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Khanra S, Reddy P, Giménez-Palomo A, Park CHJ, Panizzutti B, McCallum M, Arumugham SS, Umesh S, Debnath M, Das B, Venkatasubramanian G, Ashton M, Turner A, Dean OM, Walder K, Vieta E, Yatham LN, Pacchiarotti I, Reddy YCJ, Goyal N, Kesavan M, Colomer L, Berk M, Kim JH. Metabolic regulation to treat bipolar depression: mechanisms and targeting by trimetazidine. Mol Psychiatry 2023; 28:3231-3242. [PMID: 37386057 PMCID: PMC10618096 DOI: 10.1038/s41380-023-02134-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 05/14/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023]
Abstract
Bipolar disorder's core feature is the pathological disturbances in mood, often accompanied by disrupted thinking and behavior. Its complex and heterogeneous etiology implies that a range of inherited and environmental factors are involved. This heterogeneity and poorly understood neurobiology pose significant challenges to existing drug development paradigms, resulting in scarce treatment options, especially for bipolar depression. Therefore, novel approaches are needed to discover new treatment options. In this review, we first highlight the main molecular mechanisms known to be associated with bipolar depression-mitochondrial dysfunction, inflammation and oxidative stress. We then examine the available literature for the effects of trimetazidine in said alterations. Trimetazidine was identified without a priori hypothesis using a gene-expression signature for the effects of a combination of drugs used to treat bipolar disorder and screening a library of off-patent drugs in cultured human neuronal-like cells. Trimetazidine is used to treat angina pectoris for its cytoprotective and metabolic effects (improved glucose utilization for energy production). The preclinical and clinical literature strongly support trimetazidine's potential to treat bipolar depression, having anti-inflammatory and antioxidant properties while normalizing mitochondrial function only when it is compromised. Further, trimetazidine's demonstrated safety and tolerability provide a strong rationale for clinical trials to test its efficacy to treat bipolar depression that could fast-track its repurposing to address such an unmet need as bipolar depression.
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Affiliation(s)
- Sourav Khanra
- Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
| | - Preethi Reddy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Anna Giménez-Palomo
- Bipolar and Depressive Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Biomedical Research Networking Center (CIBERSAM), Madrid, Spain
| | - Chun Hui J Park
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Bruna Panizzutti
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Madeleine McCallum
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Shyam Sundar Arumugham
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Shreekantiah Umesh
- Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
| | - Monojit Debnath
- Department of Human Genetics, NIMHANS, Bengaluru, Karnataka, India
| | - Basudeb Das
- Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
| | - Ganesan Venkatasubramanian
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Melanie Ashton
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Alyna Turner
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Olivia M Dean
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Ken Walder
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Biomedical Research Networking Center (CIBERSAM), Madrid, Spain
| | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Isabella Pacchiarotti
- Bipolar and Depressive Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Biomedical Research Networking Center (CIBERSAM), Madrid, Spain
| | - Y C Janardhan Reddy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Nishant Goyal
- Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
| | - Muralidharan Kesavan
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Lluc Colomer
- Bipolar and Depressive Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Biomedical Research Networking Center (CIBERSAM), Madrid, Spain
| | - Michael Berk
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia.
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.
| | - Jee Hyun Kim
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, VIC, Australia.
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.
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Xu H, Du Y, Wang Q, Chen L, Huang J, Liu Y, Zhou C, Du B. Comparative efficacy, acceptability, and tolerability of adjunctive anti-inflammatory agents on bipolar disorder: A systemic review and network meta-analysis. Asian J Psychiatr 2023; 80:103394. [PMID: 36525766 DOI: 10.1016/j.ajp.2022.103394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/19/2022] [Accepted: 10/02/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We performed a network meta-analysis (NMA) with up-to-date evidence to compare different anti-inflammatory agents to improve the treatment of bipolar disorder (BD) patients. METHODS Four databases (i.e., the Cochrane Library, Web of Science, PubMed, and Embase) were searched for randomized controlled trials (RCTs) published between 1995 and 2022 on the use of anti-inflammatory agents in the treatment of BD. A systematic review and NMA were conducted. RESULTS Adjunctive N-acetylcysteine (NAC) was superior to placebo for the treatment of BD according to the endpoint scale score (SMD -0.65, 95% confidence interval (CI): - 0.99 to - 0.31), response rate (odds ratio (OR) 3.42, 95% CI: 1.23-9.52), remission rate (OR 4.94, 95% CI: 1.03-41.38) and surface under the cumulative ranking curve (SUCRA) value of the endpoint scale score (0.84). Adjunctive nonsteroidal anti-inflammatory drugs (NSAIDs) were more favorable than placebo based on the remission rate (OR 3.93, 95% CI: 1.15-13.43) and were significantly more acceptable than other treatments (OR 0.60, 95% CI: 0.36-0.99). Adjunctive coenzyme Q10 (CoQ10) was superior to other agents in terms of the response rate (OR 18.85, 95% CI: 2.63-135.00), with a SUCRA value for the response rate of 0.90 and that for the remission rate of 0.71. CONCLUSION Adjunctive NAC is recommended for the treatment of BD. Adjunctive NSAIDs and CoQ10 are still seen as effective, but more high-quality clinical studies are needed to verify their efficacy. Other anti-inflammatory agents may not be recommended for clinical use at present. All anti-inflammatory agents demonstrated a good safety profile. We call for further research on the combined treatment of BD with different anti-inflammatory agents to be included in future trials.
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Affiliation(s)
- Han Xu
- School of Pharmacy, North Sichuan Medical College, Nanchong, Sichuan 637000, China
| | - Yang Du
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Qiong Wang
- Department of Pharmacy, Ningxia Medical University, Ningxia 750004, China
| | - Lizhi Chen
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Juan Huang
- School of Pharmacy, North Sichuan Medical College, Nanchong, Sichuan 637000, China
| | - Yin Liu
- School of Pharmacy, North Sichuan Medical College, Nanchong, Sichuan 637000, China
| | - Chunyang Zhou
- School of Pharmacy, North Sichuan Medical College, Nanchong, Sichuan 637000, China
| | - Biao Du
- School of Pharmacy, North Sichuan Medical College, Nanchong, Sichuan 637000, China; Department of Pharmacy, Chongqing University Three Gorges Hospital, Chongqing 404000, China.
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Methamphetamine induced neurotoxic diseases, molecular mechanism, and current treatment strategies. Biomed Pharmacother 2022; 154:113591. [PMID: 36007276 DOI: 10.1016/j.biopha.2022.113591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/21/2022] Open
Abstract
Methamphetamine (MA) is a extremely addictive psychostimulant drug with a significant abuse potential. Long-term MA exposure can induce neurotoxic effects through oxidative stress, mitochondrial functional impairment, endoplasmic reticulum stress, the activation of astrocytes and microglial cells, axonal transport barriers, autophagy, and apoptosis. However, the molecular and cellular mechanisms underlying MA-induced neurotoxicity remain unclear. MA abuse increases the chances of developing neurotoxic conditions such as Parkinson's disease (PD), Alzheimer's disease (AD) and other neurotoxic diseases. MA increases the risk of PD by increasing the expression of alpha-synuclein (ASYN). Furthermore, MA abuse is linked to high chances of developing AD and subsequent neurodegeneration due to biological variations in the brain region or genetic and epigenetic variations. To date, there is no Food and Drug Administration (FDA)-approved therapy for MA-induced neurotoxicity, although many studies are being conducted to develop effective therapeutic strategies. Most current studies are now focused on developing therapies to diminish the neurotoxic effects of MA, based on the underlying mechanism of neurotoxicity. This review article highlights current research on several therapeutic techniques targeting multiple pathways to reduce the neurotoxic effects of MA in the brain, as well as the putative mechanism of MA-induced neurotoxicity.
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Sarris J, Ravindran A, Yatham LN, Marx W, Rucklidge JJ, McIntyre RS, Akhondzadeh S, Benedetti F, Caneo C, Cramer H, Cribb L, de Manincor M, Dean O, Deslandes AC, Freeman MP, Gangadhar B, Harvey BH, Kasper S, Lake J, Lopresti A, Lu L, Metri NJ, Mischoulon D, Ng CH, Nishi D, Rahimi R, Seedat S, Sinclair J, Su KP, Zhang ZJ, Berk M. Clinician guidelines for the treatment of psychiatric disorders with nutraceuticals and phytoceuticals: The World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce. World J Biol Psychiatry 2022; 23:424-455. [PMID: 35311615 DOI: 10.1080/15622975.2021.2013041] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The therapeutic use of nutrient-based 'nutraceuticals' and plant-based 'phytoceuticals' for the treatment of mental disorders is common; however, despite recent research progress, there have not been any updated global clinical guidelines since 2015. To address this, the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Disorders (CANMAT) convened an international taskforce involving 31 leading academics and clinicians from 15 countries, between 2019 and 2021. These guidelines are aimed at providing a definitive evidence-informed approach to assist clinicians in making decisions around the use of such agents for major psychiatric disorders. We also provide detail on safety and tolerability, and clinical advice regarding prescription (e.g. indications, dosage), in addition to consideration for use in specialised populations. METHODS The methodology was based on the WFSBP guidelines development process. Evidence was assessed based on the WFSBP grading of evidence (and was modified to focus on Grade A level evidence - meta-analysis or two or more RCTs - due to the breadth of data available across all nutraceuticals and phytoceuticals across major psychiatric disorders). The taskforce assessed both the 'level of evidence' (LoE) (i.e. meta-analyses or RCTs) and the assessment of the direction of the evidence, to determine whether the intervention was 'Recommended' (+++), 'Provisionally Recommended' (++), 'Weakly Recommended' (+), 'Not Currently Recommended' (+/-), or 'Not Recommended' (-) for a particular condition. Due to the number of clinical trials now available in the field, we firstly examined the data from our two meta-reviews of meta-analyses (nutraceuticals conducted in 2019, and phytoceuticals in 2020). We then performed a search of additional relevant RCTs and reported on both these data as the primary drivers supporting our clinical recommendations. Lower levels of evidence, including isolated RCTs, open label studies, case studies, preclinical research, and interventions with only traditional or anecdotal use, were not assessed. RESULTS Amongst nutraceuticals with Grade A evidence, positive directionality and varying levels of support (recommended, provisionally recommended, or weakly recommended) was found for adjunctive omega-3 fatty acids (+++), vitamin D (+), adjunctive probiotics (++), adjunctive zinc (++), methylfolate (+), and adjunctive s-adenosyl methionine (SAMe) (+) in the treatment of unipolar depression. Monotherapy omega-3 (+/-), folic acid (-), vitamin C (-), tryptophan (+/-), creatine (+/-), inositol (-), magnesium (-), and n-acetyl cysteine (NAC) (+/-) and SAMe (+/-) were not supported for this use. In bipolar disorder, omega-3 had weak support for bipolar depression (+), while NAC was not currently recommended (+/-). NAC was weakly recommended (+) in the treatment of OCD-related disorders; however, no other nutraceutical had sufficient evidence in any anxiety-related disorder. Vitamin D (+), NAC (++), methylfolate (++) were recommended to varying degrees in the treatment of the negative symptoms in schizophrenia, while omega-3 fatty acids were not, although evidence suggests a role for prevention of transition to psychosis in high-risk youth, with potential pre-existing fatty acid deficiency. Micronutrients (+) and vitamin D (+) were weakly supported in the treatment of ADHD, while omega-3 (+/-) and omega-9 fatty acids (-), acetyl L carnitine (-), and zinc (+/-) were not supported. Phytoceuticals with supporting Grade A evidence and positive directionality included St John's wort (+++), saffron (++), curcumin (++), and lavender (+) in the treatment of unipolar depression, while rhodiola use was not supported for use in mood disorders. Ashwagandha (++), galphimia (+), and lavender (++) were modestly supported in the treatment of anxiety disorders, while kava (-) and chamomile (+/-) were not recommended for generalised anxiety disorder. Ginkgo was weakly supported in the adjunctive treatment of negative symptoms of schizophrenia (+), but not supported in the treatment of ADHD (+/-). With respect to safety and tolerability, all interventions were deemed to have varying acceptable levels of safety and tolerability for low-risk over-the-counter use in most circumstances. Quality and standardisation of phytoceuticals was also raised by the taskforce as a key limiting issue for firmer confidence in these agents. Finally, the taskforce noted that such use of nutraceuticals or phytoceuticals be primarily recommended (where supportive evidence exists) adjunctively within a standard medical/health professional care model, especially in cases of more severe mental illness. Some meta-analyses reviewed contained data from heterogenous studies involving poor methodology. Isolated RCTs and other data such as open label or case series were not included, and it is recognised that an absence of data does not imply lack of efficacy. CONCLUSIONS Based on the current data and clinician input, a range of nutraceuticals and phytoceuticals were given either a supportive recommendation or a provisional recommendation across a range of various psychiatric disorders. However several had only a weak endorsement for potential use; for a few it was not possible to reach a clear recommendation direction, largely due to mixed study findings; while some other agents showed no obvious therapeutic benefit and were clearly not recommended for use. It is the intention of these guidelines to inform psychiatric/medical, and health professional practice globally.
