cyclodextrins (CDs) are cyclic polysaccharides characterized by their unique hollow structure, making them highly effective carriers for pharmaceutical agents. CD-based delivery systems are extensively utilized to enhance drug stability, increase solubility, improve oral bioavailability, and facilitate controlled release and targeted delivery. This review initially provides a concise overview of nano drug delivery systems, followed by a detailed introduction of the structural features and benefits of CDs. It further summarizes the applications of CD-based delivery systems and offers insights for the rational design of drug delivery systems. In this review, CD-based delivery systems are categorized into several types, such as covalently modified CD derivatives, non-modified CD inclusion complexes, poly-cyclodextrins and others. The application of CD-based systems for the delivery of genetic therapeutic agents and co-delivery of gene and drug is also presented. Finally, this review discusses potential challenges and opportunities that may arise in the future. With the development of nanotechnology and optimization of preparation process, CD-based drug delivery systems will provide a more effective, precise and safe approach to drug therapy.

The Association Among Bipolar Disorder, Mitochondrial Dysfunction, and Reactive Oxygen Species

Mitochondria, often known as the cell's powerhouses, are primarily responsible for generating energy through aerobic oxidative phosphorylation. However, their functions extend far beyond just energy production. Mitochondria play crucial roles in maintaining calcium balance, regulating apoptosis (programmed cell death), supporting cellular signaling, influencing cell metabolism, and synthesizing reactive oxygen species (ROS). Recent research has highlighted a strong link between bipolar disorder (BD) and mitochondrial dysfunction. Mitochondrial dysfunction contributes to oxidative stress, particularly through the generation of ROS, which are implicated in the pathophysiology of BD. Oxidative stress arises when there is an imbalance between the production of ROS and the cell's ability to neutralize them. In neurons, excessive ROS can damage various cellular components, including proteins in neuronal membranes and intracellular enzymes. Such damage may interfere with neurotransmitter reuptake and the function of critical enzymes, potentially affecting brain regions involved in mood regulation and emotional control, which are key aspects of BD. In this review, we will explore how various types of mitochondrial dysfunction contribute to the production of ROS. These include disruptions in energy metabolism, impaired ROS management, and defects in mitochondrial quality control mechanisms such as mitophagy (the process by which damaged mitochondria are selectively degraded). We will also examine how abnormalities in calcium signaling, which is crucial for synaptic plasticity, can lead to mitochondrial dysfunction. Additionally, we will discuss the specific mitochondrial dysfunctions observed in BD, highlighting how these defects may contribute to the disorder's pathophysiology. Finally, we will identify potential therapeutic targets to improve mitochondrial function, which could pave the way for new treatments to manage or mitigate symptoms of BD.

Zuranolone for Postpartum Depression After Highly Lethal Suicide Attempt: Two Case Illustrations and a Narrative Literature Review

BACKGROUND

In the United States, suicide is one of the leading causes of death in the first year postpartum, possibly accounting for up to 20% of deaths. The Food and Drug Administration recently approved 2 fast-acting medications, brexanolone and zuranolone, for the treatment of postpartum depression (PPD), which shares many clinical features with postpartum suicidality.

OBJECTIVE

Determining the efficacy of zuranolone in the treatment of severe PPD in the context of highly lethal suicide attempts.

METHODS

We describe 2 illustrative cases of zuranolone treatment of PPD after a gunshot suicide attempt. Following treatment, both women demonstrated a rapid reduction in depressive symptoms and readiness for safe discharge. We also conducted a review of the literature on suicide attempts associated with PPD.

RESULTS

Our case series demonstrated that zuranolone may effectively treat PPD with rapid-onset highly lethal suicide attempts.

CONCLUSIONS

Postpartum suicidality is complex and often emerges rapidly. We advocate for more research on fast-acting novel treatments, such as zuranolone and brexanolone, for PPD and postpartum suicidality.

An update on the pharmacotherapy of postpartum depression

Extensive research has been conducted on postpartum depression (PPD) over the past century, and yet no definitive answer regarding its etiopathogenesis, risk factors, genetic predilection, and treatment has been found. The few preclinical and clinical studies propose that maternal brain adaptations to the endocrinological, immunological, and behavioral changes and external sociodemographic risk factors in the perinatal period make women more vulnerable to anxiety and depression. Irrespective of the cause, a dilemma exists regarding the type of help to provide postpartum mothers. With very few treatment options at our disposal, deciding between psychotherapy, pharmacological, and non-pharmacological therapy on a case-by-case basis is unproductive because in developing countries infrastructure is limited and the availability of medications, especially for psychiatric illnesses, is still evolving. Hence, regardless of psychotherapy, antidepressants remain the first line of treatment with selective serotonin reuptake inhibitors (SSRIs); sertraline has the best efficacy and safety profile in breastfeeding women. As endocrine factors play a significant role in etiopathogenesis, hormonal therapy with oxytocin has been shown to be efficacious, and studies investigating the role of testosterone in treating PPD are also under way. In 2019, the US Food and Drug Administration (FDA) approved the first and only drug for the sole purpose of treating PPD, brexanolone. Zuranolone, a drug recently approved by the FDA, has a similar mechanism of action to brexanolone. For breastfeeding mothers reluctant to use pharmacotherapy, somatic therapy has been studied, including bright light therapy, vagal nerve stimulation, and newer noninvasive interventions. This article encompasses a short note on PPD, including its etiopathogenesis and clinical characteristics, and recapitulates the various available and evolving pharmacological and nonpharmacological therapies.

