Possible role of more positive social behaviour in the clinical effect of antidepressant drugs

Preclinical Models of Chronic Stress: Adaptation or Pathology?

The experience of prolonged stress changes how individuals interact with their environment and process interoceptive cues, with the end goal of optimizing survival and well-being in the face of a now-hostile world. The chronic stress response includes numerous changes consistent with limiting further damage to the organism, including development of passive or active behavioral strategies and metabolic adjustments to alter energy mobilization. These changes are consistent with symptoms of pathology in humans, and as a result, chronic stress has been used as a translational model for diseases such as depression. While it is of heuristic value to understand symptoms of pathology, we argue that the chronic stress response represents a defense mechanism that is, at its core, adaptive in nature. Transition to pathology occurs only after the adaptive capacity of an organism is exhausted. We offer this perspective as a means of framing interpretations of chronic stress studies in animal models and how these data relate to adaptation as opposed to pathology.

Relationship between change in social evaluation learning and mood in early antidepressant treatment: A prospective cohort study in primary care

BACKGROUND

Antidepressants are proposed to work by increasing sensitivity to positive versus negative information. Increasing positive affective learning within social contexts may help remediate negative self-schema. We investigated the association between change in biased learning of social evaluations about the self and others, and mood during early antidepressant treatment.

METHOD

Prospective cohort assessing patients recruited from primary care in South West England at four timepoints over the first 8 weeks of antidepressant treatment (n = 29). At each timepoint, participants completed self-report measures of depression (Beck Depression Inventory II (BDI-II) and Patient Health Questionnaire 9 (PHQ-9)), anxiety (Generalised Anxiety Disorder Questionnaire 7 (GAD-7)), and a computerised task measuring learning of social evaluations about the self, a friend and a stranger.

RESULTS

We did not find evidence that learning about the self was associated with a reduction in PHQ-9 (b = 0.08, 95% CI: -0.05, 0.20, p = 0.239) or BDI-II scores (b = 0.10, 95% CI: -0.18, 0.38, p = 0.469). We found some weak evidence that increased positive learning about the friend was associated with a reduction in BDI-II scores (b = 0.30, 95% CI: -0.02, 0.62, p = 0.069). However, exploratory analyses indicated stronger evidence that increased positive learning about the self (b = 0.18, 95% CI: 0.07, 0.28, p = 0.002) and a friend (b = 0.22, 95% CI: 0.10, 0.35, p = 0.001) was associated with reductions in anxiety.

CONCLUSIONS

Change in social evaluation learning was associated with a reduction in anxiety but not depression. Antidepressants may treat anxiety symptoms by remediating negative affective biases towards socially threatening information directed towards the self and close others. However, our findings are based on exploratory analyses within a small sample without a control group and are therefore at risk of type 1 errors and order effects. Further research with larger samples is required.

Exercise and yoga during pregnancy and their impact on depression: a systematic literature review

It is well established that exercise can improve depressive symptoms in the general population; however, it is not clear if these benefits are also seen in pregnancy. This review aimed to synthesize the evidence that examines whether exercise during pregnancy impacts depressive and associated symptoms (e.g. anxiety) during the perinatal period. The review was conducted in accordance with PRISMA guidelines and reporting criteria; literature was searched using PubMed, Scopus and Web of Science database engines. Clinical trials published in English evaluating the effects of a defined exercise protocol during pregnancy on depressive and/or anxiety symptoms during the perinatal period were included. Studies without a control group were excluded. Risk of bias was conducted by Cochrane assessment to appraise the quality of the included studies. Twenty-seven articles, between 1994 and 2019, were included. Of these, only 5 specifically recruited women with depression (n = 334), which all assessed a yoga-based intervention; 4 of these studies showed a statistically significant improvement in depressive and/or anxiety symptoms in the intervention group compared to baseline; however, 2 of these studies also showed an improvement in the control group. The remaining 22 studies used various exercise interventions in pregnant women (n = 4808) with 20 studies reporting that exercise during pregnancy has the ability to improve depressive and/or anxiety measures in the perinatal period compared to either baseline or control. The evidence suggests that exercise of various types in pregnancy can reduce depressive and/or anxiety symptoms in the perinatal period in otherwise healthy women. Specifically in women with antenatal depression, the incorporation of yoga in pregnancy can improve depressive/anxiety symptoms in the perinatal period; however, this is based on a small number of studies, and it is not clear whether this is superior to non-exercise controls. Further studies are needed to determine the potential therapeutic effects of exercise of various types during pregnancy on symptoms of antenatal depression.