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Affiliation(s)
- Jerome Sarris
- NICM Health Research Institute, Western Sydney University, Westmead, Australia.,The Professorial Unit, The Melbourne Clinic; Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Arun Ravindran
- University of Toronto and Centre for Addiction and Mental Health, Toronto, Canada
| | | | - Wolfgang Marx
- Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Julia J Rucklidge
- School of Psychology, Speech, and Hearing, University of Canterbury, Christchurch, New Zealand
| | - Roger S McIntyre
- University of Toronto, Mood Disorders Psychopharmacology Unit, Toronto, Canada
| | - Shahin Akhondzadeh
- Psychiatry and Psychology Research Centre, Roozbeh Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Francesco Benedetti
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy.,Division of Neuroscience, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Constanza Caneo
- Departamento de Psiquiatría, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Holger Cramer
- Department of Internal and Integrative Medicine, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Lachlan Cribb
- The Professorial Unit, The Melbourne Clinic; Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Michael de Manincor
- NICM Health Research Institute, Western Sydney University, Westmead, Australia
| | - Olivia Dean
- Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia.,Mental Health Research Institute of Victoria, Parkville, Australia
| | - Andrea Camaz Deslandes
- Center for Alzheimer's Disease and Related Disorders, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marlene P Freeman
- Women's Mental Health Program, Department of Psychiatry, Obstetrics and Gynaecology and Department of Nutritional Sciences, College of Medicine, University of Arizona, Tucson, United States
| | - Bangalore Gangadhar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Brian H Harvey
- Division of Pharmacology, Centre of Excellence for Pharmaceutical Sciences, School of Pharmacy, North West University, Potchefstroom, South Africa
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Center for Brain Research, Medical University of Vienna, Vienna, Austria
| | - James Lake
- NICM Health Research Institute, Western Sydney University, Westmead, Australia.,Department of Psychiatry, University of Arizona, Tuscon, United States
| | - Adrian Lopresti
- College of Science, Health, Engineering and Education, Murdoch University, Murdoch, Australia
| | - Lin Lu
- Institute of Mental Health and Peking University Sixth Hospital, Peking University and National Institute of Drug Dependence, Beijing, China
| | - Najwa-Joelle Metri
- NICM Health Research Institute, Western Sydney University, Westmead, Australia
| | - David Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chee H Ng
- The Professorial Unit, The Melbourne Clinic; Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Daisuke Nishi
- Department of Mental Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Roja Rahimi
- Department of Traditional Pharmacy, School of Persian Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Justin Sinclair
- NICM Health Research Institute, Western Sydney University, Westmead, Australia
| | - Kuan-Pin Su
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan.,An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Zhang-Jin Zhang
- School of Chinese Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China.,Department of Chinese Medicine, the University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Michael Berk
- Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Deakin University, IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia.,Orygen, National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, Parkville, Australia
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Gabriel FC, Oliveira M, Martella BDM, Berk M, Brietzke E, Jacka FN, Lafer B. Nutrition and bipolar disorder: a systematic review. Nutr Neurosci 2022; 26:637-651. [PMID: 35608150 DOI: 10.1080/1028415x.2022.2077031] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Individuals with bipolar disorder (BD) have higher rates of unhealthy lifestyles and risk for medical comorbidities Research currently suggests that dietary factors may play a role in the development of depression and anxiety. Therefore, nutritional approaches are potential strategies for the treatment of BD. The aim of this review is to summarize the available evidence on nutrition and BD. MATERIALS AND METHODS The paper was developed based on PRISMA 2020 guidelines. The search was conducted in Sep-2021 using PubMed and Cochrane Library, augmented by manually checked references lists. The search found 986 studies, of which 47 were included, combined with 13 from reference lists, totaling 60 studies. RESULTS There were 33 observational trials, of which 15 focused on fatty acids, 9 on micronutrients, 5 on specific foods, 4 on macro and micronutrients. The 27 interventional studies mainly focused on fatty acids, micronutrients and N-acetylcysteine (NAC). DISCUSSION Dietary intake or supplementation of unsaturated fatty acids, mainly Omega-3 seems to be associated with improved BD symptoms, along with seafood, folic acid and zinc. Studies found variable, mainly non-significant impacts of creatine, carnitine, vitamin D, inositol or NAC supplementation on BD. There are promising results associated with Coenzyme Q10 (Coq10) and probiotics. Taken together, these preliminary findings suggest that dietetic approaches might be included as part of BD treatment. Also considering the high risk of metabolic disorders in individuals with BD, they should be encouraged to choose healthy dietary lifestyles, including daily intake of fruits, vegetables, seafood and whole grains.
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Affiliation(s)
- Fernanda C Gabriel
- Bipolar Research Program, Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Manoela Oliveira
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL, USA
| | - Bruna De M Martella
- Bipolar Research Program, Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Michael Berk
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, The University of Melbourne, Melbourne, Australia
| | - Elisa Brietzke
- Department of Psychiatry, Queen's University School of Medicine, Kingston, Canada.,Centre for Neuroscience Studies (CNS), Queen's University, Kingston, Canada
| | - Felice N Jacka
- The Food & Mood Centre, IMPACT (the Institute for Mental and Physical Health and Clinical Translation), School of Medicine, Barwon Health, Deakin University, Geelong, Australia
| | - Beny Lafer
- Bipolar Research Program, Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
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Madireddy S, Madireddy S. Therapeutic Interventions to Mitigate Mitochondrial Dysfunction and Oxidative Stress–Induced Damage in Patients with Bipolar Disorder. Int J Mol Sci 2022; 23:ijms23031844. [PMID: 35163764 PMCID: PMC8836876 DOI: 10.3390/ijms23031844] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/26/2021] [Accepted: 12/30/2021] [Indexed: 01/10/2023] Open
Abstract
Bipolar disorder (BD) is characterized by mood changes, including recurrent manic, hypomanic, and depressive episodes, which may involve mixed symptoms. Despite the progress in neurobiological research, the pathophysiology of BD has not been extensively described to date. Progress in the understanding of the neurobiology driving BD could help facilitate the discovery of therapeutic targets and biomarkers for its early detection. Oxidative stress (OS), which damages biomolecules and causes mitochondrial and dopamine system dysfunctions, is a persistent finding in patients with BD. Inflammation and immune dysfunction might also play a role in BD pathophysiology. Specific nutrient supplements (nutraceuticals) may target neurobiological pathways suggested to be perturbed in BD, such as inflammation, mitochondrial dysfunction, and OS. Consequently, nutraceuticals may be used in the adjunctive treatment of BD. This paper summarizes the possible roles of OS, mitochondrial dysfunction, and immune system dysregulation in the onset of BD. It then discusses OS-mitigating strategies that may serve as therapeutic interventions for BD. It also analyzes the relationship between diet and BD as well as the use of nutritional interventions in the treatment of BD. In addition, it addresses the use of lithium therapy; novel antipsychotic agents, including clozapine, olanzapine, risperidone, cariprazine, and quetiapine; and anti-inflammatory agents to treat BD. Furthermore, it reviews the efficacy of the most used therapies for BD, such as cognitive–behavioral therapy, bright light therapy, imagery-focused cognitive therapy, and electroconvulsive therapy. A better understanding of the roles of OS, mitochondrial dysfunction, and inflammation in the pathogenesis of bipolar disorder, along with a stronger elucidation of the therapeutic functions of antioxidants, antipsychotics, anti-inflammatory agents, lithium therapy, and light therapies, may lead to improved strategies for the treatment and prevention of bipolar disorder.
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Affiliation(s)
- Sahithi Madireddy
- Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Correspondence:
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Maiti R, Mishra A, Mishra BR, Jena M. Comparative efficacy of mitochondrial agents for bipolar disorder during depressive episodes: a network meta-analysis using frequentist and Bayesian approaches. Psychopharmacology (Berl) 2021; 238:3347-3356. [PMID: 34751803 DOI: 10.1007/s00213-021-06019-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
RATIONALE Mitochondrial dysfunctions have emerged as new biological hypothesis and therapeutic target for bipolar disorder. This network meta-analysis has been done to evaluate the comparative efficacy of mitochondrial agents in bipolar depression. METHODS After a comprehensive literature search on PubMed/MEDLINE, Cochrane databases, and International Trials Registry Platform, efficacy data were extracted from 15 randomized controlled trials. Random-effects meta-analysis was done following both frequentist and Bayesian approaches to pool the effects across the interventions. A network graph was built, relative effects of interventions in respect to one another and placebo were calculated, and treatments were ranked as per P- and SUCRA scores. Change in depression rating score was the primary outcome. Data was entered in contrast level and arm level for frequentist and Bayesian approaches, respectively. RESULTS Amongst mitochondrial agents, N-acetylcysteine (NAC) was shown to have the highest probability of being the best treatment, followed by coenzyme Q10 and combination therapy of alpha-lipoic acid (ALA) and acetyl-L-carnitine (ALCAR) as depicted by P- and SUCRA scores. In the Bayesian approach, none of the treatments had better efficacy than placebo, but in the frequentist approach, NAC (effect estimate: - 1.18 (95% CI: - 2.05; - 0.31)) was significantly better than placebo. CONCLUSION Methodically, there may be a difference of magnitude in frequentist and Bayesian approaches, but the direction of effect and ranking probabilities do not differ. We conclude that none of the existing mitochondrial agents showed better efficacy than placebo in bipolar depression regarding depression rating scores.
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Affiliation(s)
- Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India.
| | - Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Biswa Ranjan Mishra
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Monalisa Jena
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Bortolasci CC, Turner A, Mohebbi M, Liu ZS, Ashton M, Gray L, Marx W, Walker AJ, Kowalski GM, Jacka F, Berk M, Dean OM, Walder K. Baseline serum amino acid levels predict treatment response to augmentation with N-acetylcysteine (NAC) in a bipolar disorder randomised trial. J Psychiatr Res 2021; 142:376-383. [PMID: 34438354 DOI: 10.1016/j.jpsychires.2021.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/14/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022]
Abstract
N-acetylcysteine (NAC) acts on glutamatergic and redox systems, two systems implicated in the pathophysiology of bipolar disorder (BD). This has led to the investigation of NAC as a potential candidate for the treatment of BD. The aim of this study was to investigate metabolomic markers to identify predictors of NAC response in a cohort of BD participants. This study is a secondary analysis of a 16-week, multi-site, randomized, double-blinded, parallel-group, placebo-controlled trial in BD participants with a current acute depressive episode. This study included trial participants who received either NAC 2000 mg/day, or placebo. Participants (NAC: n = 31, placebo: n = 29) were assessed at baseline and week 16 using the Montgomery Åsberg Depression Rating Scale (MADRS) and were dichotomised into "responders" (MADRS at week 16 < 50% of MADRS at baseline) and "non-responders" (MADRS at week 16 > 50% at baseline). Untargeted gas chromatography-mass spectrometry analysis was performed to analyse baseline levels of 68 serum metabolites. Of the nine metabolites that differentiated placebo and NAC groups, five were amino acids with lower levels in the NAC responder group compared with the NAC non-responders. Further analysis generated a predictive model of MADRS improvement including glycine, norleucine, threonine, proline, phenylalanine, tyrosine, glutamic acid, lysine and leucine (R2 = 0.853; adjusted R2 = 0.733). This prediction model predicted 85% of the variance in MADRS outcome after adjunctive treatment with NAC. BD participants with lower serum levels of free amino acids at baseline may be more likely to respond to adjunctive treatment with NAC.
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Affiliation(s)
- Chiara C Bortolasci
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia.
| | - Alyna Turner
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia; School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, Australia; Department of Psychiatry, University of Melbourne, Parkville, Australia
| | | | - Zoe Sj Liu
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia
| | - Melanie Ashton
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia
| | - Laura Gray
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Wolfgang Marx
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia; Department of Rehabilitation, Nutrition and Sport, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Australia
| | - Adam J Walker
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia
| | - Greg M Kowalski
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia; Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Felice Jacka
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia; Black Dog Institute, Sydney, Australia
| | - Michael Berk
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia; Department of Psychiatry, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Centre of Youth Mental Health, University of Melbourne, Parkville, Australia; Orygen Youth Health Research Centre, Parkville, Australia
| | - Olivia M Dean
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia; Department of Psychiatry, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Ken Walder
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Australia.
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Pittas S, Theodoridis X, Haidich AB, Bozikas PV, Papazisis G. The effect of N-acetylcysteine on bipolar depression: a systematic review and meta-analysis of randomized controlled trials. Psychopharmacology (Berl) 2021; 238:1729-1736. [PMID: 33641060 DOI: 10.1007/s00213-021-05789-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE The current pharmacotherapy of bipolar depression often presents limited efficacy and increased risk for adverse events. N-acetylcysteine (NAC) has been suggested as potentially effective and well-tolerated adjunctive treatment for bipolar disorder (BD). OBJECTIVES This systematic review and meta-analysis aimed to examine the efficacy of N-acetylcysteine, as an adjunctive therapy, for treating bipolar depression. METHODS PubMed, Cochrane Library, Scopus databases, and grey literature were searched for studies retrieval. Randomized controlled trials including patients with a diagnosed bipolar disorder and a current depressive episode were included in the analysis. The measured variables included symptoms, functioning, and quality of life scales. The mean change in Montgomery-Åsberg Depression Rating Scale (MADRS) was set as the primary outcome. RESULTS A total of five studies were included in the analysis. A significant improvement was not observed from the addition of NAC to standard therapy in symptomatology [MADRS (MD = -3.32; 95% CI = -12.79 to 6.16), Young Mania Rating Scale (MD = -0.7; 95% CI = -2.15 to 0.75), Bipolar Depression Rating Scale (MD = -3.19; 95% CI = -15.48 to 9.1), and Clinical Global Impression for severity (MD = -0.13; 95% CI = -0.33 to 0.08)], functioning, [Global Assessment of Functioning Scale (MD = 3.21; 95% CI = -12.55 to 18.97), Social and Occupational Functioning Assessment Scale (MD = 0.47; 95% CI = -4.60 to 5.53), or quality of life [Quality of Life Enjoyment and Satisfaction Questionnaire (MD = 2.27; 95% CI = -9.13 to 13.67)]. CONCLUSIONS There is no evidence indicating that NAC has beneficial effects as an adjunctive treatment for bipolar depression. Future trials with improved methodological design and efficient sample sizes are required to draw safer conclusions.