Peripartum allopregnanolone blood concentrations and depressive symptoms: a systematic review and individual participant data meta-analysis

Neuroactive steroids including allopregnanolone are implicated in the pathophysiology of peripartum depressive symptoms (PDS). We performed a systematic review searching PubMed/Embase/PsychInfo/Cinhail through 08/2023 (updated in 07/2024), and conducted a random-effects meta-analysis of studies comparing allopregnanolone blood concentrations in women with versus without PDS at various timepoints during the 2nd and 3rd trimester and the postpartum period, calculating standardized mean differences (SMDs) and 95% confidence intervals (CIs). Meta-regression and subgroup analyses included age, diagnoses of affective disorders before pregnancy, antidepressant treatment, analytical methods, and sample type. Study quality was assessed using the Newcastle-Ottawa-scale. The study protocol was registered on PROSPERO (registration number CRD42022354495). We retrieved 13 studies with 2509 women (n = 849 with PDS). Allopregnanolone concentrations did not differ between women with versus without PDS at any timepoint (p > 0.05). Allopregnanolone concentrations assessed during pregnancy did not differ for women with versus without PDS at postpartum follow-up (p > 0.05). Subgroup analyses indicated higher allopregnanolone concentrations in women with versus without PDS at gestational weeks 21-24 and 25-28 (SMD = 1.07, 95% CI = 0.04, 2.11 and SMD = 0.92, 95% CI = 0.26, 1.59 respectively). Moreover, we reported differences between studies using mass-spectrometry combined with chromatography versus immunoassays at gestational weeks 25-28 (p = 0.01) and plasma versus serum samples at gestational weeks 21-24 (p = 0.005). Study quality was rated as poor, good, and fair for two, one and ten studies respectively. PDS were not associated with differences for allopregnanolone concentrations. The use of heterogenous peripartum time points, study cohorts, depression symptom measures and analytical methods has hampered progress in elucidating neuroactive steroid signaling linked to PDS.

Using estrogen and progesterone to treat premenstrual dysphoric disorder, postnatal depression and menopausal depression

Female gonadal hormones, particularly estrogen and progesterone, are not only central to reproductive health but also play a crucial role in regulating mood, cognition, and overall brain health. These hormones have a significant impact on the central nervous system, influencing key processes such as neurotransmission, neuroplasticity, and brain development. Increasing evidence shows that hormonal fluctuations contribute to the onset and progression of mental health disorders that disproportionately affect women, particularly premenstrual dysphoric disorder (PMDD), postnatal depression (PND), and menopausal depression. This paper explores the current evidence regarding the neurobiological effects of female hormones on the brain and discusses the therapeutic approaches in conditions such as PMDD, PND, and menopausal depression.

Canadian Network for Mood and Anxiety Treatments 2024 Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety, and Related Disorders: Guide de pratique 2024 du Canadian Network for Mood and Anxiety Treatments pour le traitement des troubles de l'humeur, des troubles anxieux et des troubles connexes périnatals

BackgroundThe Canadian Network for Mood and Anxiety Treatments (CANMAT) publishes clinical practice guidelines for mood and anxiety disorders. This CANMAT guideline aims to provide comprehensive clinical guidance for the pregnancy and postpartum (perinatal) management of mood, anxiety and related disorders.MethodsCANMAT convened a core editorial group of interdisciplinary academic clinicians and persons with lived experience (PWLE), and 3 advisory panels of PWLE and perinatal health and perinatal mental health clinicians. We searched for systematic reviews of prevention and treatment interventions for perinatal depressive, bipolar, anxiety, obsessive-compulsive and post-traumatic stress disorders (January 2013-October 2023). We prioritized evidence from reviews of randomized controlled trials (RCTs), except for the perinatal safety of medications where reviews of large high-quality observational studies were prioritized due to the absence of RCT data. Targeted searches for individual studies were conducted when systematic reviews were limited or absent. Recommendations were organized by lines of treatment based on CANMAT-defined levels of evidence quality, supplemented by editorial group consensus to balance efficacy, safety, tolerability and feasibility considerations.ResultsThe guideline covers 10 clinical sections in a question-and-answer format that maps onto the patient care journey: case identification; organization and delivery of care; non-pharmacological (lifestyle, psychosocial, psychological), pharmacological, neuromodulation and complementary and alternative medicine interventions; high-risk clinical situations; and mental health of the father or co-parent. Equity, diversity and inclusion considerations are provided.ConclusionsThis guideline's detailed evidence-based recommendations provide clinicians with key information to promote the delivery of effective and safe perinatal mental healthcare. It is hoped that the guideline will serve as a valuable tool for clinicians in Canada and around the world to help optimize clinical outcomes in the area of perinatal mental health.

Relationships between the menstrual cycle and neuropsychiatric and physical symptoms in females with Tourette syndrome

Background

The effects of the menstrual cycle on neuropsychiatric and physical symptoms have been examined in multiple psychiatric illnesses, but research on Tourette syndrome (TS) and menstruation is limited and inconclusive. One study published in 1992 reported that 34% of female respondents experienced tic fluctuations with their menstrual cycles; however, a subsequent 2001 study found no significant relationship between menstrual cycle-related hormonal changes and tic symptoms across participants. There has been no further published exploration of this topic in the intervening 20+ years, and thus these discrepant results have not been reconciled. The current study aimed to assess tic changes across the menstrual cycle and to explore clinical predictors of tic fluctuations in adult females with TS.

Methods

An online survey was completed by 112 of 315 eligible female adults with TS. Respondents were asked to share their age of TS symptom onset, history of OCD and ADHD diagnoses, and current tic symptoms and severity. Participants also retrospectively reported their experiences with fluctuations in tics and other physical and psychiatric symptoms over the course of the menstrual cycle.

Results

26% of the 112 respondents endorsed tic changes in relation to their menstrual cycles. Univariable and multivariable logistic regression demonstrated that higher current tic severity and impairment as well as co-occurring cycle-related mood and anxiety changes significantly predicted the presence of self-reported tic fluctuations during the menstrual cycle.

Discussion

Results suggest that some females with TS experience changes in tic symptoms during their menstrual cycles, although future research is required to clarify the complex relationships between the menstrual cycle, tics, and other psychiatric symptoms. The low response rate, retrospective recall of symptoms, and lack of information about hormonal influences such as contraceptives and menopause are notable study limitations.

An Astroglial Basis of Major Depressive Disorder: Molecular, Cellular, and Circuit Features

Major depressive disorder is a common psychiatric disorder and a leading cause of disability worldwide. Astrocytes play a role in the maintenance of the function of the central nervous system, both physiologically and pathologically. Accumulated evidence indicates that the astrocyte is an important contributor to the pathophysiology of major depressive disorder including blood-brain barrier integrity, gap junctions, gliotransmission, glutamate homeostasis, and energy metabolism. Here, we comprehensively summarize an astroglial basis for major depressive disorder based on molecular, cellular, and circuit properties, suggesting that astrocytes appear to be highly sensitive to stress and are likely to be uniquely positioned to integrate peripheral and central stress responses.