Accuracy in recognising happy facial expressions is associated with antidepressant response to a NOP receptor antagonist but not placebo treatment

BACKGROUND

Clinical trials with putative antidepressants can be difficult to execute as it can take up to 8 weeks before differences emerge between drug and placebo, and long expensive trials often fail. Implementation of early response biomarkers could aid this process significantly with potential to identify new treatments.

AIMS

In a secondary analysis, we examined the association of early effects on emotional processing with later clinical outcome following treatment with the novel NOP antagonist LY2940094 versus placebo. We hypothesised that early induction of positive bias would be associated with reduced severity of depression after 8 weeks of treatment.

METHODS

This was a multicentre, randomised, double-blind, parallel-group, fixed-dose, placebo-controlled, 8 week study to assess sensitivity of the facial emotional recognition task (FERT) to early changes in emotional bias induced by LY2940094. Patients who met diagnostic criteria for major depression were randomised to receive LY2940094 (N = 70) or placebo (N = 66). At week 1 and 6, the FERT was completed by 33 patients in the LY2940094 group and 34 in the placebo group.

RESULTS

Patients identified happy faces with higher accuracy (Wald χ²(1,33) = 14.25, p < 0.001) after 1 week treatment with LY290094 compared to placebo (Wald χ²(1,32) = 0.83, p = 0.36) and this correlated with eventual treatment response measured by the Hamilton Depression Rating Scale 7 weeks later.

CONCLUSION

These data suggest that emotional processing biomarkers may be sensitive to early effects of antidepressant treatment indicative of later clinical response. Further studies in this area may be useful in developing new treatments and clinical trial designs for predicting antidepressant response.

Symptom Cluster-Matching Antidepressant Treatment: A Case Series Pilot Study

Despite treating depression with antidepressants, their effectiveness is often insufficient. Comparative effectiveness studies and meta-analyses show the effectiveness of antidepressants; however, they do not provide clear indications as to the choice of a specific antidepressant. The rational choice of antidepressants may be based on matching their mechanisms of action to the symptomatic profiles of depression, reflecting the heterogeneity of symptoms in different patients. The authors presented a series of cases of patients diagnosed with depression in whom at least one previous antidepressant treatment was shown to be ineffective before drug targeted symptom cluster-matching treatment (SCMT). The presented pilot study shows for the first time the effectiveness of SCMT in the different clusters of depressive symptoms. All the described patients obtained recovery from depressive symptoms after introducing drug-targeted SCMT. Once validated in clinical trials, SCMT might become an effective and rational method of selecting an antidepressant according to the individual profile of depressive symptoms, the mechanism of their formation, and the mechanism of drug action. Although the study results are preliminary, SCMT can be a way to personalize treatment, increasing the likelihood of improvement even in patients who meet criteria for treatment-resistant depression.

Impact and correlates of sub-optimal social support among patients in HIV care

Social support (SS) predicts health outcomes among patients living with HIV. We administered a brief, validated measure of SS, the Multifactoral Assessment of Perceived Social Support, within a patient-reported outcomes assessment of health domains in HIV care at 4 U.S. clinics in English and Spanish (n = 708). In univariate analysis, low SS was associated with poorer engagement in care, antiretroviral adherence, and health-related quality of life; current methamphetamine/crystal use, depression, anxiety, and HIV stigma (all p < 0.001); any use of either methamphetamines/crystal, illicit opioids, or cocaine/crack (p = 0.001), current marijuana use (p = 0.012), nicotine use (p = 0.005), and concern for sexually transmitted infection exposure (p = 0.001). High SS was associated with undetectable viral load (p = 0.031). Multivariate analyses found low SS independently associated with depression (risk ratio (RR) 3.72, 95% CI 2.93-4.72), lower adherence (RR 0.76, 95% CI 0.64-0.89), poor engagement in care (RR 2.05, 95% CI 1.44-2.96), and having more symptoms (RR 2.29, 95% CI 1.92-2.75). Medium SS was independently associated with depression (RR 2.59, 95% CI 2.00-3.36), poor engagement in care (RR 1.62, 95% CI 1.15-2.29) and having more symptoms (RR 1.75, 95% CI 1.44-2.13). SS assessment may help identify patients at risk for these outcomes.