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Affiliation(s)
- Stefanos Pittas
- Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Xenophon Theodoridis
- Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Anna-Bettina Haidich
- Laboratory of Hygiene, Preventive Medicine, and Medical Statistics, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panteleimon-Vasilios Bozikas
- 2nd Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Papazisis
- Department of Clinical Pharmacology, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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10
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Elsayed NA, Boyer TM, Burd I. Fetal Neuroprotective Strategies: Therapeutic Agents and Their Underlying Synaptic Pathways. Front Synaptic Neurosci 2021; 13:680899. [PMID: 34248595 PMCID: PMC8262796 DOI: 10.3389/fnsyn.2021.680899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/28/2021] [Indexed: 01/31/2023] Open
Abstract
Synaptic signaling is integral for proper brain function. During fetal development, exposure to inflammation or mild hypoxic-ischemic insult may lead to synaptic changes and neurological damage that impairs future brain function. Preterm neonates are most susceptible to these deleterious outcomes. Evaluating clinically used and novel fetal neuroprotective measures is essential for expanding treatment options to mitigate the short and long-term consequences of fetal brain injury. Magnesium sulfate is a clinical fetal neuroprotective agent utilized in cases of imminent preterm birth. By blocking N-methyl-D-aspartate receptors, magnesium sulfate reduces glutamatergic signaling, which alters calcium influx, leading to a decrease in excitotoxicity. Emerging evidence suggests that melatonin and N-acetyl-L-cysteine (NAC) may also serve as novel putative fetal neuroprotective candidates. Melatonin has important anti-inflammatory and antioxidant properties and is a known mediator of synaptic plasticity and neuronal generation. While NAC acts as an antioxidant and a precursor to glutathione, it also modulates the glutamate system. Glutamate excitotoxicity and dysregulation can induce perinatal preterm brain injury through damage to maturing oligodendrocytes and neurons. The improved drug efficacy and delivery of the dendrimer-bound NAC conjugate provides an opportunity for enhanced pharmacological intervention. Here, we review recent literature on the synaptic pathways underlying these therapeutic strategies, discuss the current gaps in knowledge, and propose future directions for the field of fetal neuroprotective agents.
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Affiliation(s)
- Nada A. Elsayed
- Department of Gynecology and Obstetrics, Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Theresa M. Boyer
- Department of Gynecology and Obstetrics, Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Irina Burd
- Department of Gynecology and Obstetrics, Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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11
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Smaga I, Frankowska M, Filip M. N-acetylcysteine as a new prominent approach for treating psychiatric disorders. Br J Pharmacol 2021; 178:2569-2594. [PMID: 33760228 DOI: 10.1111/bph.15456] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/26/2021] [Accepted: 03/14/2021] [Indexed: 12/17/2022] Open
Abstract
N-acetylcysteine (NAC) is a well-known and safe mucolytic agent, also used in patients with paracetamol overdose. In addition to these effects, recent preclinical and clinical studies have shown that NAC exerts beneficial effects on different psychiatric disorders. Many potential mechanisms have been proposed to underlie the therapeutic effects of NAC, including the regulation of several neurotransmitters, oxidative homeostasis, and inflammatory mediators. In this paper, we summarize the current knowledge on the ability of NAC to ameliorate symptoms and neuropathologies related to different psychiatric disorders, including attention deficit hyperactivity disorder, anxiety, bipolar disorder, depression, obsessive-compulsive disorder, obsessive-compulsive-related disorder, posttraumatic stress disorder, and schizophrenia. Although preclinical studies have shown a positive effect of NAC on animal models of psychiatric disorders, the clinical efficacy of NAC is not fully established. NAC remains a strong candidate for adjunct treatment for many psychiatric disorders, but additional preclinical and clinical studies are needed.
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Affiliation(s)
- Irena Smaga
- Department of Drug Addiction Pharmacology, Maj Institute of Pharmacology Polish Academy of Sciences, Kraków, Poland
| | - Małgorzata Frankowska
- Department of Drug Addiction Pharmacology, Maj Institute of Pharmacology Polish Academy of Sciences, Kraków, Poland
| | - Małgorzata Filip
- Department of Drug Addiction Pharmacology, Maj Institute of Pharmacology Polish Academy of Sciences, Kraków, Poland
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12
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Jones GH, Rong C, Shariq AS, Mishra A, Machado-Vieira R. Intracellular Signaling Cascades in Bipolar Disorder. Curr Top Behav Neurosci 2021; 48:101-132. [PMID: 32860212 DOI: 10.1007/7854_2020_157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Bipolar spectrum disorders carry a significant public health burden. Disproportionately high rates of suicide, incarceration, and comorbid medical conditions necessitate an extraordinary focus on understanding the intricacies of this disease. Elucidating granular, intracellular details seems to be a necessary preamble to advancing promising therapeutic opportunities. In this chapter, we review a wide range of intracellular mechanisms including mitochondrial energetics, calcium signaling, neuroinflammation, the microbiome, neurotransmitter metabolism, glycogen synthase kinase 3-beta (GSK3β), protein kinase C (PKC) and diacylglycerol (DAG), and neurotrophins (especially BDNF), as well as the glutamatergic, dopaminergic, purinergic, and neurohormonal systems. Owing to the relative lack of understanding and effective therapeutic options compared to the rest of the spectrum, special attention is paid in the chapter to the latest developments in bipolar depression. Likewise, from a therapeutic standpoint, special attention should be paid to the pervasive mechanistic actions of lithium as a means of amalgamating numerous, disparate cascades into a digestible cognitive topology.
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Affiliation(s)
- Gregory H Jones
- Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Carola Rong
- Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aisha S Shariq
- Department of Psychiatry, Texas Tech University Health Science Center, El Paso, TX, USA
- Texas Tech University Health Science Center, Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Abhinav Mishra
- Texas Tech University Health Science Center, Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Rodrigo Machado-Vieira
- Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, TX, USA.
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13
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Scaini G, Andrews T, Lima CNC, Benevenuto D, Streck EL, Quevedo J. Mitochondrial dysfunction as a critical event in the pathophysiology of bipolar disorder. Mitochondrion 2021; 57:23-36. [PMID: 33340709 PMCID: PMC10494232 DOI: 10.1016/j.mito.2020.12.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/18/2020] [Accepted: 12/10/2020] [Indexed: 01/02/2023]
Abstract
The understanding of the pathophysiology of bipolar disorder (BD) remains modest, despite recent advances in neurobiological research. The mitochondrial dysfunction hypothesis of bipolar disorder has been corroborated by several studies involving postmortem brain analysis, neuroimaging, and specific biomarkers in both rodent models and humans. Evidence suggests that BD might be related to abnormal mitochondrial morphology and dynamics, neuroimmune dysfunction, and atypical mitochondrial metabolism and oxidative stress pathways. Mitochondrial dysfunction in mood disorders is also associated with abnormal Ca2+ levels, glutamate excitotoxicity, an imbalance between pro- and antiapoptotic proteins towards apoptosis, abnormal gene expression of electron transport chain complexes, and decreased ATP synthesis. This paper aims to review and discuss the implications of mitochondrial dysfunction in BD etiology and to explore mitochondria as a potential target for novel therapeutic agents.
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Affiliation(s)
- Giselli Scaini
- Translational Psychiatry Program, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA
| | - Taylor Andrews
- Translational Psychiatry Program, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA
| | - Camila N C Lima
- Translational Psychiatry Program, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA
| | - Deborah Benevenuto
- Translational Psychiatry Program, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA
| | - Emilio L Streck
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - João Quevedo
- Translational Psychiatry Program, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA; Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil; Center of Excellence on Mood Disorders, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences at McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), Houston, TX, USA; Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, USA.
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14
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Morris G, Walker AJ, Walder K, Berk M, Marx W, Carvalho AF, Maes M, Puri BK. Increasing Nrf2 Activity as a Treatment Approach in Neuropsychiatry. Mol Neurobiol 2021; 58:2158-2182. [PMID: 33411248 DOI: 10.1007/s12035-020-02212-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
Nuclear factor erythroid 2-related factor 2 (Nrf2) is a transcription factor encoded by NFE2L2. Under oxidative stress, Nrf2 does not undergo its normal cytoplasmic degradation but instead travels to the nucleus, where it binds to a DNA promoter and initiates transcription of anti-oxidative genes. Nrf2 upregulation is associated with increased cellular levels of glutathione disulfide, glutathione peroxidase, glutathione transferases, thioredoxin and thioredoxin reductase. Given its key role in governing the cellular antioxidant response, upregulation of Nrf2 has been suggested as a common therapeutic target in neuropsychiatric illnesses such as major depressive disorder, bipolar disorder and schizophrenia, which are associated with chronic oxidative and nitrosative stress, characterised by elevated levels of reactive oxygen species, nitric oxide and peroxynitrite. These processes lead to extensive lipid peroxidation, protein oxidation and carbonylation, and oxidative damage to nuclear and mitochondrial DNA. Intake of N-acetylcysteine, coenzyme Q10 and melatonin is accompanied by increased Nrf2 activity. N-acetylcysteine intake is associated with improved cerebral mitochondrial function, decreased central oxidative and nitrosative stress, reduced neuroinflammation, alleviation of endoplasmic reticular stress and suppression of the unfolded protein response. Coenzyme Q10, which acts as a superoxide scavenger in neuroglial mitochondria, instigates mitohormesis, ameliorates lipid peroxidation in the inner mitochondrial membrane, activates uncoupling proteins, promotes mitochondrial biogenesis and has positive effects on the plasma membrane redox system. Melatonin, which scavenges mitochondrial free radicals, inhibits mitochondrial nitric oxide synthase, restores mitochondrial calcium homeostasis, deacetylates and activates mitochondrial SIRT3, ameliorates increased permeability of the blood-brain barrier and intestine and counters neuroinflammation and glutamate excitotoxicity.
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Affiliation(s)
- G Morris
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Barwon Health, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - A J Walker
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Barwon Health, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - K Walder
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Barwon Health, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - M Berk
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Barwon Health, School of Medicine, Deakin University, Geelong, VIC, Australia.,CMMR Strategic Research Centre, School of Medicine, Deakin University, Geelong, VIC, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, The Department of Psychiatry and the Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
| | - W Marx
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Barwon Health, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - A F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - M Maes
- Institute for Mental and Physical Health and Clinical Translation (IMPACT), Barwon Health, School of Medicine, Deakin University, Geelong, VIC, Australia.,Department of Psychiatry, Chulalongkorn University, Bangkok, Thailand
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15
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Giménez-Palomo A, Dodd S, Anmella G, Carvalho AF, Scaini G, Quevedo J, Pacchiarotti I, Vieta E, Berk M. The Role of Mitochondria in Mood Disorders: From Physiology to Pathophysiology and to Treatment. Front Psychiatry 2021; 12:546801. [PMID: 34295268 PMCID: PMC8291901 DOI: 10.3389/fpsyt.2021.546801] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/24/2021] [Indexed: 12/30/2022] Open
Abstract
Mitochondria are cellular organelles involved in several biological processes, especially in energy production. Several studies have found a relationship between mitochondrial dysfunction and mood disorders, such as major depressive disorder and bipolar disorder. Impairments in energy production are found in these disorders together with higher levels of oxidative stress. Recently, many agents capable of enhancing antioxidant defenses or mitochondrial functioning have been studied for the treatment of mood disorders as adjuvant therapy to current pharmacological treatments. A better knowledge of mitochondrial physiology and pathophysiology might allow the identification of new therapeutic targets and the development and study of novel effective therapies to treat these specific mitochondrial impairments. This could be especially beneficial for treatment-resistant patients. In this article, we provide a focused narrative review of the currently available evidence supporting the involvement of mitochondrial dysfunction in mood disorders, the effects of current therapies on mitochondrial functions, and novel targeted therapies acting on mitochondrial pathways that might be useful for the treatment of mood disorders.
