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Vasiliu O. Investigational Drugs for the Treatment of Depression (Part 2): Glutamatergic, Cholinergic, Sestrin Modulators, and Other Agents. Front Pharmacol 2022; 13:884155. [PMID: 35847011 PMCID: PMC9284317 DOI: 10.3389/fphar.2022.884155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/21/2022] [Indexed: 11/29/2022] Open
Abstract
Many investigational drugs with antidepressant activity are currently explored in different phases of clinical research, with indications such as major depressive disorder, treatment-resistant major depression, bipolar depression, post-partum depression, and late-life depression. Although the vast majority of the antidepressants in clinical use are based on the monoaminergic hypothesis of depression, recent data supported the launching on the market of two new, non-monoamine-modulating drugs. Esketamine for treatment-resistant major depression and brexanolone for post-partum depression are two exceptions from the monoaminergic model, although their use is still limited by high costs, unique way of administration (only intravenously for brexanolone), physicians’ reluctance to prescribe new drugs, and patients’ reticence to use them. Glutamatergic neurotransmission is explored based on the positive results obtained by intranasal esketamine, with subanesthetic intravenous doses of ketamine, and D-cycloserine, traxoprodil, MK-0657, AXS-05, AVP-786, combinations of cycloserine and lurasidone, or dextromethorphan and quinidine, explored as therapeutic options for mono- or bipolar depression. Sestrin modulators, cholinergic receptor modulators, or onabotulinumtoxinA have also been investigated for potential antidepressant activity. In conclusion, there is hope for new treatments in uni- and bipolar depression, as it became clear, after almost 7 decades of monoamine-modulating antidepressants, that new pathogenetic pathways should be targeted to increase the response rate in this population.
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Demchenko I, Tassone VK, Kennedy SH, Dunlop K, Bhat V. Intrinsic Connectivity Networks of Glutamate-Mediated Antidepressant Response: A Neuroimaging Review. Front Psychiatry 2022; 13:864902. [PMID: 35722550 PMCID: PMC9199367 DOI: 10.3389/fpsyt.2022.864902] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
Conventional monoamine-based pharmacotherapy, considered the first-line treatment for major depressive disorder (MDD), has several challenges, including high rates of non-response. To address these challenges, preclinical and clinical studies have sought to characterize antidepressant response through monoamine-independent mechanisms. One striking example is glutamate, the brain's foremost excitatory neurotransmitter: since the 1990s, studies have consistently reported altered levels of glutamate in MDD, as well as antidepressant effects following molecular targeting of glutamatergic receptors. Therapeutically, this has led to advances in the discovery, testing, and clinical application of a wide array of glutamatergic agents, particularly ketamine. Notably, ketamine has been demonstrated to rapidly improve mood symptoms, unlike monoamine-based interventions, and the neurobiological basis behind this rapid antidepressant response is under active investigation. Advances in brain imaging techniques, including functional magnetic resonance imaging, magnetic resonance spectroscopy, and positron emission tomography, enable the identification of the brain network-based characteristics distinguishing rapid glutamatergic modulation from the effect of slow-acting conventional monoamine-based pharmacology. Here, we review brain imaging studies that examine brain connectivity features associated with rapid antidepressant response in MDD patients treated with glutamatergic pharmacotherapies in contrast with patients treated with slow-acting monoamine-based treatments. Trends in recent brain imaging literature suggest that the activity of brain regions is organized into coherent functionally distinct networks, termed intrinsic connectivity networks (ICNs). We provide an overview of major ICNs implicated in depression and explore how treatment response following glutamatergic modulation alters functional connectivity of limbic, cognitive, and executive nodes within ICNs, with well-characterized anti-anhedonic effects and the enhancement of "top-down" executive control. Alterations within and between the core ICNs could potentially exert downstream effects on the nodes within other brain networks of relevance to MDD that are structurally and functionally interconnected through glutamatergic synapses. Understanding similarities and differences in brain ICNs features underlying treatment response will positively impact the trajectory and outcomes for adults suffering from MDD and will facilitate the development of biomarkers to enable glutamate-based precision therapeutics.
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Affiliation(s)
- Ilya Demchenko
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Vanessa K Tassone
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Sidney H Kennedy
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katharine Dunlop
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Venkat Bhat
- Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Center for Depression and Suicide Studies, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Keenan Research Center for Biomedical Science, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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3
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Borbély É, Simon M, Fuchs E, Wiborg O, Czéh B, Helyes Z. Novel drug developmental strategies for treatment-resistant depression. Br J Pharmacol 2021; 179:1146-1186. [PMID: 34822719 PMCID: PMC9303797 DOI: 10.1111/bph.15753] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 10/17/2021] [Accepted: 11/14/2021] [Indexed: 11/30/2022] Open
Abstract
Major depressive disorder is a leading cause of disability worldwide. Because conventional therapies are ineffective in many patients, novel strategies are needed to overcome treatment‐resistant depression (TRD). Limiting factors of successful drug development in the last decades were the lack of (1) knowledge of pathophysiology, (2) translational animal models and (3) objective diagnostic biomarkers. Here, we review novel drug targets and drug candidates currently investigated in Phase I–III clinical trials. The most promising approaches are inhibition of glutamatergic neurotransmission by NMDA and mGlu5 receptor antagonists, modulation of the opioidergic system by κ receptor antagonists, and hallucinogenic tryptamine derivates. The only registered drug for TRD is the NMDA receptor antagonist, S‐ketamine, but add‐on therapies with second‐generation antipsychotics, certain nutritive, anti‐inflammatory and neuroprotective agents seem to be effective. Currently, there is an intense research focus on large‐scale, high‐throughput omics and neuroimaging studies. These results might provide new insights into molecular mechanisms and potential novel therapeutic strategies.