Emotional and interpersonal mechanisms in community SSRI treatment of social anxiety disorder

BACKGROUND

Affective and interpersonal behavioural patterns characteristic of social anxiety disorder show improvement during treatment with serotonin agonists (e.g., selective serotonin reuptake inhibitors), commonly used in the treatment of social anxiety disorder. The present study sought to establish whether, during community psychopharmacological treatment of social anxiety disorder, changes in positive or negative affect and agreeable or quarrelsome behaviour mediate improvement in social anxiety symptom severity or follow from it.

METHODS

Adults diagnosed with social anxiety disorder (n = 48) recorded their interpersonal behaviour and affect naturalistically in an event-contingent recording procedure for 1-week periods before and during the first 4 months of treatment with paroxetine. Participants and treating psychiatrists assessed the severity of social anxiety symptoms monthly. A multivariate latent change score framework examined temporally lagged associations of change in affect and interpersonal behaviour with change in social anxiety symptom severity.

RESULTS

Elevated agreeable behaviour and positive affect predicted greater subsequent reduction in social anxiety symptom severity over the following month of treatment. Elevated negative affect, but not quarrelsome behaviour, predicted less subsequent reduction in symptom severity.

LIMITATIONS

Limitations included limited assessment of extreme behaviour (e.g., violence) that may have precluded examining the efficacy of paroxetine because of the lack of a placebo control group.

CONCLUSION

The present study suggests that interpersonal behaviour and affect may be putative mechanisms of action for serotonergic treatment of social anxiety disorder. Prosocial behaviour and positive affect increase during serotonergic treatment of social anxiety disorder. Specifically, modulating agreeable behaviour, positive affect and negative affect in individuals' daily lives may partially explain and refine clinical intervention.

Weight Loss in Women Taking Flibanserin for Hypoactive Sexual Desire Disorder (HSDD): Insights Into Potential Mechanisms

INTRODUCTION

Flibanserin, a multifunctional serotonin receptor agonist and antagonist, is currently approved in the United States and Canada for the treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. A post hoc analysis of HSDD clinical trial data found that flibanserin treatment was associated with statistically significant weight loss relative to placebo, even though study patients were not selected for being overweight/obese and were provided no expectation for weight reduction or interventions intended to promote weight loss.

AIM

To understand possible mechanisms by which flibanserin may produce weight loss.

METHODS

A literature review was performed using Medline database for relevant publications on the mechanisms of action by which flibanserin may provide weight loss and the links between sexual function and weight management.

MAIN OUTCOME MEASURES

Examination of (i) biopsychosocial factors regulating sexual desire, food intake, and weight regulation; (ii) clinical pharmacology of flibanserin; (iii) neurobiology of brain reward circuitry; and (iv) identification of possible mechanisms common to flibanserin and weight loss.

RESULTS

Based on flibanserin clinical trial data, there was no consistent correlation between weight loss and improvement in sexual function, as assessed by HSDD outcome measures. Nausea, a common adverse event associated with flibanserin use, also did not appear to be a contributing factor to weight loss. Hypothetical links between flibanserin treatment and weight loss include modulation of peripheral 5-HT_2A receptors and factors such as improved mood and improved sleep.

CONCLUSION

Mechanisms of flibanserin-induced weight loss have not been well characterized but may involve indirect beneficial effects on peripheral 5-HT_2A receptors and central regulation of mood and sleep. Future research may better elucidate the links between sexual function and weight management and the mechanism(s) by which flibanserin use may result in weight loss. Simon JA, Kingsberg SA, Goldstein I, et al. Weight Loss in Women Taking Flibanserin for Hypoactive Sexual Desire Disorder (HSDD): Insights into Potential Mechanisms. Sex Med Rev 2019;7:575-586.