The Interplay Between Sleep Apnea and Postpartum Depression

The complicated association between sleep apnea and postpartum depression (PPD), two diseases that can have a major influence on a mother's health and well-being, is examined in this thorough review. An increasing number of people are realizing that sleep apnea, which is defined by repeated bouts of upper airway obstruction during sleep, may be a risk factor for PPD. The literature currently available on the frequency, common risk factors, and possible processes relating these two disorders is summarized in this study. We investigate the potential roles that sleep apnea-related hormone fluctuations, intermittent hypoxia, and fragmented sleep may play in the onset or aggravation of PPD. We also talk about the difficulties in identifying sleep apnea in the postpartum phase and how it can affect childcare and mother-infant attachment. The evaluation assesses the effectiveness of existing screening techniques, available treatments, and how well they manage both illnesses at the same time. Lastly, we identify research gaps and suggest future lines of inquiry to enhance maternal health outcomes.

Transformative Therapies for Depression: Postpartum Depression, Major Depressive Disorder, and Treatment-Resistant Depression

Depressive disorders present an enormous global public health burden. A notable treatment gap exists between the prevalence of depression and our ability to provide rapid-acting, effective treatment that achieves remission. Brexanolone and zuranolone, the first US Food and Drug Administration-approved drugs for postpartum depression, signify a critical advancement in addressing the unmet needs of a vulnerable patient population. Psilocybin shows promise for treatment-resistant depression and for those who have struggled to find relief with existing treatments. This review discusses transformative therapies that represent significant advancements in postpartum depression, major depressive disorder, and treatment-resistant depression.

Menstrually-related mood disorders and postpartum depression: Convergent aspects in aetiology

Females diagnosed with Menstrually-related mood disorders (MRMDs) have more risk to develop postpartum depression (PPD). There are overlapping symptoms between MRMDs and PPD such as anxiety, depressed mood, irritability, that can contribute to a lower quality of life. MRMDs and PPD share components in their etiology such as dramatic hormonal oscillations, and alterations in Hypothalamus-Pituitary-Adrenal (HPA) axis activity that may impair GABAergic neurotransmission. As well, stressful events that impact HPA regulation may play an important role in the etiology of MRMDs and PPD. Here we review common hormone fluctuations across the menstrual cycle and pregnancy/postpartum to identify shared pathways that could contribute to greater sensitivity in people with MRMDs and PPD. This review summarizes hormone sensitivity, HPA axis activity and neurosteroids effects on GABAergic transmission and the potential role of chronic stress in developing MRMDs and PPD. In addition, other potential etiopathological factors, such as serotonin and the immune system, are discussed. Investigating the etiopathology of MRMDs and PDD will help to better understand the complexity of factors involved in these disorders that affect females across the reproductive years.

Comparative effectiveness of interventions for the prevention and treatment of perinatal depression: A systematic review and network meta-analysis

BACKGROUND

Several interventions have been investigated addressing perinatal depression; however, interventions have not been compared using both direct and indirect evidence. This study compared the relative effectiveness of all interventions that prevent depression (objective 1) or treat depression symptoms (objective 2) in perinatal women.

METHODS

Eight databases searched from their inception to March 2024. Inclusion criteria were randomised controlled trials in perinatal women participants evaluating any interventions that addressed prevention or treatment of depression. Two random-effects Bayesian network meta-analyses were conducted using studies with perinatal women participants reporting frequency of depression or reporting depression severity. For objective 1 odds ratios (OR) and objective 2 standardised mean differences (SMD) were used.

RESULTS

A total of 177 articles were included (n = 76 objective 1, n = 101 objective 2). For objective 1; mindfulness was the highest-ranking intervention (SCURA=88), with significant OR compared to treatment as usual (TAU) (OR=0.21; 0.06, 0.71 95 %CrI). Other interventions with significant OR, compared to TAU included: pharmacological treatments, CBT, physical activities, education, and collaborative care. For objective 2; interpersonal therapy plus massage was the highest-ranking intervention (SCURA=89) with significant SMD compared to TAU (SMD=-1.38; -2.54, -0.21). Other interventions with significant SMD compared to TAU: IPT, alternative therapies, physical activities, mindfulness, CBT, collaborative care, education, and enhanced TAU. Pharmacological treatments were effective compared to sham/placebo.

CONCLUSION

CBT, mindfulness, physical activity, collaborative care, education, and pharmacological interventions were effective in addressing prevention and treatment of perinatal depression symptoms compared to control arms. Healthcare providers may consider offering these interventions to perinatal women.

Ginsenoside Rg1: A Neuroprotective Natural Dammarane-Type Triterpenoid Saponin With Anti-Depressive Properties

BACKGROUND

Depression, a widespread mental disorder, presents significant risks to both physical and mental health due to its high rates of recurrence and suicide. Currently, single-target antidepressants typically alleviate depressive symptoms or delay the progression of depression rather than cure it. Ginsenoside Rg1 is one of the main ginsenosides found in Panax ginseng roots. It improves depressive symptoms through various mechanisms, suggesting its potential as a treatment for depression.

MATERIALS AND METHODS

We evaluated preclinical studies to comprehensively discuss the antidepressant mechanism of ginsenoside Rg1 and review its toxicity and medicinal value. Additionally, pharmacological network and molecular docking analyses were performed to further validate the antidepressant effects of ginsenoside Rg1.

RESULTS

The antidepressant mechanism of ginsenoside Rg1 may involve various pharmacological mechanisms and pathways, such as inhibiting neuroinflammation and over-activation of microglia, preserving nerve synapse structure, promoting neurogenesis, regulating monoamine neurotransmitter levels, inhibiting hyperfunction of the hypothalamic-pituitary-adrenal axis, and combatting antioxidative stress. Moreover, ginsenoside Rg1 preserves astrocyte gap junction function by regulating connexin43 protein biosynthesis and degradation, contributing to its antidepressant effect. Pharmacological network and molecular docking studies identified five targets (AKT1, STAT3, EGFR, PPARG, and HSP90AA1) as potential molecular regulatory sites of ginsenoside Rg1.

CONCLUSIONS

Ginsenoside Rg1 may exert its antidepressant effects via various pharmacological mechanisms. In addition, multicenter clinical case-control and molecular targeted studies are required to confirm both the clinical efficacy of ginsenoside Rg1 and its potential direct targets.