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Affiliation(s)
- Anna Giménez-Palomo
- Bipolar and Depressives Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Research Networking Center (CIBERSAM), Madrid, Spain
| | - Seetal Dodd
- Deakin University, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, VIC, Australia.,Department of Psychiatry, Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Gerard Anmella
- Bipolar and Depressives Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Research Networking Center (CIBERSAM), Madrid, Spain
| | - Andre F Carvalho
- Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Giselli Scaini
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Joao Quevedo
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States.,Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, United States.,Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina, Criciúma, Brazil.,Center of Excellence in Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Isabella Pacchiarotti
- Bipolar and Depressives Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Research Networking Center (CIBERSAM), Madrid, Spain
| | - Eduard Vieta
- Bipolar and Depressives Disorders Unit, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Mental Health Research Networking Center (CIBERSAM), Madrid, Spain
| | - Michael Berk
- School of Medicine, The Institute for Mental and Physical Health and Clinical Translation, Deakin University, Barwon Health, Geelong, VIC, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia.,Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
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16
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Kishi T, Miyake N, Okuya M, Sakuma K, Iwata N. N-acetylcysteine as an adjunctive treatment for bipolar depression and major depressive disorder: a systematic review and meta-analysis of double-blind, randomized placebo-controlled trials. Psychopharmacology (Berl) 2020; 237:3481-3487. [PMID: 32767039 DOI: 10.1007/s00213-020-05629-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022]
Abstract
RATIONALE It remains unclear whether using N-acetylcysteine as an adjunctive treatment has any benefit for bipolar depression and major depressive disorder. OBJECTIVES A systematic review and random-effect meta-analysis of double-blind, randomized placebo-controlled trials was conducted to explore the clinical question. METHODS Outcomes included improvement in depression scale scores (primary), Young Mania Rating Scale score, Hamilton Anxiety Rating Scale score, Clinical Global Impression-Severity Scale (CGI-S) score, Global Assessment of Functioning Scale score, Social and Occupational Functioning Assessment Scale score, Range of Impaired Functioning Tool score, Streamed Longitudinal Interval Clinical Evaluation for the Longitudinal Interview Follow-Up Evaluation score, quality of life scales scores, and the incidence of all-cause discontinuation and individual adverse events. RESULTS Seven studies (n = 728, 8-24 weeks, mean age = 46.81, % female = 58.45%) were included. N-acetylcysteine did not improve depressive symptoms compared with placebo (N = 7, n = 579, standardized mean difference (SMD) = - 0.12, 95% confidence interval (95% CI) = - 0.38, 0.14, p = 0.38, I2 = 52.74%). The meta-regression analysis detected an association between effect size and publication year (coefficient = 0.06, 95% CI = 0.00, 0.11, p = 0.04, I2 = 27.56%). Although N-acetylcysteine was superior to placebo in CGI-S score (N = 6, n = 563, SMD = - 0.28, 95% CI = - 0.47, - 0.10, p < 0.01, I2 = 14.88%), there was no significant difference in the other efficacy outcomes between the treatment groups. Although N-acetylcysteine was associated with a higher incidence of gastrointestinal adverse events compared with placebo (N = 4, n = 537, risk ratio = 1.79, 95% CI = 1.37, 2.32, p < 0.01, I2 = 0.00%, number needed to treat to harm = 7), there was no significant difference in all-cause discontinuation and other safety outcomes between the treatments. CONCLUSIONS Although N-acetylcysteine decreased CGI-S score, no specific improvements in symptoms were identified.
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Affiliation(s)
- Taro Kishi
- Department of Psychiatry, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Nobumi Miyake
- Department of Neuropsychiatry, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Makoto Okuya
- Department of Psychiatry, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Kenji Sakuma
- Department of Psychiatry, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
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17
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Zalachoras I, Hollis F, Ramos-Fernández E, Trovo L, Sonnay S, Geiser E, Preitner N, Steiner P, Sandi C, Morató L. Therapeutic potential of glutathione-enhancers in stress-related psychopathologies. Neurosci Biobehav Rev 2020; 114:134-155. [DOI: 10.1016/j.neubiorev.2020.03.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
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Yalin N, Young AH. Pharmacological Treatment of Bipolar Depression: What are the Current and Emerging Options? Neuropsychiatr Dis Treat 2020; 16:1459-1472. [PMID: 32606699 PMCID: PMC7294105 DOI: 10.2147/ndt.s245166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022] Open
Abstract
Depression accounts for the predominant burden associated with bipolar disorder. The identification and management of bipolar depression are challenging, since bipolar depression differs from unipolar depression, responding poorly to traditional antidepressants, which may also induce a switch to hypomania/mania, mixed states and/or cause rapid cycling. Current treatment options for bipolar depression are limited and guidelines vary greatly in their recommendations, reflecting gaps and inconsistencies in the current evidence base. Moreover, some treatment options, such as quetiapine and olanzapine-fluoxetine, although clearly efficacious, may be associated with adverse cardiometabolic side effects, which can be detrimental to the long-term physical health and well-being of patients, increasing the likelihood of treatment non-adherence and relapse. Evidence for some more recent therapeutic options, including lurasidone and cariprazine, suggests that patients' symptoms can be effectively managed without compromising their physical health. In addition, novel agents targeting alternative neurotransmitter pathways and inflammatory processes (such as ketamine and N-acetyl cysteine) are emerging as promising potential options for the treatment of bipolar depression in the future.
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Affiliation(s)
- Nefize Yalin
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Allan H Young
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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Lv Q, Hu Q, Zhang W, Huang X, Zhu M, Geng R, Cheng X, Bao C, Wang Y, Zhang C, He Y, Li Z, Yi Z. Disturbance of Oxidative Stress Parameters in Treatment-Resistant Bipolar Disorder and Their Association With Electroconvulsive Therapy Response. Int J Neuropsychopharmacol 2020; 23:207-216. [PMID: 31967315 PMCID: PMC7177162 DOI: 10.1093/ijnp/pyaa003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 12/17/2019] [Accepted: 01/16/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is an effective option for treatment-resistant bipolar disorder (trBD). However, the mechanisms of its effect are unknown. Oxidative stress is thought to be involved in the underpinnings of BD. Our study is the first, to our knowledge, to report the association between notable oxidative stress parameters (superoxide dismutase [SOD], glutathione peroxidase [GSH-Px], catalase [CAT], and malondialdehyde [MDA]) levels and ECT response in trBD patients. METHODS A total 28 trBD patients and 49 controls were recruited. Six-week ECT and naturalistic follow-up were conducted. SOD, GSH-Px, CAT, and MDA levels were measured by enzyme-linked immunosorbent assay, and the 17-item Hamilton Depression Rating Scale and Young Mania Rating Scale were administered at baseline and the end of the 6th week. MANCOVA, ANCOVA, 2 × 2 ANCOVA, and a multiple regression model were conducted. RESULTS SOD levels were lower in both trBD mania and depression (P = .001; P = .001), while GSH-Px (P = .01; P = .001) and MDA (P = .001; P = .001) were higher in both trBD mania and depression compared with controls. CAT levels were positively associated with 17-item Hamilton Depression Rating Scale scores in trBD depression (radjusted = 0.83, P = .005). MDA levels in trBD decreased after 6 weeks of ECT (P = .001). Interestingly, MDA levels decreased in responders (P = .001) but not in nonresponders (P > .05). CONCLUSIONS Our study indicates that decreased SOD could be a trait rather than a state in trBD. Oxidative stress levels are associated with illness severity and ECT response. This suggests that the mechanism of oxidative stress plays a crucial role in the pathophysiology of trBD.
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Affiliation(s)
- Qinyu Lv
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiongyue Hu
- Qingdao Mental Health Center, Qingdao, China
| | | | - Xinxin Huang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minghuan Zhu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruijie Geng
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyan Cheng
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenxi Bao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingyi Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongguang He
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zezhi Li
- Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Correspondence: Zezhi Li, MD, PhD, Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China, 1630 Dongfang Road, 200127 Shanghai, China (); and Zhenghui Yi, MD, PhD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 South Wan Ping Road, Shanghai 200030, China ()
| | - Zhenghui Yi
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Correspondence: Zezhi Li, MD, PhD, Department of Neurology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China, 1630 Dongfang Road, 200127 Shanghai, China (); and Zhenghui Yi, MD, PhD, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 South Wan Ping Road, Shanghai 200030, China ()
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20
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Rosenblat JD. Targeting the immune system in the treatment of bipolar disorder. Psychopharmacology (Berl) 2019; 236:2909-2921. [PMID: 30756134 DOI: 10.1007/s00213-019-5175-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/16/2019] [Indexed: 12/14/2022]
Abstract
RATIONALE Immune dysfunction has been strongly implicated in the pathophysiology of bipolar disorder (BD). As such, numerous clinical trials have investigated the effects of anti-inflammatory agents in the treatment of BD. OBJECTIVES Review clinical studies evaluating the effects of anti-inflammatory agents in the treatment of BD during all illness phases (e.g., depression, mania, and euthymia). METHODS Relevant databases were searched from inception to August 27, 2018 for clinical studies evaluating the effects of anti-inflammatory agents in BD. RESULTS The majority of identified clinical trials evaluated adjunctive anti-inflammatory agents in the acute treatment of bipolar depression, demonstrating antidepressant effects with N-acetylcysteine (NAC), pioglitazone, minocycline, and coenzyme Q10, along with mixed evidence for omega-3s, and non-steroidal anti-inflammatory drugs (NSAIDs). The anti-manic effects of adjunctive anti-inflammatory agents have been minimally studied, with some promising preliminary results supporting potential anti-manic effects of adjunctive celecoxib and NAC. Maintenance studies are also limited, with inadequate evidence to support mood stabilizing effects of anti-inflammatories while euthymic. Regardless of illness phase, early results suggest that anti-inflammatory agents are likely most beneficial in the subgroup of BD with immune dysregulation. CONCLUSIONS Several proof-of-concept clinical trials have shown promising results for anti-inflammatory agents in the treatment of bipolar depression with moderate effect sizes and good tolerability. The effects of anti-inflammatory agents during manic and euthymic periods remains uncertain. Future larger studies, using stratified samples, enriched for participants with immune dysfunction, are required to determine the role of immune modulating agents in the treatment of BD.
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Affiliation(s)
- Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, Department of Psychiatry and Pharmacology, University Health Network, University of Toronto, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada.
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Fusar-Poli L, Surace T, Vanella A, Meo V, Patania F, Furnari R, Signorelli MS, Aguglia E. The effect of adjunctive nutraceuticals in bipolar disorder: A systematic review of randomized placebo-controlled trials. J Affect Disord 2019; 252:334-349. [PMID: 30999090 DOI: 10.1016/j.jad.2019.04.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/11/2019] [Accepted: 04/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nutraceuticals are a group of compounds of growing interest for mental health professionals. Given the implication of certain nutrients in the onset of bipolar disorder, it has been hypothesized that nutraceuticals might be effective in improving symptoms of the condition (i.e. mania or depression). Our systematic review aimed to evaluate the effectiveness of adjunctive nutraceuticals compared to placebo. METHODS We searched the following databases from inception to February 2019: Web of Science, CINAHL, Embase, and PsycINFO. We included only original randomized controlled trials written in English, testing the efficacy of nutraceuticals in add-on to standard care, compared to placebo, in patients with bipolar disorder. RESULTS After identifying 6584 potentially relevant publications, we finally included 25 studies, among which six used fatty acids, seven micronutrients, seven amino acids. One study tested probiotics, while in four trials a combination of different types of nutraceuticals was used. Even if some compounds have shown promising results (i.e. fatty acids and N-acetyl cysteine for depression, amino acid drinks and folic acid for mania), the majority of nutraceuticals did not cause significant improvements in comparison to placebo. LIMITATIONS We could not perform a meta-analysis due to the high heterogeneity of trials, which were also affected by some methodological caveats. CONCLUSIONS Evidence regarding the efficacy of adjunctive nutraceuticals in bipolar disorder is inconsistent. Nevertheless, they appear generally free from relevant side effects. Well-designed trials are needed to further explore the potential role of nutraceuticals in different mood episodes.
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Affiliation(s)
- Laura Fusar-Poli
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy.
| | - Teresa Surace
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy
| | - Antonio Vanella
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy
| | - Valeria Meo
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy
| | - Federica Patania
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy
| | - Rosaria Furnari
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy
| | - Maria Salvina Signorelli
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Italy; U.O.C. Clinica Psichiatrica, A.O.U. Policlinico-Vittorio Emanuele, Presidio "G. Rodolico", Catania, Italy
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Ellegaard PK, Licht RW, Nielsen RE, Dean OM, Berk M, Poulsen HE, Mohebbi M, Nielsen CT. The efficacy of adjunctive N-acetylcysteine in acute bipolar depression: A randomized placebo-controlled study. J Affect Disord 2019; 245:1043-1051. [PMID: 30699846 DOI: 10.1016/j.jad.2018.10.083] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/10/2018] [Accepted: 10/05/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate the efficacy of adjunctive N-acetylcysteine (NAC) for the treatment of acute bipolar depression. METHOD A randomized, double-blind, multicentre, placebo-controlled trial including adult subjects diagnosed with bipolar disorder, currently experiencing a depressive episode. Participants were treated with 3 g/day NAC or placebo as an adjunctive to standard treatment for 20 weeks, followed by a 4-week washout where the blinding was maintained. The primary outcome was the mean change in the Montgomery Asberg Depression Rating Scale (MADRS) score over the 20-week treatment phase. Linear Mixed Effects Repeated Measures (LMERM) was used for analysing the primary outcome. RESULTS A total of 80 subjects were included. The mean MADRS score at baseline was 30.1 and 28.8 in participants randomized to NAC and placebo, respectively. Regarding the primary outcome measure, the between-group difference (NAC vs. placebo) was 0.5, which was statistically non-significant (95% CI: -7.0-5.9;p = 0.88). All findings regarding secondary outcomes were statistically or clinically insignificant. LIMITATIONS The study had a placebo response rate of 55.6% - high placebo response rates are associated with failure to separate from placebo. CONCLUSIONS Based on our primary outcome measure, we could not confirm previous studies showing a therapeutic effect of adjunctive NAC treatment on acute bipolar depression. Further studies with larger samples are needed to elucidate if specific subgroups could benefit from adjunctive NAC treatment.