Affect, interpersonal behaviour and interpersonal perception during open-label, uncontrolled paroxetine treatment of people with social anxiety disorder: a pilot study

BACKGROUND

Laboratory-based research with community samples has suggested changes in affective, behavioural and cognitive processes as possible explanations for the effects of serotonergic medications. Examining the effects of serotonergic medications using an ecological momentary measure (such as event-contingent recording) in the daily lives of people with social anxiety disorder would contribute to establishing the effects of these medications on affect, behaviour and one form of cognition: perception of others’ behaviour.

METHODS

The present study assessed changes in affect, interpersonal behaviour and perception of others’ behaviour in adults with social anxiety disorder using ecological momentary assessment at baseline and over 4 months of a single-arm, uncontrolled, open-label trial of treatment with the selective serotonin reuptake inhibitor paroxetine.

RESULTS

Anxiety and concurrent depressive symptoms decreased. Participants also reported increased positive and decreased negative affect; increased agreeable and decreased quarrelsome behaviour; increased dominant and decreased submissive behaviour; and increased perception that others behaved agreeably toward them. Moreover, participants demonstrated reduced intraindividual variability in affect, interpersonal behaviour and perception of others’ behaviour.

LIMITATIONS

Limitations included the lack of a placebo group, the inability to identify the temporal order of changes and the restricted assessment of extreme behaviour.

CONCLUSION

The results of the present study demonstrate changes during pharmacotherapy in the manifestation of affect, interpersonal behaviour and interpersonal perception in the daily lives of people with social anxiety disorder. Given the importance of interpersonal processes to social anxiety disorder, these results may guide future research seeking to clarify mechanisms of action for serotonergic medications.

Experience sampling and ecological momentary assessment studies in psychopharmacology: A systematic review

Experience sampling methods (ESM) and ecological momentary assessment (EMA) offer insight into daily life experiences, including symptoms of mental disorders. The application of ESM/EMA in psychopharmacology can be a valuable addition to more traditional measures such as retrospective self-report questionnaires because they may help reveal the impact of psychotropic medication on patients' actual experiences. In this paper we systematically review the existing literature on the use of ESM/EMA in psychopharmacology research. To this end, we searched the PsycInfo and Medline databases for all available ESM/EMA studies on the use of psychotropic medication in patients with DSM-III-R and DSM-IV disorders. Dissertations were excluded. We included 18 studies that applied ESM/EMA to study the effects of medication on patients with major depressive disorder, substance use disorder, attention-deficit hyperactivity disorder, psychotic disorder, and anxiety disorder. We found that ESM/EMA may allow researchers and clinicians to track patients during different phases of treatment: before treatment to predict outcome, during treatment to examine the effects of treatment on symptoms and different aspects of daily life experience, and after treatment to detect vulnerability for relapse. Moreover, ESM/EMA can potentially help determine how long and in what contexts medications are effective. Thus, ESM/EMA may benefit both researchers and clinicians and might prove to be an effective tool for improving the treatment of psychiatric patients.

Autism biomarkers: challenges, pitfalls and possibilities

Network perspectives, in their emphasis on components and their interactions, might afford the best approach to the complexities of the ASD realm. Categorical approaches are unlikely to be fruitful as one should not expect to find a single or even predominant underlying cause of autism behavior across individuals. It is possible that the complex, highly interactive, heterogeneous and individualistic nature of the autism realm is intractable in terms of identifying clinically useful biomarker tests. It is hopeful from an emergenic perspective that small corrective changes in a single component of a deleterious network/configuration might have large beneficial consequences on developmental trajectories and in later treatment. It is suggested that the relationship between ASD and intellectual disability might be fundamentally different in single-gene versus nonsyndromic ASD. It is strongly stated that available biomarker "tests" for autism/ASD will do more harm than good. Finally, the serotonin-melatonin-oxidative stress-placental intersection might be an especially fruitful area of biological investigation.

The Effects of Tryptophan on Everyday Interpersonal Encounters and Social Cognitions in Individuals with a Family History of Depression

BACKGROUND

Individuals with a family history of depression show subtle abnormalities in the processing of social stimuli. This could negatively affect their interpersonal functioning and contribute to their depression risk. Repeated administration of the serotonin precursor tryptophan has previously been shown to increase agreeable behavior and reduce quarrelsome behavior in irritable people, who are also considered at risk for depression.