Nonsedating anxiolytics

Anxiety disorders are the most prevalent psychiatric pathology with substantial cost to society, but the existing treatments are often inadequate. This has rekindled the interest in the GABAA-receptor (GABAAR) positive allosteric modulator (PAM) compounds, which have a long history in treatment of anxiety beginning with diazepam, chlordiazepoxide, and alprazolam. While the GABAAR PAMs possess remarkable anxiolytic efficacy, they have fallen out of favor due to a host of adverse effects including sedation, motor impairment, addictive potential and tolerance development. A substantial effort was thus devoted to the design of GABAAR PAMs as anxiolytics with reduced sedative liabilities. Several non-benzodiazepine (BZD) GABAAPAMs progressed to clinical trials (bretazenil, abecarnil, alpidem, and ocinaplon) with alpidem obtaining regulatory approval as anxiolytic, but later withdrawn from market due to hepatotoxicity. Advances in molecular biology gave birth to a host of subtype selective GABAAR-PAMs which suffered from signs of sedation and motor impairment and only three compounds progressed to proof-of-concept studies (TPA-023, AZD7325 and PF-06372865). TPA-023 was terminated due to toxicity in preclinical species while AZD7325 and PF-06372865 did not achieve efficacy endpoints in patients. We highlight a new compound, KRM-II-81, that is an imidazodiazepine selective for GABAAR containing α2/3 and β3 proteins. In preclinical studies KRM-II-81 produced anxiolytic-like effects but with minimal sedation, respiratory depression, and abuse liability. Thus, KRM-II-81 is a newly discovered, non- BZD anxiolytic compound, which targets a selective population of GABAAR for improved therapeutic gain and reduced side effects.

The pathophysiology of estrogen in perinatal depression: conceptual update

PURPOSE

Estrogen levels fall sharply after parturition and have long been considered an etiologic contributor to postpartum depression (PPD); however, no differences have been reported in plasma hormone concentrations in people who develop PPD. We examine the question: What is the current view of estrogen and the neurophysiologic processes it impacts in the development and treatment of PPD?

METHODS

A literature review of the role of estrogen on candidate hormonal and epigenetic systems in the peripartum period was performed, including landmark historical studies and recent publications on estrogen-related research. The authors reviewed these papers and participated in reaching consensus on a conceptual framework of estrogen activity within the complexity of pregnancy physiology to examine its potential role for driving novel interventions.

RESULTS

Estrogen fluctuations must be conceptualized in the context of multiple dramatic and interacting changes inherent in pregnancy and after birth, including progesterone, corticosteroids, inflammation, circadian biology and psychosocial challenges. Individuals who develop PPD have increased sensitivity to epigenetic alteration at estrogen-responsive genes, and these changes are highly predictive of PPD. An effective estrogen-based treatment for PPD has yet to be found, but interventions focused on associated inflammation and circadian rhythms are promising.

CONCLUSIONS

Our understanding of the biological basis of PPD, one of the most common morbidities of the perinatal period, is expanding beyond changes in gynecologic hormone concentrations to include their impact on other systems. This growing understanding of the many processes influencing PPD will allow for the development of novel prevention and treatment strategies.

The updated understanding of advanced maternal age

The rising rates of pregnancies associated with advanced maternal age (AMA) have created unique challenges for healthcare systems worldwide. The elevated risk of poor maternal outcomes among AMA pregnancies is only partially understood and hotly debated. Specifically, AMA is associated with reduced fertility and an increased incidence of pregnancy complications. Finding a balance between global fertility policy, socioeconomic development and health care optimization ultimately depends on female fertility. Therefore, there is an urgent need to develop technologies and identify effective interventions. Support strategies should include prepregnancy screening, intervention and postpartum maintenance. Although some reviews have considered the relationship between AMA and adverse pregnancy outcomes, no previous work has comprehensively considered the long-term health effects of AMA on mothers. In this review, we will begin by presenting the current knowledge of global health issues associated with AMA and the effects of advanced age on the female reproductive system, endocrine metabolism, and placental function. We will then discuss physiological alterations, pregnancy complications, and long-term health problems caused by AMA.

Direct measurements of neurosteroid binding to specific sites on GABAA receptors

BACKGROUND AND PURPOSE

Neurosteroids are allosteric modulators of GABAA currents, acting through several functional binding sites although their affinity and specificity for each site are unknown. The goal of this study was to measure steady-state binding affinities of various neurosteroids for specific sites on the GABAA receptor.

EXPERIMENTAL APPROACH

Two methods were developed to measure neurosteroid binding affinity: (1) quenching of specific tryptophan residues in neurosteroid binding sites by the neurosteroid 17-methylketone group, and (2) FRET between MQ290 (an intrinsically fluorescent neurosteroid) and tryptophan residues in the binding sites. The assays were developed using ELIC-α1GABAAR, a chimeric receptor containing transmembrane domains of the α1-GABAA receptor. Tryptophan mutagenesis was used to identify specific interactions.

KEY RESULTS

Allopregnanolone (3α-OH neurosteroid) was shown to bind at intersubunit and intrasubunit sites with equal affinity, whereas epi-allopregnanolone (3β-OH neurosteroid) binds at the intrasubunit site. MQ290 formed a strong FRET pair with W246, acting as a site-specific probe for the intersubunit site. The affinity and site-specificity of several neurosteroid agonists and inverse agonists was measured using the MQ290 binding assay. The FRET assay distinguishes between competitive and allosteric inhibition of MQ290 binding and demonstrated an allosteric interaction between the two neurosteroid binding sites.

CONCLUSIONS AND IMPLICATIONS

The affinity and specificity of neurosteroid binding to two sites in the ELIC-α1GABAAR were directly measured and an allosteric interaction between the sites was revealed. Adaptation of the MQ290 FRET assay to a plate-reader format will enable screening for high affinity agonists and antagonists for neurosteroid binding sites.