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Affiliation(s)
- Pernille Kempel Ellegaard
- Institute of Regional Health Services Research, Faculty of Health Sciences, University of Southern Denmark, Denmark; Research Unit, Mental Health Service Esbjerg, The Region of Southern Denmark, Denmark; OPEN, Odense Patient Data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Denmark.
| | - Rasmus Wentzer Licht
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - René Ernst Nielsen
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Olivia May Dean
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia; University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, Australia
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Australia; Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia; University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Henrik Enghusen Poulsen
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Clinical Pharmacology, Bispebjerg Frederiksberg Hospital, Denmark
| | | | - Connie Thuroee Nielsen
- Institute of Regional Health Services Research, Faculty of Health Sciences, University of Southern Denmark, Denmark; Mental Health Service Vejle, The Region of Southern Denmark, Denmark
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Mediator effects of parameters of inflammation and neurogenesis from a N-acetyl cysteine clinical-trial for bipolar depression. Acta Neuropsychiatr 2018; 30:334-341. [PMID: 30008280 DOI: 10.1017/neu.2018.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE This study aimed to explore effects of adjunctive treatment with N-acetyl cysteine (NAC) on markers of inflammation and neurogenesis in bipolar depression. METHODS This is a secondary analysis of a placebo-controlled randomised trial. Serum samples were collected at baseline, week 8, and week 32 of the open-label and maintenance phases of the clinical trial to determine changes in interleukin (IL)-6, IL-8, IL-10, tumour necrosis factor-α (TNF-α), C-reactive protein (CRP) and brain-derived neurotrophic factor (BDNF) following adjunctive NAC treatment, and to explore mediation and moderator effects of the listed markers. RESULTS Levels of brain-derived neurotrophic factor (BDNF), tumour necrosis factor-α (TNF-α), C-reactive protein (CRP), interleukins (IL) -6, 8, or 10 were not significantly changed during the course of the trial or specifically in the open-label and maintenance phases. There were no mediation or moderation effects of the biological factors on the clinical parameters. CONCLUSION The results suggest that these particular biological parameters may not be directly involved in the therapeutic mechanism of action of adjunctive NAC in bipolar depression.
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N-Acetylcysteine for the Treatment of Psychiatric Disorders: A Review of Current Evidence. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2469486. [PMID: 30426004 PMCID: PMC6217900 DOI: 10.1155/2018/2469486] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 10/09/2018] [Indexed: 01/09/2023]
Abstract
N-acetylcysteine, a sulphur-containing amino acid for the treatment of paracetamol overdose and chronic obstructive pulmonary disease, is a widely available off-the-shelf oral antioxidant supplement in many countries. With the potential to modulate several neurological pathways, including glutamate dysregulation, oxidative stress, and inflammation that can be beneficial to the brain functions, N-acetylcysteine is being explored as an adjunctive therapy for many psychiatric conditions. This narrative review synthesises and presents the current evidence from systematic reviews, meta-analyses, and latest clinical trials on N-acetylcysteine for addiction and substance abuse, schizophrenia, obsessive-compulsive and related disorders, and mood disorders. Good evidence exists to support the use of N-acetylcysteine as an adjunct treatment to reduce the total and negative symptoms of schizophrenia. N-acetylcysteine also appears to be effective in reducing craving in substance use disorders, especially for the treatment of cocaine and cannabis use among young people, in addition to preventing relapse in already abstinent individuals. Effects of N-acetylcysteine on obsessive-compulsive and related disorders, as well as on mood disorders, remain unclear with mixed reviews, even though promising evidence does exist. Larger and better-designed studies are required to further investigate the clinical effectiveness of N-acetylcysteine in these areas. Oral N-acetylcysteine is safe and well tolerated without any considerable adverse effects. Current evidence supports its use as an adjunctive therapy clinically for psychiatric conditions, administered concomitantly with existing medications, with a recommended dosage between 2000 and 2400 mg/day.
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Muneer A, Mazommil R. The Staging of Major Mood Disorders: Clinical and Neurobiological Correlates. Psychiatry Investig 2018; 15:747-758. [PMID: 30134644 PMCID: PMC6111216 DOI: 10.30773/pi.2018.05.26] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/12/2018] [Accepted: 05/26/2018] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Staging of psychiatric disorders is gaining momentum and the purpose of this review is to examine whether major mood disorders can be defined according to stages. METHODS In April 2018 the PubMed electronic data base was scrutinized by a combination of various search terms like "major depressive disorder and staging," "bipolar disorder and neuroprogression," etc. To incorporate the latest findings the search was limited to the last 10 years. Both original and review articles were examined by reading the abstracts, and papers which were found to be particularly applicable were read in full and their reference lists were also consulted. RESULTS A significant increase occurred in the number of papers published on the topic of staging of mood disorders. Staging formats were found for both major mood disorders, with the caveat that many more articles were discovered for bipolar disorder. Current evidence points to allostatic load and neuroprogression as the basis for staging of mood disorders. CONCLUSION Principal affective illnesses may be characterized by distinct stages, for instance early, intermediate and late. These phases inform the management so that clinicians should incorporate the staging schema into everyday practice and implement treatment strategies according to the phase of the illness.
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Affiliation(s)
- Ather Muneer
- Islamic International Medical College, Riphah International University, Islamabad, Pakistan
| | - Rana Mazommil
- Department of Psychiatry, Government Khawaja Safdar Medical College, Sialkot, Pakistan
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Yang X, Wang Y, Li Q, Zhong Y, Chen L, Du Y, He J, Liao L, Xiong K, Yi CX, Yan J. The Main Molecular Mechanisms Underlying Methamphetamine- Induced Neurotoxicity and Implications for Pharmacological Treatment. Front Mol Neurosci 2018; 11:186. [PMID: 29915529 PMCID: PMC5994595 DOI: 10.3389/fnmol.2018.00186] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/14/2018] [Indexed: 01/07/2023] Open
Abstract
Methamphetamine (METH) is a popular new-type psychostimulant drug with complicated neurotoxicity. In spite of mounting evidence on METH-induced damage of neural cell, the accurate mechanism of toxic effect of the drug on central nervous system (CNS) has not yet been completely deciphered. Besides, effective treatment strategies toward METH neurotoxicity remain scarce and more efficacious drugs are to be developed. In this review, we summarize cellular and molecular bases that might contribute to METH-elicited neurotoxicity, which mainly include oxidative stress, excitotoxicity, and neuroinflammation. We also discuss some drugs that protect neural cells suffering from METH-induced neurotoxic consequences. We hope more in-depth investigations of exact details that how METH produces toxicity in CNS could be carried out in future and the development of new drugs as natural compounds and immunotherapies, including clinic trials, are expected.
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Affiliation(s)
- Xue Yang
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Yong Wang
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Qiyan Li
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Yaxian Zhong
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Liangpei Chen
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Yajun Du
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Jing He
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
| | - Lvshuang Liao
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, China
| | - Kun Xiong
- Department of Anatomy and Neurobiology, School of Basic Medical Science, Central South University, Changsha, China
| | - Chun-Xia Yi
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jie Yan
- Department of Forensic Science, School of Basic Medical Sciences, Central South University, Changsha, China
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Pereira C, Chavarria V, Vian J, Ashton MM, Berk M, Marx W, Dean OM. Mitochondrial Agents for Bipolar Disorder. Int J Neuropsychopharmacol 2018; 21:550-569. [PMID: 29596661 PMCID: PMC6007750 DOI: 10.1093/ijnp/pyy018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Bipolar disorder is a chronic and often debilitating illness. Current treatment options (both pharmaco- and psychotherapy) have shown efficacy, but for many leave a shortfall in recovery. Advances in the understanding of the pathophysiology of bipolar disorder suggest that interventions that target mitochondrial dysfunction may provide a therapeutic benefit. Methods This review explores the current and growing theoretical rationale as well as existing preclinical and clinical data for those therapies aiming to target the mitochondrion in bipolar disorder. A Clinicaltrials.gov and ANZCTR search was conducted for complete and ongoing trials on mitochondrial agents used in psychiatric disorders. A PubMed search was also conducted for literature published between January 1981 and July 2017. Systematic reviews, randomized controlled trials, observational studies, case series, and animal studies with an emphasis on agents affecting mitochondrial function and its role in bipolar disorder were included. The search was augmented by manually searching the references of key papers and related literature. The results were presented as a narrative review. Results Mitochondrial agents offer new horizons in mood disorder treatment. While some negative effects have been reported, most compounds are overall well tolerated and have generally benign side-effect profiles. Conclusions The study of neuroinflammation, neurodegeneration, and mitochondrial function has contributed the understanding of bipolar disorder's pathophysiology. Agents targeting these pathways could be a potential therapeutic strategy. Future directions include identification of novel candidate mitochondrial modulators as well as rigorous and well-powered clinical trials.
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Affiliation(s)
- Círia Pereira
- Psychiatry and Mental Health Department, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | | | - João Vian
- Psychiatry and Mental Health Department, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
- Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Melanie Maree Ashton
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Australia
- University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, Australia
- Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Australia
- University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, Australia
- Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
- Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Wolfgang Marx
- Deakin University, Food & Mood Centre, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Australia
| | - Olivia May Dean
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, Australia
- University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, Australia
- Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
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Mohebbi M, Dodd S, Dean O, Berk M. Patient centric measures for a patient centric era: Agreement and convergent between ratings on The Patient Global Impression of Improvement (PGI-I) scale and the Clinical Global Impressions – Improvement (CGI-S) scale in bipolar and major depressive disorder. Eur Psychiatry 2018; 53:17-22. [DOI: 10.1016/j.eurpsy.2018.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 10/14/2022] Open
Abstract
AbstractBackground:Concordant with an increased emphasis on consumer engagement, the Patient Global Impression Scale of Improvement (PGI-I) is commonly used as an outcome measure in studies evaluating the efficacy of treatments in medical and psychiatric conditions with subjective symptom domains. The current study evaluated the agreement between PGI-I and Clinician Global Impression Scale of Improvement (CGI-I) ratings and convergent validity of PGI-I among individuals with bipolar or major depressive disorders.Method:Data were derived from three double-blind, placebo-controlled, multicentre studies conducted from 2007 to 2015 among adult individuals (N = 472). Clinicians were asked to rate participants symptoms using the CGI-I as well as severity of depression by the Montgomery-Åsberg Depression (MADRS), quality of life (Q-LES-Q), social and occupational functioning (SOFAS), and functional impairment (LIFE–RIFT). Participants were asked to assess their symptom improvement with the PGI-I. Bland-Altman agreement plots and Intra-class correlations were used to evaluate agreement, and Spearman correlation coefficients were implemented to examine convergent validity. Sub-group analyses for disorder type (bipolar and major depression) were performed.Results:There was high agreement between the PGI-I and CGI-I ratings across follow-up time points (weeks 2, 4, 6, 8, 12, 16, 20, 24, and 28). Similar results were observed in male only and female only data and after adjustment for age and gender. Both PGI-I and CGI-I ratings were robustly positively correlated with MADRS, and LIFE-RIFT and negatively correlated with SOFAS and Q-LES-Q, supporting the convergent validity of the PGI-I. Sub-group analyses for bipolar and major depressive disorder showed similar findings.Conclusion:Our findings support the utility of the PGI-I as a participant rated measure of global improvement among individuals with bipolar or major depressive disorders.
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Ellegaard PK, Licht RW, Poulsen HE, Nielsen RE, Berk M, Dean OM, Mohebbi M, Nielsen CT. Add-on treatment with N-acetylcysteine for bipolar depression: a 24-week randomized double-blind parallel group placebo-controlled multicentre trial (NACOS-study protocol). Int J Bipolar Disord 2018; 6:11. [PMID: 29619634 PMCID: PMC6162004 DOI: 10.1186/s40345-018-0117-9] [Citation(s) in RCA: 9] [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: 10/23/2017] [Accepted: 01/02/2018] [Indexed: 12/28/2022] Open
Abstract
Background Oxidative stress and inflammation may be involved in the development and progression of mood disorders, including bipolar disorder. Currently, there is a scarcity of useful treatment options for bipolar depressive episodes, especially compared with the efficacy of treatment for acute mania. N-Acetylcysteine (NAC) has been explored for psychiatric disorders for some time given its antioxidant and anti-inflammatory properties. The current trial aims at testing the clinical effects of adjunctive NAC treatment (compared to placebo) for bipolar depression. We will also explore the biological effects of NAC in this context. We hypothesize that adjunctive NAC treatment will reduce symptoms of depression, which will be reflected by changes in selected markers of oxidative stress. Methods and analysis In the study, we will include adults diagnosed with bipolar disorder, in a currently depressive episode. Participants will undertake a 20-week, adjunctive, randomized, double-blinded, parallel group placebo-controlled trial comparing 3 grams of adjunctive NAC daily with placebo. The primary outcome is the mean change over time from baseline to end of study on the Montgomery–Asberg Depression Rating Scale (MADRS). Among the secondary outcomes are mean changes from baseline to end of study on the Bech-Rafaelsen Melancholia Scale (MES), the Young Mania Rating Scale (YMRS), the WHO-Five Well-being Index (WHO-5), the Global Assessment of Functioning scale (GAF-F), the Global Assessment of Symptoms scale (GAF-S) and the Clinical Global Impression-Severity scale (CGI-S). The potential effects on oxidative stress by NAC treatment will be measured through urine and blood samples. DNA will be examined for potential polymorphisms related to oxidative defences. Trial registration: Registered at The European Clinical Trials Database, ClinicalTrials.gov: NCT02294591 and The Danish Data Protection Agency: 2008-58-0035.