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Affiliation(s)
- Éva Borbély
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Hungary.,Molecular Pharmacology Research Group, Szentágothai János Research Centre, University of Pécs, Pécs, Hungary
| | - Mária Simon
- Department of Psychiatry and Psychotherapy, Clinical Centre, Medical School, University of Pécs, Hungary
| | - Eberhard Fuchs
- German Primate Center, Leibniz Institute for Primate Research, Göttingen, Germany
| | - Ove Wiborg
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Boldizsár Czéh
- Neurobiology of Stress Research Group, Szentágothai János Research Centre, University of Pécs, Pécs, Hungary.,Department of Laboratory Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Hungary.,Molecular Pharmacology Research Group, Szentágothai János Research Centre, University of Pécs, Pécs, Hungary
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Honda S, Matsumoto M, Tajinda K, Mihara T. Enhancing Clinical Trials Through Synergistic Gamma Power Analysis. Front Psychiatry 2020; 11:537. [PMID: 32587536 PMCID: PMC7299152 DOI: 10.3389/fpsyt.2020.00537] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/26/2020] [Indexed: 12/14/2022] Open
Abstract
While the etiology of many neuropsychiatric disorders remains unknown, increasing evidence suggests that aberrant sensory processing plays a central role. For this class of disorders, which are characterized by affective, cognitive, and behavioral symptoms, electroencephalography remains the dominant tool for providing insight into the physiological and molecular underpinnings of the disease state and predicting the effectiveness of investigational new drugs. Within the spectrum of electrical activity present in the CNS, high-frequency oscillations in the gamma band are frequently altered in these patient populations. Measurement of gamma oscillation can be further classified into baseline and evoked, each of which offers a specific commentary on disease state. Baseline gamma analysis provides a surrogate of pharmacodynamics and predicting the time course effects of clinical candidate drugs, while alterations in evoked (time-locked) gamma power may serve as a disease biomarker and have utility in assessing patient response to new drugs. Together, these techniques offer complimentary methods of analysis for discrete realms of clinical and translational medicine. In terms of drug development, comprehensive analysis containing aspects of both baseline and evoked gamma oscillations may prove more useful in establishing better workflow and more accurate criteria for the testing of investigational new drugs.
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Affiliation(s)
- Sokichi Honda
- Neuroscience, La Jolla Laboratory, Astellas Research Institute of America LLC, San Diego, CA, United States
| | - Mitsuyuki Matsumoto
- Neuroscience, La Jolla Laboratory, Astellas Research Institute of America LLC, San Diego, CA, United States
| | - Katsunori Tajinda
- Neuroscience, La Jolla Laboratory, Astellas Research Institute of America LLC, San Diego, CA, United States
| | - Takuma Mihara
- Candidate Discovery Research Labs, DDR, Astellas Pharm Inc., Tsukuba, Japan
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Lijffijt M, Green CE, Balderston N, Iqbal T, Atkinson M, Vo-Le B, Vo-Le B, O’Brien B, Grillon C, Swann AC, Mathew SJ. A Proof-of-Mechanism Study to Test Effects of the NMDA Receptor Antagonist Lanicemine on Behavioral Sensitization in Individuals With Symptoms of PTSD. Front Psychiatry 2019; 10:846. [PMID: 31920733 PMCID: PMC6923195 DOI: 10.3389/fpsyt.2019.00846] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/24/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Individuals with post-traumatic stress disorder (PTSD) have a heightened sensitivity to subsequent stressors, addictive drugs, and symptom recurrence, a form of behavioral sensitization. N-methyl-D-aspartate receptors (NMDARs) are involved in the establishment and activation of sensitized behavior. Objective: We describe a protocol of a randomized placebo-controlled Phase 1b proof-of-mechanism trial to examine target engagement, safety, tolerability, and possible efficacy of the NMDAR antagonist lanicemine in individuals with symptoms of PTSD (Clinician Administered PTSD Scale [CAPS-5] score ≥ 25) and evidence of behavioral sensitization measured as enhanced anxiety-potentiated startle (APS; T-score ≥ 2.8). Methods: Subjects (n = 24; age range 21-65) receive three 60-min intravenous infusions of placebo or 100 mg lanicemine over 5 non-consecutive days. Primary endpoint is change in APS from pre-treatment baseline to after the third infusion. NMDAR engagement is probed with resting state EEG gamma band power, 40 Hz auditory steady state response, the mismatch negativity amplitude, and P50 sensory gating. Change in CAPS-5 scores is an exploratory clinical endpoint. Bayesian statistical methods will evaluate endpoints to determine suitability of this agent for further study. Conclusion: In contrast to traditional early-phase trials that use symptom severity to track treatment efficacy, this study tracks engagement of the study drug on expression of behavioral sensitization, a functional mechanism likely to cut across disorders. This experimental therapeutics design is consistent with recent NIMH-industry collaborative studies, and could serve as a template for testing novel pharmacological agents in psychiatry. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03166501.
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Affiliation(s)
- Marijn Lijffijt
- Research Service Line, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Charles E. Green
- Department of Psychiatry and Behavioral Sciences, UTHealth McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
- Department of Pediatrics - Center for Evidence Based Medicine, UTHealth McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Nicholas Balderston
- Section on Neurobiology of Fear and Anxiety, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Tabish Iqbal
- Research Service Line, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Megan Atkinson
- Department of Anesthesiology, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, United States
| | - Brittany Vo-Le
- Research Service Line, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Bylinda Vo-Le
- Research Service Line, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Brittany O’Brien
- Research Service Line, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Christian Grillon
- Department of Pediatrics - Center for Evidence Based Medicine, UTHealth McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Alan C. Swann
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Sanjay J. Mathew
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, TX, United States
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