Unlocking the potential of wearable device wear time to enhance postpartum depression screening and detection

Postpartum depression (PPD) is a mood disorder affecting one in seven women after childbirth that is often under-screened and under-detected. If not diagnosed and treated, PPD is associated with long-term developmental challenges in the child and maternal morbidity. Wearable technologies, such as smartwatches and fitness trackers (e.g., Fitbit), offer continuous and longitudinal digital phenotyping for mood disorder diagnosis and monitoring, with device wear time being an important yet understudied aspect. Using the All of Us Research Program (AoURP) dataset, we assessed the percentage of days women with PPD wore Fitbit devices across pre-pregnancy, pregnancy, postpartum, and PPD periods, as determined by electronic health records. Wear time was compared in women with and without PPD using linear regression models. Results showed a strong trend that women in the PPD cohort wore their Fitbits more those without PPD during the postpartum (PPD: mean=72.9%, SE=13.8%; non-PPD: mean=58.9%, SE=12.2%, P-value=0.09) and PPD time periods (PPD: mean=70.7%, SE=14.5%; non-PPD: mean=55.6%, SE=12.9%, P-value=0.08). We hypothesize this may be attributed to hypervigilance, given the common co-occurrence of anxiety symptoms among women with PPD. Future studies should assess the link between PPD, hypervigilance, and wear time patterns. We envision that device wear patterns with digital biomarkers like sleep and physical activity could enhance early PPD detection using machine learning by alerting clinicians to potential concerns facilitating timely screenings, which may have implications for other mental health disorders.

Excitation-inhibition imbalance in medial preoptic area circuits underlies chronic stress-induced depression-like states

Dysregulation of brain homeostasis is associated with neuropsychiatric conditions such as major depressive disorder. However, underlying neural-circuit mechanisms remain not well-understood. We show in mice that chronic restraint stress (CRS) and social defeat stress (SDS) are both associated with disruption of excitation (E)-inhibition (I) balance, with increased E/I ratios, in medial preoptic area (MPOA) circuits, but through affecting different neuronal types. CRS results in elevated activity in glutamatergic neurons, and their suppression mitigates CRS-induced depressive-like behaviors. Paraventricular hypothalamic input to these neurons contributes to induction but not expression of depressive-like behaviors. Their projections to ventral tegmental area and periaqueductal gray/dorsal raphe suppress midbrain dopaminergic and serotonergic activity, respectively, and mediate expression of divergent depressive-like symptoms. By contrast, SDS results in reduced activity of GABAergic neurons, and their activation alleviates SDS-induced depressive-like behaviors. Thus, E/I imbalance with relatively increased excitation in MPOA circuits may be a general mechanism underlying depression caused by different etiological factors.

Exosomes-mediated delivery of miR-486-3p alleviates neuroinflammation via SIRT2-mediated inhibition of mitophagy after subarachnoid hemorrhage

BACKGROUND

Neuroinflammation participates in the pathogenesis of subarachnoid haemorrhage (SAH); however, no effective treatments exist. MicroRNAs regulate several aspects of neuronal dysfunction. In a previous study, we found that exosomal miR-486-3p is involved in the pathophysiology of SAH. Targeted delivery of miR-486-3p without blood-brain barrier (BBB) restriction to alleviate SAH is a promising neuroinflammation approach.

METHODS

In this study, we modified exosomes (Exo) to form an RVG-miR-486-3p-Exo (Exo/miR) to achieve targeted delivery of miR-486-3p to the brain. Neurological scores, brain water content, BBB damage, flow cytometry and FJC staining were used to determine the effect of miR-486-3p on SAH. Western blot analysis, ELISA and RT-qPCR were used to measure relevant protein and mRNA levels. Immunofluorescence staining and laser confocal detection were used to measure the expression of mitochondria, lysosomes and autophagosomes, and transmission electron microscopy was used to observe the level of mitophagy in the brain tissue of mice after SAH.

RESULTS

Tail vein injection of Exo/miR improved targeting of miR-486-3p to the brains of SAH mice. The injection reduced levels of neuroinflammation-related factors by changing the phenotype switching of microglia, inhibiting the expression of sirtuin 2 (SIRT2) and enhancing mitophagy. miR-486-3p treatment alleviated neurobehavioral disorders, brain oedema, BBB damage and neurodegeneration. Further research found that the mechanism was achieved by regulating the acetylation level of peroxisome proliferator-activated receptor γ coactivator l alpha (PGC-1α) after SIRT2 enters the nucleus.

CONCLUSION

Exo/miR treatment attenuates neuroinflammation after SAH by inhibiting SIRT2 expression and stimulating mitophagy, suggesting potential clinical applications.

New treatments: Opportunities and challenges

Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each patient. Furthermore, provider, local, and systemic factors complicate access to current treatment options. New and emerging approaches offer the potential of more effective treatment for specific perinatal psychiatric disorders. From neuroactive steroid medications to accelerated psychotherapy interventions, recent innovations have demonstrated enhanced efficacy on a faster timeline. Optimally, these developments will also lower barriers to care but this is not necessarily true. We review novel and upcoming interventions across perinatal mental illness and place them in the context of existing treatments and common challenges.

The alterations in CD4+Treg cells across various phases of major depression

BACKGROUND

Major depression (MD) is recurrent and devastating mental disease with a high worldwide prevalence. Mounting evidence suggests neuroinflammation triggers cellular immune dysregulation, characterized by increased proportions of circulating monocytes, and T helper 17 cells and proinflammatory cytokines, thereby increasing susceptibility to MD. However, there is ambiguity in the findings of clinical studies that investigate CD4+ T regulatory (Treg) cells in MD.

METHODS

The proportion of CD4+ Treg cell from blood mononuclear cells was examined using flow cytometry in healthy controls (HCs: n = 96) and patients with first (FEMD: n = 62) or recurrent (RMD: n = 41) disease episodes of MD at baseline (T0; hospital admission) and after a two-week antidepressant treatment (T14). All participants underwent comprehensive neuropsychological assessments.

RESULTS

The initial scores on emotional assessments in patients with MD significantly differed from those of HCs. Both FEMD and RMD patients exhibited a significant decrease in CD4+ Treg cell proportion at baseline compared to HCs. Treg cell proportion rose significantly from T0 to T14 in FEMD patients, who responded to antidepressant therapy, whereas no significant changes were observed in FEMD patients in non-response as well as RMD patients. The improvement of 24-item Hamilton Depression Scale was correlate with changes of Treg cell proportion from T0 to T14 in FEMD patients in response, and the change in Treg cell proportion over a 14-day period exhibited an AUC curve of 0.710.

CONCLUSIONS

A decrease in the proportion of CD4+ Treg cells points towards immune system abnormalities in patients with MD. Furthermore, our finding suggests that the immune activation state varies across different stages of depression.