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Affiliation(s)
- Pernille Kempel Ellegaard
- Institute of Regional Health Services Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark. .,Research Unit, Mental Health Service Esbjerg, Gl. Vardevej 101, 6715, Esbjerg N, The Region of Southern Denmark, Denmark. .,OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Rasmus Wentzer Licht
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Henrik Enghusen Poulsen
- Clinical Pharmacology, Bispebjerg Frederiksberg Hospital, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - René Ernst Nielsen
- Unit for Psychiatric Research, Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Australia.,Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia.,Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Olivia May Dean
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Australia.,Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Australia.,Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | | | - Connie Thuroee Nielsen
- Institute of Regional Health Services Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Mental Health Service Vejle, Odense, The Region of Southern Denmark, Denmark
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Brown GM, McIntyre RS, Rosenblat J, Hardeland R. Depressive disorders: Processes leading to neurogeneration and potential novel treatments. Prog Neuropsychopharmacol Biol Psychiatry 2018; 80:189-204. [PMID: 28433459 DOI: 10.1016/j.pnpbp.2017.04.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/01/2017] [Indexed: 12/18/2022]
Abstract
Mood disorders are wide spread with estimates that one in seven of the population are affected at some time in their life (Kessler et al., 2012). Many of those affected with severe depressive disorders have cognitive deficits which may progress to frank neurodegeneration. There are several peripheral markers shown by patients who have cognitive deficits that could represent causative factors and could potentially serve as guides to the prevention or even treatment of neurodegeneration. Circadian rhythm misalignment, immune dysfunction and oxidative stress are key pathologic processes implicated in neurodegeneration and cognitive dysfunction in depressive disorders. Novel treatments targeting these pathways may therefore potentially improve patient outcomes whereby the primary mechanism of action is outside of the monoaminergic system. Moreover, targeting immune dysfunction, oxidative stress and circadian rhythm misalignment (rather than primarily the monoaminergic system) may hold promise for truly disease modifying treatments that may prevent neurodegeneration rather than simply alleviating symptoms with no curative intent. Further research is required to more comprehensively understand the contributions of these pathways to the pathophysiology of depressive disorders to allow for disease modifying treatments to be discovered.
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Affiliation(s)
- Gregory M Brown
- Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, 250 College St. Toronto, ON M5T 1R8, Canada.
| | - Roger S McIntyre
- Psychiatry and Pharmacology, University of Toronto, Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada.
| | - Joshua Rosenblat
- Resident of Psychiatry, Clinician Scientist Stream, University of Toronto, Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada
| | - Rüdiger Hardeland
- Johann Friedrich Blumenbach Institut für Zoologie und Anthropologie, Universität Göttingen, Buergerstrasse 50, D-37073 Göttingen, Germany.
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Bipolar Disorder and Immune Dysfunction: Epidemiological Findings, Proposed Pathophysiology and Clinical Implications. Brain Sci 2017; 7:brainsci7110144. [PMID: 29084144 PMCID: PMC5704151 DOI: 10.3390/brainsci7110144] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 10/25/2017] [Accepted: 10/27/2017] [Indexed: 12/22/2022] Open
Abstract
Bipolar disorder (BD) is strongly associated with immune dysfunction. Replicated epidemiological studies have demonstrated that BD has high rates of inflammatory medical comorbidities, including autoimmune disorders, chronic infections, cardiovascular disease and metabolic disorders. Cytokine studies have demonstrated that BD is associated with chronic low-grade inflammation with further increases in pro-inflammatory cytokine levels during mood episodes. Several mechanisms have been identified to explain the bidirectional relationship between BD and immune dysfunction. Key mechanisms include cytokine-induced monoamine changes, increased oxidative stress, pathological microglial over-activation, hypothalamic-pituitary-adrenal (HPA) axis over-activation, alterations of the microbiome-gut-brain axis and sleep-related immune changes. The inflammatory-mood pathway presents several potential novel targets in the treatment of BD. Several proof-of-concept clinical trials have shown a positive effect of anti-inflammatory agents in the treatment of BD; however, further research is needed to determine the clinical utility of these treatments. Immune dysfunction is likely to only play a role in a subset of BD patients and as such, future clinical trials should also strive to identify which specific group(s) of BD patients may benefit from anti-inflammatory treatments.
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Solé B, Jiménez E, Torrent C, Reinares M, Bonnin CDM, Torres I, Varo C, Grande I, Valls E, Salagre E, Sanchez-Moreno J, Martinez-Aran A, Carvalho AF, Vieta E. Cognitive Impairment in Bipolar Disorder: Treatment and Prevention Strategies. Int J Neuropsychopharmacol 2017; 20:670-680. [PMID: 28498954 PMCID: PMC5570032 DOI: 10.1093/ijnp/pyx032] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/08/2017] [Indexed: 12/21/2022] Open
Abstract
Over the last decade, there has been a growing appreciation of the importance of identifying and treating cognitive impairment associated with bipolar disorder, since it persists in remission periods. Evidence indicates that neurocognitive dysfunction may significantly influence patients' psychosocial outcomes. An ever-increasing body of research seeks to achieve a better understanding of potential moderators contributing to cognitive impairment in bipolar disorder in order to develop prevention strategies and effective treatments. This review provides an overview of the available data from studies examining treatments for cognitive dysfunction in bipolar disorder as well as potential novel treatments, from both pharmacological and psychological perspectives. All these data encourage the development of further studies to find effective strategies to prevent and treat cognitive impairment associated with bipolar disorder. These efforts may ultimately lead to an improvement of psychosocial functioning in these patients.
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Affiliation(s)
- Brisa Solé
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Esther Jiménez
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Carla Torrent
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Maria Reinares
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Caterina del Mar Bonnin
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Imma Torres
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Cristina Varo
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Iria Grande
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Elia Valls
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Estela Salagre
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Jose Sanchez-Moreno
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Anabel Martinez-Aran
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - André F Carvalho
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
| | - Eduard Vieta
- Barcelona Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Drs Sole, Jimenez, Torrent, Reinares, del Mar Bonnin, Torres, Varo, Grande, Valls, Salagre, Sanchez-Moreno, Martinez-Aran, and Vieta); Translational Psychiatry Research Group, Faculty of Medicine, Federal University of Ceará, Fortaleza, CE, Brazil (Dr Carvalho)
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Skvarc DR, Dean OM, Byrne LK, Gray L, Lane S, Lewis M, Fernandes BS, Berk M, Marriott A. The effect of N-acetylcysteine (NAC) on human cognition - A systematic review. Neurosci Biobehav Rev 2017; 78:44-56. [PMID: 28438466 DOI: 10.1016/j.neubiorev.2017.04.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 04/13/2017] [Accepted: 04/15/2017] [Indexed: 12/15/2022]
Abstract
Oxidative stress, neuroinflammation and neurogenesis are commonly implicated as cognitive modulators across a range of disorders. N-acetylcysteine (NAC) is a glutathione precursor with potent antioxidant, pro-neurogenesis and anti-inflammatory properties and a favourable safety profile. A systematic review of the literature specifically examining the effect of NAC administration on human cognition revealed twelve suitable articles for inclusion: four examining Alzheimer's disease; three examining healthy participants; two examining physical trauma; one examining bipolar disorder, one examining schizophrenia, and one examining ketamine-induced psychosis. Heterogeneity of studies, insufficiently powered studies, infrequency of cognition as a primary outcome, heterogeneous methodologies, formulations, co-administered treatments, administration regimes, and assessment confounded the drawing of firm conclusions. The available data suggested statistically significant cognitive improvements following NAC treatment, though the paucity of NAC-specific research makes it difficult to determine if this effect is meaningful. While NAC may have a positive cognitive effect in a variety of contexts; larger, targeted studies are warranted, specifically evaluating its role in other clinical disorders with cognitive sequelae resulting from oxidative stress and neuroinflammation.
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Affiliation(s)
- David R Skvarc
- School of Psychology, Deakin University, Melbourne, Australia; Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia
| | - Olivia M Dean
- Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Deakin University, School of Medicine, Geelong, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, the Department of Psychiatry and the Florey Institute of Neuroscience and Mental Health, the University of Melbourne, Parkville, Australia
| | - Linda K Byrne
- School of Psychology, Deakin University, Melbourne, Australia
| | - Laura Gray
- Deakin University, School of Medicine, Geelong, Australia
| | - Stephen Lane
- Deakin University, School of Medicine, Geelong, Australia; Biostatistics Unit, Barwon Health, Geelong, Australia
| | - Matthew Lewis
- School of Psychology, Deakin University, Melbourne, Australia; Aged Psychiatry Service, Caulfield Hospital, Alfred Health, Caulfield, Australia
| | - Brisa S Fernandes
- Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Laboratory of Calcium Binding Proteins in the Central Nervous System, Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Michael Berk
- Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Deakin University, School of Medicine, Geelong, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, the Department of Psychiatry and the Florey Institute of Neuroscience and Mental Health, the University of Melbourne, Parkville, Australia
| | - Andrew Marriott
- Department of Anaesthesia, Perioperative Medicine & Pain Management, Barwon Health, Geelong, Australia; Deakin University, Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Barwon Health, Geelong, Australia; Deakin University, School of Medicine, Geelong, Australia.
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Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier P, Kasper S, Moeller HJ. The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 2: Review, Grading of the Evidence, and a Precise Algorithm. Int J Neuropsychopharmacol 2017; 20:121-179. [PMID: 27816941 PMCID: PMC5409012 DOI: 10.1093/ijnp/pyw100] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/29/2016] [Accepted: 11/03/2016] [Indexed: 02/05/2023] Open
Abstract
Background The current paper includes a systematic search of the literature, a detailed presentation of the results, and a grading of treatment options in terms of efficacy and tolerability/safety. Material and Methods The PRISMA method was used in the literature search with the combination of the words 'bipolar,' 'manic,' 'mania,' 'manic depression,' and 'manic depressive' with 'randomized,' and 'algorithms' with 'mania,' 'manic,' 'bipolar,' 'manic-depressive,' or 'manic depression.' Relevant web pages and review articles were also reviewed. Results The current report is based on the analysis of 57 guideline papers and 531 published papers related to RCTs, reviews, posthoc, or meta-analysis papers to March 25, 2016. The specific treatment options for acute mania, mixed episodes, acute bipolar depression, maintenance phase, psychotic and mixed features, anxiety, and rapid cycling were evaluated with regards to efficacy. Existing treatment guidelines were also reviewed. Finally, Tables reflecting efficacy and recommendation levels were created that led to the development of a precise algorithm that still has to prove its feasibility in everyday clinical practice. Conclusions A systematic literature search was conducted on the pharmacological treatment of bipolar disorder to identify all relevant random controlled trials pertaining to all aspects of bipolar disorder and graded the data according to a predetermined method to develop a precise treatment algorithm for management of various phases of bipolar disorder. It is important to note that the some of the recommendations in the treatment algorithm were based on the secondary outcome data from posthoc analyses.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Lakshmi Yatham
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Heinz Grunze
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Eduard Vieta
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Allan Young
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Pierre Blier
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Siegfried Kasper
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Hans Jurgen Moeller
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
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Data-Franco J, Singh A, Popovic D, Ashton M, Berk M, Vieta E, Figueira ML, Dean OM. Beyond the therapeutic shackles of the monoamines: New mechanisms in bipolar disorder biology. Prog Neuropsychopharmacol Biol Psychiatry 2017; 72:73-86. [PMID: 27616052 DOI: 10.1016/j.pnpbp.2016.09.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/31/2016] [Accepted: 09/06/2016] [Indexed: 02/08/2023]
Abstract
Multiple novel biological mechanisms putatively involved in the etiology of bipolar disorders are being explored. These include oxidative stress, altered glutamatergic neurotransmission, mitochondrial dysfunction, inflammation, cell signaling, apoptosis and impaired neurogenesis. Important clinical translational potential exists for such mechanisms to help underpin development of novel therapeutics - much needed given limitations of current therapies. These new mechanisms also help improve our understanding of how current therapeutics might exert their effects. Lithium, for example, appears to have antioxidant, immunomodulatory, signaling, anti-apoptotic and neuroprotective properties. Similar properties have been attributed to other mood stabilizers such as valproate, lamotrigine, and quetiapine. Perhaps of greatest translational value has been the recognition of such mechanisms leading to the emergence of novel therapeutics for bipolar disorders. These include the antioxidant N-acetylcysteine, the anti-inflammatory celecoxib, and ketamine - with effects on the glutamatergic system and microglial inhibition. We review these novel mechanisms and emerging therapeutics, and comment on next steps in this space.