METHODS

To examine the effects of tryptophan on social functioning in individuals with a family history of depression, 40 men and women with at least one first-degree relative with depression received tryptophan (1g three times a day) and placebo for 14 days each in a double-blind crossover design and recorded their social behavior and mood during everyday interpersonal encounters. Participants also provided daily ratings of their positive and negative cognitions concerning their social functioning.

RESULTS

Tryptophan improved mood. Unexpectedly, tryptophan increased quarrelsome behavior and reduced agreeable behavior, specifically during interactions at home. The behavioral effects of tryptophan were not moderated by mood or by the interaction partner. Negative social cognitions were lower when tryptophan was given second and lower during placebo when placebo was given second.

CONCLUSION

Overall, tryptophan may not alter social behavior in individuals with a family history of depression as it does in irritable people. However, the behavioral effects of tryptophan at home might be seen as a way for individuals with a family history of depression to achieve more control. Over time, this may positively influence the way they feel and think about themselves in a social context.

Studying the neurobiology of human social interaction: Making the case for ecological validity

With this commentary we make the case for an increased focus on the ecological validity of the measures used to assess aspects of human social functioning. Impairments in social functioning are seen in many types of psychopathology, negatively affecting the lives of psychiatric patients and those around them. Yet the neurobiology underlying abnormal social interaction remains unclear. As an example of human social neuroscience research with relevance to biological psychiatry and clinical psychopharmacology, this commentary discusses published experimental studies involving manipulation of the human brain serotonin system that included assessments of social behavior. To date, these studies have mostly been laboratory-based and included computer tasks, observations by others, or single-administration self-report measures. Most laboratory measures used so far inform about the role of serotonin in aspects of social interaction, but the relevance for real-life interaction is often unclear. Few studies have used naturalistic assessments in real life. We suggest several laboratory methods with high ecological validity as well as ecological momentary assessment, which involves intensive repeated measures in naturalistic settings. In sum, this commentary intends to stimulate experimental research on the neurobiology of human social interaction as it occurs in real life.

The ability of early changes in motivation to predict later antidepressant treatment response

INTRODUCTION

Baseline values and early changes of emotional reactivity, cognitive speed, psychomotor function, motivation, and sensory perception have not been studied to any extent in unipolar depression, although they could help to characterize different dimensions of illness that are harder to capture by clinicians, give new insights on how patients improve, and offer new early clinical markers for later treatment response.

METHODS

About 1,565 adult outpatients with major depressive disorder receiving agomelatine completed the clinician-rated 16-item quick inventory of depressive symptoms, Clinical Global Impression, and Multidimensional Assessment of Thymic States (MAThyS) rating scales at inclusion, Week 2 and Week 6. The MAThyS includes a 20-item self-rated visual analog scale (from inhibition [0] to activation [10], with [5] representing the usual state) leading to five a priori dimensions (emotional reactivity, cognitive speed, psychomotor function, motivation, and sensory perception).

RESULTS

All MAThyS dimension scores increased from inclusion to Week 2 and from inclusion to Week 6 (P<0.001). Improvement was around 2 points (out of 10) for motivation, 1.5 points for psychomotor function, and 0.5 points for other dimensions. Motivation showed a trend to being more severely impaired at inclusion in future nonresponders (t=1.25, df=1,563, P=0.10). Its improvement at Week 2 was the most discriminating MAThyS dimension between future responders and nonresponders, and represents the best predictor of future response, with the highest area under the receptor operating characteristic curve (area under curve =0.616, 95% confidence interval [0.588-0.643], P<0.001). Finally, improvements in motivation correlated the most strongly with clinician-rated 16-item quick inventory of depressive symptoms improvement (r=-0.491, df=1,563, P<0.001).

CONCLUSION

Motivation had the most capacity for early improvement, the best predictive value for response, and the largest global margin of progress in depressed outpatients. Assessing the evolution of self-reported motivation over time in major depressive disorder could offer an interesting complementary approach to predict response.