Local and global effects of sedation in resting-state fMRI: a randomized, placebo-controlled comparison between etifoxine and alprazolam

TSPO ligands are promising alternatives to benzodiazepines in the treatment of anxiety, as they display less pronounced side effects such as sedation, cognitive impairment, tolerance development and abuse potential. In a randomized double-blind repeated-measures study we compare a benzodiazepine (alprazolam) to a TSPO ligand (etifoxine) by assessing side effects and acquiring resting-state fMRI data from 34 healthy participants after 5 days of taking alprazolam, etifoxine or a placebo. To study the effects of the pharmacological interventions in fMRI in detail and across different scales, we combine in our study complementary analysis strategies related to whole-brain functional network connectivity, local connectivity analysis expressed in regional homogeneity, fluctuations in low-frequency BOLD amplitudes and coherency of independent resting-state networks. Participants reported considerable adverse effects such as fatigue, sleepiness and concentration impairments, related to the administration of alprazolam compared to placebo. In resting-state fMRI we found a significant decrease in functional connection density, network efficiency and a decrease in the networks rich-club coefficient related to alprazolam. While observing a general decrease in regional homogeneity in high-level brain networks in the alprazolam condition, we simultaneously could detect an increase in regional homogeneity and resting-state network coherence in low-level sensory regions. Further we found a general increase in the low-frequency compartment of the BOLD signal. In the etifoxine condition, participants did not report any significant side effects compared to the placebo, and we did not observe any corresponding modulations in our fMRI metrics. Our results are consistent with the idea that sedation globally disconnects low-level functional networks, but simultaneously increases their within-connectivity. Further, our results point towards the potential of TSPO ligands in the treatment of anxiety and depression.

Neurosteroid [3α,5α]3-hydroxypregnan-20-one inhibition of chemokine monocyte chemoattractant protein-1 in alcohol-preferring rat brain neurons, microglia, and astroglia

BACKGROUND

Neuroimmune dysfunction in alcohol use disorder (AUD) is associated with activation of myeloid differentiation primary response 88 (MyD88)-dependent Toll-like receptors (TLR) resulting in overexpression of the chemokine monocyte chemoattractant protein-1 (MCP-1/CCL2). MCP-1 overexpression in the brain is linked to anxiety, higher alcohol intake, neuronal death, and activation of microglia observed in AUD. The neurosteroid [3α,5α][3-hydroxypregnan-20-one (3α,5α-THP) has been reported as an inhibitor of MyD88-dependent TLR activation and MCP-1 overexpression in mouse and human macrophages and the brain of alcohol-preferring (P) rats.

METHODS

We investigated how 3α,5α-THP regulates MCP-1 expression at the cellular level in P rat nucleus accumbens (NAc) and central amygdala (CeA). We focused on neurons, microglia, and astrocytes, examining the individual voxel density of MCP-1, neuronal marker NeuN, microglial marker IBA1, astrocytic marker GFAP, and their shared voxel density, defined as intersection. Ethanol-naïve male and female P rats were perfused 1 h after IP injections of 15 mg/kg of 3α,5α-THP, or vehicle. The NAc and CeA were imaged using confocal microscopy following double-immunofluorescence staining for MCP-1 with NeuN, IBA1, and GFAP, respectively.

RESULTS

MCP-1 intersected with NeuN predominantly and IBA1/GFAP negligibly. 3α,5α-THP reduced MCP-1 expression in NeuN-labeled cells by 38.27 ± 28.09% in male and 56.11 ± 21.46% in female NAc, also 37.99 ± 19.53% in male and 54.96 ± 30.58% in female CeA. In females, 3α,5α-THP reduced the MCP-1 within IBA1 and GFAP-labeled voxels in the NAc and CeA. Conversely, in males, 3α,5α-THP did not significantly alter the MCP-1 within IBA1 in NAc or with GFAP in the CeA. Furthermore, 3α,5α-THP decreased levels of IBA1 in both regions and sexes with no impact on GFAP or NeuN levels. Secondary analysis performed on data normalized to % control values indicated that no significant sex differences were present.

CONCLUSIONS

These data suggest that 3α,5α-THP inhibits neuronal MCP-1 expression and decreases the proliferation of microglia in P rats. These results increase our understanding of potential mechanisms for 3α,5α-THP modulation of ethanol consumption.

Antidepressant effects of activation of infralimbic cortex via upregulation of BDNF and β-catenin in an estradiol withdrawal model

RATIONALE

Clinical and preclinical studies have demonstrated that estradiol withdrawal after delivery is one of important factors involved in the pathogenesis of postpartum depression (PPD). The infralimbic cortex (IL) is related to anxiety and mood disorders. Whether IL neurons mediate PPD is still unclear.

OBJECTIVES

This study was to observe the antidepressant effect and expression of BDNF and β-catenin in IL by allopregnanolone (ALLO) treatment or the selective activation or inhibition of IL neurons using a chemogenetic approach in a pseudopregnancy model of PPD.

METHODS

Administration of estradiol combined with progesterone and the abrupt withdrawal of estradiol simulated the pregnancy and early postpartum periods to induce depression in ovariectomized rats. The relative expression levels of β-catenin and BDNF were observed by western blotting.

RESULTS

Immobility time was significantly increased in the forced swim test and open-arm movement was reduced in the elevated plus maze test in the estradiol-withdrawn rats. After ALLO treatment, the immobility time were lower and open-arm traveling times higher than those of the estradiol-withdrawn rats. Meanwhile, the expression level of BDNF or β-catenin in the IL was reduced significantly in estradiol-withdrawn rats, which was prevented by treatment with ALLO. The hM3Dq chemogenetic activation of pyramidal neurons in the IL reversed the immobility and open-arm travel time trends in the estradiol-withdrawal rat model, but chemogenetic inhibition of IL neurons failed to affect this. Upregulated BDNF and β-catenin expression and increased c-Fos in the basolateral amygdala were found following IL neuron excitation in model rats.

CONCLUSIONS

Our results demonstrated that pseudopregnancy and estradiol withdrawal produced depressive-like behavior and anxiety. ALLO treatment or specific excitement of IL pyramidal neurons relieved abnormal behaviors and upregulated BDNF and β-catenin expression in the IL in the PPD model, suggesting that hypofunction of IL neurons may be involved in the pathogenesis of PPD.