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Affiliation(s)
- João Data-Franco
- Psychiatric Department, Hospital Beatriz Ângelo, Loures, Portugal; University of Lisbon, Faculty of Medicine, Lisbon, Portugal.
| | - Ajeet Singh
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, VIC, Australia
| | - Dina Popovic
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Psychiatry Division, The Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Melanie Ashton
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, VIC, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, VIC, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia; Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia; Orygen Youth Health Research Centre, Parkville, VIC, Australia
| | - Eduard Vieta
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - M L Figueira
- University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Olivia M Dean
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, VIC, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia; Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
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Minarini A, Ferrari S, Galletti M, Giambalvo N, Perrone D, Rioli G, Galeazzi GM. N-acetylcysteine in the treatment of psychiatric disorders: current status and future prospects. Expert Opin Drug Metab Toxicol 2016; 13:279-292. [PMID: 27766914 DOI: 10.1080/17425255.2017.1251580] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION N-acetylcysteine (NAC) is widely known for its role as a mucolytic and as an antidote to paracetamol overdose. There is increasing interest in the use of NAC in the treatment of several psychiatric disorders. The rationale for the administration of NAC in psychiatric conditions is based on its role as a precursor to the antioxidant glutathione, and its action as a modulating agent of glutamatergic, dopaminergic, neurotropic and inflammatory pathways. Areas covered: This study reviews the available data regarding the use of NAC in different psychiatric disorders including substance use disorders, autism, obsessive-compulsive spectrum disorders, schizophrenia, depression, bipolar disorder. Promising results were found in trials testing the use of NAC, mainly as an add-on treatment, in cannabis use disorder in young people, depression in bipolar disorder, negative symptoms in schizophrenia, and excoriation (skin-picking) disorder. Despite initial optimism, recent findings regarding NAC efficacy in autism have been disappointing. Expert opinion: These preliminary positive results require further confirmation in larger samples and with longer follow-ups. Given its high tolerability and wide availability, NAC represents an important target to investigate in the field of new adjunctive treatments for psychiatric conditions.
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Affiliation(s)
- Alessandro Minarini
- a Department of Diagnostic-Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Silvia Ferrari
- a Department of Diagnostic-Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Martina Galletti
- a Department of Diagnostic-Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Nina Giambalvo
- a Department of Diagnostic-Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Daniela Perrone
- a Department of Diagnostic-Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Giulia Rioli
- a Department of Diagnostic-Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
| | - Gian Maria Galeazzi
- a Department of Diagnostic-Clinical Medicine and Public Health , University of Modena and Reggio Emilia , Modena , Italy
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Skvarc DR, Dean OM, Byrne LK, Gray LJ, Ives K, Lane SE, Lewis M, Osborne C, Page R, Stupart D, Turner A, Berk M, Marriott AJ. The Post-Anaesthesia N-acetylcysteine Cognitive Evaluation (PANACEA) trial: study protocol for a randomised controlled trial. Trials 2016; 17:395. [PMID: 27502769 PMCID: PMC4977889 DOI: 10.1186/s13063-016-1529-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/26/2016] [Indexed: 12/18/2022] Open
Abstract
Background Some degree of cognitive decline after surgery occurs in as many as one quarter of elderly surgical patients, and this decline is associated with increased morbidity and mortality. Cognition may be affected across a range of domains, including memory, psychomotor skills, and executive function. Whilst the exact mechanisms of cognitive change after surgery are not precisely known, oxidative stress and subsequent neuroinflammation have been implicated. N-acetylcysteine (NAC) acts via multiple interrelated mechanisms to influence oxidative homeostasis, neuronal transmission, and inflammation. NAC has been shown to reduce oxidative stress and inflammation in both human and animal models. There is clinical evidence to suggest that NAC may be beneficial in preventing the cognitive decline associated with both acute physiological insults and dementia-related disorders. To date, no trials have examined perioperative NAC as a potential moderator of postoperative cognitive changes in the noncardiac surgery setting. Methods and design This is a single-centre, randomised, double-blind, placebo-controlled clinical trial, with a between-group, repeated-measures, longitudinal design. The study will recruit 370 noncardiac surgical patients at the University Hospital Geelong, aged 60 years or older. Participants are randomly assigned to receive either NAC or placebo (1:1 ratio), and groups are stratified by age and surgery type. Participants undergo a series of neuropsychological tests prior to surgery, 7 days, 3 months, and 12 months post surgery. It is hypothesised that the perioperative administration of NAC will reduce the degree of postoperative cognitive changes at early and long-term follow-up, as measured by changes on individual measures of the neurocognitive battery, when compared with placebo. Serum samples are taken on the day of surgery and on day 2 post surgery to quantitate any changes in levels of biomarkers of inflammation and oxidative stress. Discussion The PANACEA trial aims to examine the potential efficacy of perioperative NAC to reduce the severity of postoperative cognitive dysfunction in an elderly, noncardiac surgery population. This is an entirely novel approach to the prevention of postoperative cognitive dysfunction and will have high impact and translatable outcomes if NAC is found to be beneficial. Trial registration The PANACEA trial has been registered with the Therapeutic Goods Administration, and the Australian New Zealand Clinical Trials Registry: ACTRN12614000411640; registered on 15 April 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1529-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David R Skvarc
- School of Psychology, Deakin University, 221 Burwood Highway, Burwood, 3215, VIC, Australia.,Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Olivia M Dean
- Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Linda K Byrne
- School of Psychology, Deakin University, 221 Burwood Highway, Burwood, 3215, VIC, Australia
| | - Laura J Gray
- School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Kathryn Ives
- Department of Anaesthesia, Perioperative Medicine and Pain Management, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Stephen E Lane
- School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,Biostatistics Unit, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Matthew Lewis
- Aged Psychiatry Service, Caulfield Hospital, Alfred Health, 260 Kooyong Road, Caulfield, 3162, Victoria, Australia
| | - Cameron Osborne
- Department of Anaesthesia, Perioperative Medicine and Pain Management, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Richard Page
- School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,Barwon Orthopaedic Research Unit, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Douglas Stupart
- Department of General Surgery, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Alyna Turner
- Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Michael Berk
- Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Andrew J Marriott
- Department of Anaesthesia, Perioperative Medicine and Pain Management, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia. .,Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia. .,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.
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Rosenblat JD, Gregory JM, McIntyre RS. Pharmacologic implications of inflammatory comorbidity in bipolar disorder. Curr Opin Pharmacol 2016; 29:63-9. [DOI: 10.1016/j.coph.2016.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/22/2016] [Indexed: 12/13/2022]
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Scaini G, Rezin GT, Carvalho AF, Streck EL, Berk M, Quevedo J. Mitochondrial dysfunction in bipolar disorder: Evidence, pathophysiology and translational implications. Neurosci Biobehav Rev 2016; 68:694-713. [PMID: 27377693 DOI: 10.1016/j.neubiorev.2016.06.040] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 01/05/2023]
Abstract
Bipolar disorder (BD) is a chronic psychiatric illness characterized by severe and biphasic changes in mood. Several pathophysiological mechanisms have been hypothesized to underpin the neurobiology of BD, including the presence of mitochondrial dysfunction. A confluence of evidence points to an underlying dysfunction of mitochondria, including decreases in mitochondrial respiration, high-energy phosphates and pH; changes in mitochondrial morphology; increases in mitochondrial DNA polymorphisms; and downregulation of nuclear mRNA molecules and proteins involved in mitochondrial respiration. Mitochondria play a pivotal role in neuronal cell survival or death as regulators of both energy metabolism and cell survival and death pathways. Thus, in this review, we discuss the genetic and physiological components of mitochondria and the evidence for mitochondrial abnormalities in BD. The final part of this review discusses mitochondria as a potential target of therapeutic interventions in BD.
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Affiliation(s)
- Giselli Scaini
- Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; Laboratory of Bioenergetics, Graduate Program in Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Gislaine T Rezin
- Laboratory of Clinical and Experimental Pathophysiology, Graduate Program in Health Sciences, Universidade do Sul de Santa Catarina, Tubarão, SC, Brazil
| | - Andre F Carvalho
- Translational Psychiatry Research Group and Department of Clinical Medicine, Faculty of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
| | - Emilio L Streck
- Laboratory of Bioenergetics, Graduate Program in Health Sciences, Health Sciences Unit, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Faculty of Health, Geelong, Victoria, Australia; Orygen, The National Centre of Excellence in Youth Mental Health and The Centre for Youth Mental Health, The Department of Psychiatry and The Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - João Quevedo
- Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; Center of Excellence on Mood Disorders, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; Neuroscience Graduate Program, The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA; Laboratory of Neurosciences, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil.
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McKetin R, Dean OM, Baker AL, Carter G, Turner A, Kelly PJ, Berk M. A potential role for N-acetylcysteine in the management of methamphetamine dependence. Drug Alcohol Rev 2016; 36:153-159. [PMID: 27241765 DOI: 10.1111/dar.12414] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 12/01/2022]
Abstract
Methamphetamine dependence is a growing problem in Australia and globally. Currently, there are no approved pharmacotherapy options for the management of methamphetamine dependence. N-acetylcysteine is one potential pharmacotherapy option. It has received growing attention as a therapy for managing addictions because of its capacity to restore homeostasis to brain glutamate systems disrupted in addiction and thereby reduce craving and the risk of relapse. N-acetylcysteine also has antioxidant properties that protect against methamphetamine-induced toxicity and it may therefore assist in the management of the neuropsychiatric and neurocognitive effects of methamphetamine. This commentary overviews the actions of N-acetylcysteine and evidence for its efficacy in treating addiction with a particular focus on its potential utility for methamphetamine dependence. We conclude that the preliminary evidence indicates a need for full-scale trials to definitively establish whether N-acetylcysteine has a therapeutic benefit and the nature of this benefit, for managing methamphetamine dependence. [McKetin R, Dean O, Baker A. L, Carter G, Turner A, Kelly P. J, Berk M. A potential role for N-acetylcysteine in the management of methamphetamine dependence. Drug Alcohol Rev 2017;36:153-159].
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Affiliation(s)
- Rebecca McKetin
- National Drug Research Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Olivia M Dean
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Geelong, Australia.,Florey Institute for Neuroscience and Mental Health, Department of Psychiatry and Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, Australia.,Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Amanda L Baker
- Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle, Newcastle, Australia
| | - Greg Carter
- Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle, Newcastle, Australia
| | - Alyna Turner
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Geelong, Australia.,Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle, Newcastle, Australia
| | - Peter J Kelly
- School of Psychology, University of Wollongong, Wollongong, Australia
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Geelong, Australia.,Florey Institute for Neuroscience and Mental Health, Department of Psychiatry and Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, Australia.,Department of Psychiatry, University of Melbourne, Melbourne, Australia
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Abstract
The pathophysiology of bipolar disorder (BD) remains poorly understood. Current psychopharmacologic treatments are often poorly tolerated and carry high rates of treatment resistance. Mounting evidence has suggested that innate immune system dysfunction may play a role in the pathophysiology of BD. Elevated proinflammatory cytokine levels have been identified. The innate immune system is a novel therapeutic target in BD. Lithium has been shown to have antiinflammatory properties. Further research is needed to establish the role of antiinflammatory agents in the treatment of BD; however, evidence from several clinical trials indicates that antiinflammatory agents may be incorporated into clinical practice soon.
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Affiliation(s)
- Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, University Health Network, University of Toronto, 399 Bathurst Street, MP 9-325, Toronto, Ontario M5T 2S8, Canada
| | - Roger S McIntyre
- Mood Disorder Psychopharmacology Unit, University Health Network, University of Toronto, 399 Bathurst Street, MP 9-325, Toronto, Ontario M5T 2S8, Canada.
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42
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Rosenblat JD, Kakar R, Berk M, Kessing LV, Vinberg M, Baune BT, Mansur RB, Brietzke E, Goldstein BI, McIntyre RS. Anti-inflammatory agents in the treatment of bipolar depression: a systematic review and meta-analysis. Bipolar Disord 2016; 18:89-101. [PMID: 26990051 DOI: 10.1111/bdi.12373] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/08/2015] [Accepted: 12/11/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Inflammation has been implicated in the risk, pathophysiology, and progression of mood disorders and, as such, has become a target of interest in the treatment of bipolar disorder (BD). Therefore, the objective of the current qualitative and quantitative review was to determine the overall antidepressant effect of adjunctive anti-inflammatory agents in the treatment of bipolar depression. METHODS Completed and ongoing clinical trials of anti-inflammatory agents for BD published prior to 15 May 15 2015 were identified through searching the PubMed, Embase, PsychINFO, and Clinicaltrials.gov databases. Data from randomized controlled trials (RCTs) assessing the antidepressant effect of adjunctive mechanistically diverse anti-inflammatory agents were pooled to determine standard mean differences (SMDs) compared with standard therapy alone. RESULTS Ten RCTs were identified for qualitative review. Eight RCTs (n = 312) assessing adjunctive nonsteroidal anti-inflammatory drugs (n = 53), omega-3 polyunsaturated fatty acids (n = 140), N-acetylcysteine (n = 76), and pioglitazone (n = 44) in the treatment of BD met the inclusion criteria for quantitative analysis. The overall effect size of adjunctive anti-inflammatory agents on depressive symptoms was -0.40 (95% confidence interval -0.14 to -0.65, p = 0.002), indicative of a moderate and statistically significant antidepressant effect. The heterogeneity of the pooled sample was low (I² = 14%, p = 0.32). No manic/hypomanic induction or significant treatment-emergent adverse events were reported. CONCLUSIONS Overall, a moderate antidepressant effect was observed for adjunctive anti-inflammatory agents compared with conventional therapy alone in the treatment of bipolar depression. The small number of studies, diversity of agents, and small sample sizes limited interpretation of the current analysis.
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Affiliation(s)
- Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Department of Psychiatry and Pharmacology, University of Toronto, Toronto, Canada
| | - Ron Kakar
- Mood Disorders Psychopharmacology Unit, University Health Network, Department of Psychiatry and Pharmacology, University of Toronto, Toronto, Canada.,Department of Psychiatry, Western University, London and Windsor, ON, Canada
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, Vic., Australia.,Department of Psychiatry, The Florey Institute of Neuroscience and Mental Health, and Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, University of Melbourne, Parkville, Vic., Australia
| | - Lars V Kessing
- Psychiatric Center Copenhagen, Faculty of Health and Medical Sciences and Department O, University of Copenhagen, Copenhagen, Denmark
| | - Maj Vinberg
- Psychiatric Center Copenhagen, Faculty of Health and Medical Sciences and Department O, University of Copenhagen, Copenhagen, Denmark
| | - Bernhard T Baune
- Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Department of Psychiatry and Pharmacology, University of Toronto, Toronto, Canada.,Interdisciplinary Laboratory of Clinical Neurosciences (LINC), Federal University of Sao Paulo, São Paulo, Brazil.,Program of Recognition and Intervention in Individuals in AT-Risk Mental States (PRISMA), Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Elisa Brietzke
- Interdisciplinary Laboratory of Clinical Neurosciences (LINC), Federal University of Sao Paulo, São Paulo, Brazil.,Program of Recognition and Intervention in Individuals in AT-Risk Mental States (PRISMA), Department of Psychiatry, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Benjamin I Goldstein
- Departments of Psychiatry, Pharmacology, and Psychological Clinical Science, Centre for Youth Bipolar Disorder, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Department of Psychiatry and Pharmacology, University of Toronto, Toronto, Canada
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Abstract
As with physical conditions, bipolar disorder is likely to be impacted by diet and nutrition. Patients with bipolar disorder have been noted to have relatively unhealthy diets, which may in part be the reason they also have an elevated risk of metabolic syndrome and obesity. An improvement in the quality of the diet should improve a bipolar patient's overall health risk profile, but it may also improve their psychiatric outcomes. New insights into biological dysfunctions that may be present in bipolar disorder have presented new theoretic frameworks for understanding the relationship between diet and bipolar disorder.
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Affiliation(s)
- John L Beyer
- Duke University Medical Center, Box 3519 DUMC, Room 4082B, Yellow Zone, Duke South Clinics, Durham, NC 27710, USA.
| | - Martha E Payne
- Office of Research Development, Duke University School of Medicine, Davison Building/Green Zone, Suite 410, Durham, NC 27705, USA
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Racz R, Sweet BV, Sohoni P. Oral acetylcysteine for neuropsychiatric disorders. Am J Health Syst Pharm 2016; 72:923-6, 928-9. [PMID: 25987686 DOI: 10.2146/ajhp140732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Rebecca Racz
- College of PharmacyUniversity of Michigan (UM)Ann Arbor, MI
| | | | - Pamela Sohoni
- St. Mary Mercy Outpatient Psychiatric ServicesSaint Joseph Mercy Health SystemAnn Arbor, MI
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Rosenblat JD, Brietzke E, Mansur RB, Maruschak NA, Lee Y, McIntyre RS. Inflammation as a neurobiological substrate of cognitive impairment in bipolar disorder: Evidence, pathophysiology and treatment implications. J Affect Disord 2015; 188:149-59. [PMID: 26363613 DOI: 10.1016/j.jad.2015.08.058] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/05/2015] [Accepted: 08/26/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bipolar disorder (BD) has been associated with cognitive impairment during depressed, manic and euthymic periods. Inflammation has been shown to be involved in the pathophysiology of BD and cognitive impairment. METHODS For this systematic review, the MEDLINE/PubMed, Embase, Google Scholar and ClinicalTrials.gov databases were searched for relevant articles assessing the association between cognitive function and inflammatory markers in BD subjects. A discussion of potential mechanisms and therapeutic implications is also included to provide further context to the subject matter. RESULTS Eight studies, including a total of 555 BD subjects, assessing the association between cognitive function and inflammatory markers were identified. Cognitive dysfunction was associated with elevated levels of pro-inflammatory markers YKL40, IL-6, sCD40L, IL-1Ra, hsCRP and TNF-α. Mechanistically, elevation in inflammatory cytokines alters monoamine levels leading to cognitive and affective dysfunction. Neuro-inflammation, manifesting as microglial activation, leads to increased oxidative stress, pathologic synaptic pruning and impaired neuroplasticity in key brain regions sub-serving mood and cognition. Immune dysfunction also activates the hypothalamic-pituitary-adrenal (HPA) axis leading to hypercortisolemia and metabolic dysfunction, further promoting neuronal dysfunction. Anti-inflammatory agents are therefore currently being investigated in the treatment of BD and appear to exert an antidepressant effect; however, cognitive outcomes have yet to be reported. CONCLUSION Several studies suggest that immune dysfunction is associated with cognitive impairment in BD. Several neurobiological pathways have been identified whereby immune dysfunction may promote cognitive impairment in BD. Future investigations of anti-inflammatory agents targeting cognitive function as a treatment outcome are merited.
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Affiliation(s)
- Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Elisa Brietzke
- Interdisciplinary Laboratory of Clinical Neurosciences (LINC), Federal University of Sao Paulo, Sao Paulo, Brazil; Program of Recognition and Intervention in Individuals in AT-Risk Mental States (PRISMA), Department of Psychiatry, Universidade FeInterdisciplinary Laboratory of Clinical Neurosciences (LINC), Federal University of Sao Pauloderal de São Paulo, São Paulo, Brazil
| | - Rodrigo B Mansur
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Interdisciplinary Laboratory of Clinical Neurosciences (LINC), Federal University of Sao Paulo, Sao Paulo, Brazil; Program of Recognition and Intervention in Individuals in AT-Risk Mental States (PRISMA), Department of Psychiatry, Universidade FeInterdisciplinary Laboratory of Clinical Neurosciences (LINC), Federal University of Sao Pauloderal de São Paulo, São Paulo, Brazil
| | - Nadia A Maruschak
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Yena Lee
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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46
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Brady RO, Keshavan M. Emergent treatments based on the pathophysiology of bipolar disorder: A selective review. Asian J Psychiatr 2015; 18:15-21. [PMID: 26525885 PMCID: PMC4745256 DOI: 10.1016/j.ajp.2015.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 07/08/2015] [Accepted: 07/10/2015] [Indexed: 12/20/2022]
Abstract
Bipolar disorder is a chronic psychiatric disorder that is a cause of significant symptomatology even in the setting of optimal treatment. Most current treatments are developed from serendipity, and not based on known pathophysiology. In this review we examine a number of somatic and pharmacologic therapies that are poised to become part of the armamentarium of interventions to treat bipolar illness. As a group, these interventions are derived from a growing understanding of the biological underpinnings of bipolar disorders. We will look at emergent treatments based on our understanding of the molecular biology, neuroanatomy, and the genetics of bipolar disorder.
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Affiliation(s)
- Roscoe O Brady
- Department of Psychiatry, Beth-Israel Deaconess Medical Center, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States.
| | - Matcheri Keshavan
- Department of Psychiatry, Beth-Israel Deaconess Medical Center, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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Logan RW, McClung CA. Animal models of bipolar mania: The past, present and future. Neuroscience 2015; 321:163-188. [PMID: 26314632 DOI: 10.1016/j.neuroscience.2015.08.041] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 08/17/2015] [Accepted: 08/18/2015] [Indexed: 12/19/2022]
Abstract
Bipolar disorder (BD) is the sixth leading cause of disability in the world according to the World Health Organization and affects nearly six million (∼2.5% of the population) adults in the United State alone each year. BD is primarily characterized by mood cycling of depressive (e.g., helplessness, reduced energy and activity, and anhedonia) and manic (e.g., increased energy and hyperactivity, reduced need for sleep, impulsivity, reduced anxiety and depression), episodes. The following review describes several animal models of bipolar mania with a focus on more recent findings using genetically modified mice, including several with the potential of investigating the mechanisms underlying 'mood' cycling (or behavioral switching in rodents). We discuss whether each of these models satisfy criteria of validity (i.e., face, predictive, and construct), while highlighting their strengths and limitations. Animal models are helping to address critical questions related to pathophysiology of bipolar mania, in an effort to more clearly define necessary targets of first-line medications, lithium and valproic acid, and to discover novel mechanisms with the hope of developing more effective therapeutics. Future studies will leverage new technologies and strategies for integrating animal and human data to reveal important insights into the etiology, pathophysiology, and treatment of BD.
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Affiliation(s)
- R W Logan
- University of Pittsburgh School of Medicine, Department of Psychiatry, 450 Technology Drive, Suite 223, Pittsburgh, PA 15219, United States
| | - C A McClung
- University of Pittsburgh School of Medicine, Department of Psychiatry, 450 Technology Drive, Suite 223, Pittsburgh, PA 15219, United States.
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Santos CL, Bobermin LD, Souza DG, Bellaver B, Bellaver G, Arús BA, Souza DO, Gonçalves CA, Quincozes-Santos A. Lipoic acid and N-acetylcysteine prevent ammonia-induced inflammatory response in C6 astroglial cells: The putative role of ERK and HO1 signaling pathways. Toxicol In Vitro 2015; 29:1350-7. [PMID: 26043815 DOI: 10.1016/j.tiv.2015.05.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/03/2015] [Accepted: 05/30/2015] [Indexed: 02/05/2023]
Abstract
Hyperammonemia induces significant changes in the central nervous system (CNS) in direct association with astroglial functions, such as oxidative damage, glutamatergic excitotoxicity, and impaired glutamine synthetase (GS) activity and pro-inflammatory cytokine release. Classically, lipoic acid (LA) and N-acetylcysteine (NAC) exhibit antioxidant and anti-inflammatory activities by increasing glutathione (GSH) biosynthesis and decreasing pro-inflammatory mediator levels in glial cells. Thus, we evaluated the protective effects of LA and NAC against ammonia cytotoxicity in C6 astroglial cells. Ammonia decreased GSH levels and increased cytokine release and NFκB transcriptional activation. LA and NAC prevented these effects by the modulation of ERK and HO1 pathways. Taken together, these observations show that LA and NAC prevent the ammonia-induced inflammatory response.
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Affiliation(s)
- Camila Leite Santos
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Larissa Daniele Bobermin
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Débora Guerini Souza
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Bruna Bellaver
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Gabriela Bellaver
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Bernardo Assein Arús
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Diogo Onofre Souza
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Carlos-Alberto Gonçalves
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - André Quincozes-Santos
- Departamento de Bioquímica, Programa de Pós-Graduação em Ciências Biológicas: Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Clinical trials of N-acetylcysteine in psychiatry and neurology: A systematic review. Neurosci Biobehav Rev 2015; 55:294-321. [PMID: 25957927 DOI: 10.1016/j.neubiorev.2015.04.015] [Citation(s) in RCA: 277] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/30/2015] [Accepted: 04/25/2015] [Indexed: 01/19/2023]
Abstract
N-acetylcysteine (NAC) is recognized for its role in acetaminophen overdose and as a mucolytic. Over the past decade, there has been growing evidence for the use of NAC in treating psychiatric and neurological disorders, considering its role in attenuating pathophysiological processes associated with these disorders, including oxidative stress, apoptosis, mitochondrial dysfunction, neuroinflammation and glutamate and dopamine dysregulation. In this systematic review we find favorable evidence for the use of NAC in several psychiatric and neurological disorders, particularly autism, Alzheimer's disease, cocaine and cannabis addiction, bipolar disorder, depression, trichotillomania, nail biting, skin picking, obsessive-compulsive disorder, schizophrenia, drug-induced neuropathy and progressive myoclonic epilepsy. Disorders such as anxiety, attention deficit hyperactivity disorder and mild traumatic brain injury have preliminary evidence and require larger confirmatory studies while current evidence does not support the use of NAC in gambling, methamphetamine and nicotine addictions and amyotrophic lateral sclerosis. Overall, NAC treatment appears to be safe and tolerable. Further well designed, larger controlled trials are needed for specific psychiatric and neurological disorders where the evidence is favorable.
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Taking the fuel out of the fire: evidence for the use of anti-inflammatory agents in the treatment of bipolar disorders. J Affect Disord 2015; 174:467-78. [PMID: 25553408 DOI: 10.1016/j.jad.2014.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 12/03/2014] [Accepted: 12/04/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Inflammation has emerged as a potentially important factor - and thus putative pharmacological target - in the pathology of bipolar disorders. However to date no systematic evaluations of the efficacy of add on anti-inflammatory treatment for the depressive and manic episodes have been carried out. METHODS Sixteen articles were ultimately identified - by computer searches of databases (including PsycINFO, MEDLINE, and EMBASE), supplemented by hand searches and personal communication - as meeting study inclusion criteria. RESULTS Anti-manic effects were evaluated in two trials, one of adjunctive n-acetyl cysteine (NAC), one of omega-3 fatty acids (O3FA), and significant improvements only emerged for NAC. Celecoxib had a rapid but short-lived antidepressant effect. Despite limited effects of O3FA on symptoms, imaging data demonstrated alterations in neuronal functioning that might have longer-term therapeutic effects. Evidence was strongest for adjunctive NAC in bipolar depression though conclusions are limited by small sample sizes. LIMITATIONS Definitive conclusions are limited by the paucity of data, small study sizes, and the variability in methodology used. CONCLUSIONS Current evidence for aspirin or celecoxib is insufficient though further investigation of the potential of celecoxib in early illness onset is warranted. Variable evidence exists for add-on O3FA though an indication of short-term treatment effects on membrane fluidity and neuronal activity suggest longer follow-up assessment is needed. The strongest evidence emerged for NAC in depression and future studies must address the role of illness duration and patients׳ baseline medications on outcomes. Careful consideration of lithium toxicity in the elderly and renal impaired is essential.
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