A single intravenous reelin injection restores corticosterone-induced neurochemical and behavioral alterations in dams during the post-partum period

Introduction

Treatment with the synaptic plasticity protein reelin has rapid antidepressant-like effects in adult corticosterone (CORT)-induced depressed rats, whether administered repeatedly or acutely. However, these effects remain unexplored in the context of post-partum depression (PPD).

Methods

This study investigated the antidepressant-like effect of a single injection of reelin in a CORT-induced model of PPD. Long-Evans female dams received either daily subcutaneous CORT (40 mg/kg) or saline injections (controls) from the post-partum day (PD) 2 to 22, and on PD22 were treated with a single intravenous reelin (3 μg) or vehicle injection.

Results

Reelin treatment fully normalized to control levels the CORT-induced increase in Forced Swim Test (FST) immobility and the decrease in reelin-positive cells in the subgranular zone of the intermediate hippocampus. It also increased the number of oxytocin-positive cells in the paraventricular nucleus (PVN), the number of reelin-positive cells in the dorsal and ventral hippocampus, and the dendritic complexity of newborn neurons in the intermediate hippocampus, causing a partial recovery compared to controls. None of these changes were associated with fluctuations in estrogen levels measured peripherally.

Discussion

This study brings new insights into the putative antidepressant-like effect of peripherally administered reelin in an animal model of PPD. Future studies should be conducted to investigate these effects on a dose-response paradigm and to further elucidate the mechanisms underlying the antidepressant-like effects of reelin.

The impact of pubertal stress and adult hormone exposure on the transcriptome of the developing hypothalamus

Why individuals suffer negative consequences following stress is a complex phenomenon that is dictated by individual factors, the timing of stress within the lifespan, and when in the lifespan the consequences are measured. Women who undergo adverse childhood experiences are at risk for lasting biological consequences, including affective and stress dysregulation. We have shown that pubertal adversity is associated with a blunted hypothalamic-pituitary-adrenal axis glucocorticoid response in peripartum humans and mice. In mice, our prior examination of the paraventricular nucleus (PVN) of the hypothalamus showed that pubertal stress led to an upregulation of baseline mRNA expression of six immediate early genes (IEGs) in the PVN of adult, pregnant mice. Separately, we showed that the pregnancy-associated hormone allopregnanolone is necessary and sufficient to produce the blunted stress response phenotype in pubertally stressed mice. In the current study, we further examined a potential mechanistic role for the IEGs in the PVN. We found that in pubertally stressed adult female, but not male, mice, intra-PVN allopregnanolone was sufficient to recapitulate the baseline IEG mRNA expression profile previously observed in pubertally stressed, pregnant mice. We also examined baseline IEG mRNA expression during adolescence, where we found that IEGs have developmental trajectories that showed sex-specific disruption by pubertal stress. Altogether, these data establish that IEGs may act as a key molecular switch involved in increased vulnerability to negative outcomes in adult, pubertally stressed animals. How the factors that produce vulnerability combine throughout the lifespan is key to our understanding of the etiology of stress-related disorders.

Safety assessment of brexanolone in the FAERS database: real adverse event analysis and discussion of side effects

BACKGROUND

Postpartum depression (PPD) is linked to hormonal changes. Brexanolone, the first FDA-approved drug for PPD, is a potential treatment. This study analyzes Brexanolone's safety using the FAERS database, highlighting its adverse effects and potential risk factors.

METHODS

We analyzed FAERS data from Q3 2019 to Q3 2023, evaluating adverse reactions to Brexanolone. The analysis includes demographics, reporting regions, reporter identities, and types of adverse reactions.

RESULTS

Most reports are from the United States, with consumers and physicians as primary reporters. Adverse reactions mainly involve severe systemic diseases, administration site reactions, injuries, intoxication, operational complications, and mental disorders. Specific adverse reactions include incorrect drug monitoring, PPD, intrusive thoughts, delayed treatment efficacy, sedation complications, product discontinuation, misuse, infusion site leakage and pain, and medication errors.

CONCLUSION

The study confirms known safety information about Brexanolone and provides comprehensive data for medical practices and public health decisions. However, relying on spontaneous reports may introduce biases and incomplete information. Continued monitoring and reporting of adverse reactions to newer drugs like Brexanolone remain crucial.

Update on the assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form-2 (ATHF-SF2)

All definitions of treatment-resistant depression (TRD) require that patients have experienced insufficient benefit from one or more adequate antidepressant trials. Thus, identifying "failed, adequate trials" is key to the assessment of TRD. The Antidepressant Treatment History Form (ATHF) was one of the first and most widely used instruments that provided objective criteria in making these assessments. The original ATHF was updated in 2018 to the ATHF-SF, changing to a checklist format for scoring, and including specific pharmacotherapy, brain stimulation, and psychotherapy interventions as potentially adequate antidepressant treatments. The ATHF-SF2, presented here, is based on the consensus of the ATHF workgroup about the novel interventions introduced since the last revision and which should/should not be considered effective treatments for major depressive episodes. This document describes the rationale for these choices and, for each intervention, the minimal criteria for determining the adequacy of treatment administration. The Supplementary Material that accompanies this article provide the Scoring Checklist, Data Collection Forms (current episode and composite of previous episodes), and Instruction Manual for the ATHF-SF2.

Supportive care of female hormones in brain health: what and how?

Female hormones, functioning as neuroactive steroids, are utilized beyond menopausal hormone therapy. The rapid onset of allopregnanolone analogs, such as brexanolone and zuranolone, in treating depression, and the effectiveness of megestrol acetate in addressing appetite and weight gain, prompted the Food and Drug Administration to authorize the use of progesterone for treating postpartum depression and cancer-related cachexia. Progesterone has also been found to alleviate neuropathic pain in animal studies. These off-label applications offer a promising option for patients with advanced cancer who often experience various mood disorders such as depression, persistent pain, social isolation, and physical complications like cachexia. These patients have shown low tolerance to opioids and mood-regulating medications. However, the potential risks and uncertainties associated with hormone therapy treatment modalities can be daunting for both patients and medical professionals. This review aims to offer a comprehensive understanding of the non-reproductive functions and mechanisms of female hormones in brain health.

Emerging evidence for pregnane steroid therapeutics for alcohol use disorders

Many lines of research have suggested that the neuroactive pregnane steroids, including pregnenolone, progesterone, and allopregnanolone ([3α,5α]-3-hydroxypregnan-20-one, 3α,5α-THP), have therapeutic potential for treatment of alcohol use disorders (AUDs). In this chapter, we systematically address the preclinical and clinical evidence that supports this approach for AUD treatment, describe the underlying neurobiology of AUDs that are targeted by these treatments, and delineate how pregnane steroids may address various components of the disease. This review updates the theoretical framework for understanding how endogenous steroids that modulate the effects of alcohol, stress, excitatory/inhibitory and dopamine transmission, and the innate immune system appear to play a key role in the prevention and mitigation of AUDs. We further discuss newly discovered limitations of pregnane steroid therapies as well as the challenges that are inherent to development of endogenous compounds for therapeutics. We argue that overcoming these challenges presents the opportunity to help millions who suffer from AUDs across the world.

Fibromyalgia pathogenesis explained by a neuroendocrine multistable model

Fibromyalgia (FM) is a central disorder characterized by chronic pain, fatigue, insomnia, depression, and other minor symptoms. Knowledge about pathogenesis is lacking, diagnosis difficult, clinical approach puzzling, and patient management disappointing. We conducted a theoretical study based on literature data and computational analysis, aimed at developing a comprehensive model of FM pathogenesis and addressing suitable therapeutic targets. We started from the evidence that FM must involve a dysregulation of central pain processing, is female prevalent, suggesting a role for the hypothalamus-pituitary-gonadal (HPG) axis, and is stress-related, suggesting a role for the HP-adrenocortical (HPA) axis. Central pathogenesis was supposed to involve a pain processing loop system including the thalamic ventroposterolateral nucleus (VPL), the primary somatosensory cortex (SSC), and the thalamic reticular nucleus (TRN). For decreasing GABAergic and/or increasing glutamatergic transmission, the loop system crosses a bifurcation point, switching from monostable to bistable, and converging on a high-firing-rate steady state supposed to be the pathogenic condition. Thereafter, we showed that GABAergic transmission is positively correlated with gonadal-hormone-derived neurosteroids, notably allopregnanolone, whereas glutamatergic transmission is positively correlated with stress-induced glucocorticoids, notably cortisol. Finally, we built a dynamic model describing a multistable, double-inhibitory loop between HPG and HPA axes. This system has a high-HPA/low-HPG steady state, allegedly reached in females under combined premenstrual/postpartum brain allopregnanolone withdrawal and stress condition, driving the thalamocortical loop to the high-firing-rate steady state, and explaining the connection between endocrine and neural mechanisms in FM pathogenesis. Our model accounts for FM female prevalence and stress correlation, suggesting the use of neurosteroid drugs as a possible solution to currently unsolved problems in the clinical treatment of the disease.

Neurosteroid [3α,5α]-3-Hydroxy-pregnan-20-one Enhances the CX3CL1-CX3CR1 Pathway in the Brain of Alcohol-Preferring Rats with Sex-Specificity

This study investigates the impact of allopregnanolone ([3α,5α]3-hydroxypregnan-20-one or 3α,5α-tetrahydroprogesterone (3α,5α-THP); 10 mg/kg, IP) on fractalkine/CX3-C motif chemokine ligand 1 (CX3CL1) levels, associated signaling components, and markers for microglial and astrocytic cells in the nucleus accumbens (NAc) of male and female alcohol-preferring (P) rats. Previous research suggested that 3α,5α-THP enhances anti-inflammatory interleukin-10 (IL-10) cytokine production in the brains of male P rats, with no similar effect observed in females. This study reveals that 3α,5α-THP elevates CX3CL1 levels by 16% in the NAc of female P rats, with no significant changes observed in males. The increase in CX3CL1 levels induced by 3α,5α-THP was observed in females across multiple brain regions, including the NAc, amygdala, hypothalamus, and midbrain, while no significant effect was noted in males. Additionally, female P rats treated with 3α,5α-THP exhibited notable increases in CX3CL1 receptor (CX3CR1; 48%) and transforming growth factor-beta 1 (TGF-β1; 24%) levels, along with heightened activation (phosphorylation) of signal transducer and activator of transcription 1 (STAT1; 85%) in the NAc. Conversely, no similar alterations were observed in male P rats. Furthermore, 3α,5α-THP decreased glial fibrillary acidic protein (GFAP) levels by 19% in both female and male P rat NAc, without affecting microglial markers ionized calcium-binding adaptor molecule 1 (IBA1) and transmembrane protein 119 (TMEM119). These findings indicate that 3α,5α-THP enhances the CX3CL1/CX3CR1 pathway in the female P rat brain but not in males, primarily influencing astrocyte reactivity, with no observed effect on microglial activation.

Neurosteroids and translocator protein 18 kDa (TSPO) ligands as novel treatment options in depression

Recently, the gamma-aminobutyric acid (GABA) system has come into focus for the treatment of anxiety, postpartum depression, and major depressive disorder. Endogenous 3α-reduced steroids such as allopregnanolone are potent positive allosteric modulators of GABAA receptors and have been known for decades. Current industry developments and first approvals by the U.S. food and drug administration (FDA) for the treatment of postpartum depression with exogenous analogues of these steroids represent a major step forward in the field. 3α-reduced steroids target both synaptic and extrasynaptic GABAA receptors, unlike benzodiazepines, which bind to synaptic receptors. The first FDA-approved 3α-reduced steroid for postpartum depression is brexanolone, an intravenous formulation of allopregnanolone. It has been shown to provide rapid relief of depressive symptoms. An orally available 3α-reduced steroid is zuranolone, which also received FDA approval in 2023 for the treatment of postpartum depression. Although a number of studies have been conducted, the efficacy data were not sufficient to achieve approval of zuranolone in major depressive disorder by the FDA in 2023. The most prominent side effects of these 3α-reduced steroids are somnolence, dizziness and headache. In addition to the issue of efficacy, it should be noted that current data limit the use of these compounds to two weeks. An alternative to exogenous 3α-reduced steroids may be the use of substances that induce endogenous neurosteroidogenesis, such as the translocator protein 18 kDa (TSPO) ligand etifoxine. TSPO has been extensively studied for its role in steroidogenesis, in addition to other functions such as anti-inflammatory and neuroregenerative properties. Currently, etifoxine is the only clinically available TSPO ligand in France for the treatment of anxiety disorders. Studies are underway to evaluate its antidepressant potential. Hopefully, neurosteroid research will lead to the development of fast-acting antidepressants.