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Kajumba MM, Kakooza-Mwesige A, Nakasujja N, Koltai D, Canli T. Treatment-resistant depression: molecular mechanisms and management. MOLECULAR BIOMEDICINE 2024; 5:43. [PMID: 39414710 PMCID: PMC11485009 DOI: 10.1186/s43556-024-00205-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 09/03/2024] [Indexed: 10/18/2024] Open
Abstract
Due to the heterogeneous nature of depression, the underlying etiological mechanisms greatly differ among individuals, and there are no known subtype-specific biomarkers to serve as precise targets for therapeutic efficacy. The extensive research efforts over the past decades have not yielded much success, and the currently used first-line conventional antidepressants are still ineffective for close to 66% of patients. Most clinicians use trial-and-error treatment approaches, which seem beneficial to only a fraction of patients, with some eventually developing treatment resistance. Here, we review evidence from both preclinical and clinical studies on the pathogenesis of depression and antidepressant treatment response. We also discuss the efficacy of the currently used pharmacological and non-pharmacological approaches, as well as the novel emerging therapies. The review reveals that the underlying mechanisms in the pathogenesis of depression and antidepressant response, are not specific, but rather involve an interplay between various neurotransmitter systems, inflammatory mediators, stress, HPA axis dysregulation, genetics, and other psycho-neurophysiological factors. None of the current depression hypotheses sufficiently accounts for the interactional mechanisms involved in both its etiology and treatment response, which could partly explain the limited success in discovering efficacious antidepressant treatment. Effective management of treatment-resistant depression (TRD) requires targeting several interactional mechanisms, using subtype-specific and/or personalized therapeutic modalities, which could, for example, include multi-target pharmacotherapies in augmentation with psychotherapy and/or other non-pharmacological approaches. Future research guided by interaction mechanisms hypotheses could provide more insights into potential etiologies of TRD, precision biomarker targets, and efficacious therapeutic modalities.
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Affiliation(s)
- Mayanja M Kajumba
- Department of Mental Health and Community Psychology, Makerere University, P. O. Box 7062, Kampala, Uganda.
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pediatrics and Child Health, Mulago National Referral Hospital, Kampala, Uganda
| | - Noeline Nakasujja
- Department of Psychiatry, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deborah Koltai
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Durham, NC, USA
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
| | - Turhan Canli
- Department of Psychology, Stony Brook University, New York, USA
- Department of Psychiatry, Stony Brook University, New York, USA
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Amasi-Hartoonian N, Pariante CM, Cattaneo A, Sforzini L. Understanding treatment-resistant depression using "omics" techniques: A systematic review. J Affect Disord 2022; 318:423-455. [PMID: 36103934 DOI: 10.1016/j.jad.2022.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/26/2022] [Accepted: 09/07/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Treatment-resistant depression (TRD) results in huge healthcare costs and poor patient clinical outcomes. Most studies have adopted a "candidate mechanism" approach to investigate TRD pathogenesis, however this is made more challenging due to the complex and heterogeneous nature of this condition. High-throughput "omics" technologies can provide a more holistic view and further insight into the underlying mechanisms involved in TRD development, expanding knowledge beyond already-identified mechanisms. This systematic review assessed the information from studies that examined TRD using hypothesis-free omics techniques. METHODS PubMed, MEDLINE, Embase, APA PsycInfo, Scopus and Web of Science databases were searched on July 2022. 37 human studies met the eligibility criteria, totalling 17,518 TRD patients, 571,402 healthy controls and 62,279 non-TRD depressed patients (including antidepressant responders and untreated MDD patients). RESULTS Significant findings were reported that implicate the role in TRD of various molecules, including polymorphisms, genes, mRNAs and microRNAs. The pathways most commonly reported by the identified studies were involved in immune system and inflammation, neuroplasticity, calcium signalling and neurotransmitters. LIMITATIONS Small sample sizes, variability in defining TRD, and heterogeneity in study design and methodology. CONCLUSIONS These findings provide insight into TRD pathophysiology, proposing future research directions for novel drug targets and potential biomarkers for clinical staging and response to antidepressants (citalopram/escitalopram in particular) and electroconvulsive therapy (ECT). Further validation is warranted in large prospective studies using standardised TRD criteria. A multi-omics and systems biology strategy with a collaborative effort will likely deliver robust findings for translation into the clinic.
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Affiliation(s)
- Nare Amasi-Hartoonian
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Department of Psychological Medicine, London, UK.
| | - Carmine Maria Pariante
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Department of Psychological Medicine, London, UK; National Institute for Health and Research Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Annamaria Cattaneo
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; Laboratory of Biological Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Luca Sforzini
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Department of Psychological Medicine, London, UK
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Jeon HJ, Ju PC, Sulaiman AH, Aziz SA, Paik JW, Tan W, Bai D, Li CT. Long-term Safety and Efficacy of Esketamine Nasal Spray Plus an Oral Antidepressant in Patients with Treatment-resistant Depression- an Asian Sub-group Analysis from the SUSTAIN-2 Study. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2022; 20:70-86. [PMID: 35078950 PMCID: PMC8813327 DOI: 10.9758/cpn.2022.20.1.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/13/2022]
Abstract
Objective To evaluate the long-term safety and efficacy of intranasal esketamine in patients with treatment-resistant depression from the Asian subgroup of the SUSTAIN-2 study. Methods SUSTAIN-2 was a phase 3, open-label, single-arm, multicenter study comprising a 4-week screening, 4-week induction, 48-week optimization/maintenance, and 4-week follow-up (upon esketamine discontinuation) phase. Patients with treatment-resistant depression received esketamine plus an oral antidepressant during the treatment period. Results The incidence of ≥ 1 serious treatment-emergent adverse event (TEAE) among the 78 subjects from the Asian subgroup (Taiwan 33, Korea 26, Malaysia 19) was 11.5% (n = 9); with no fatal TEAE. 13 Asian patients (16.7%) discontinued esketamine due to TEAEs. The most common TEAEs were dizziness (37.2%), nausea (29.5%), dissociation (28.2%), and headache (21.8%). Most TEAEs were mild to moderate in severity, transient and resolved on the same day. Upon discontinuation of esketamine, no trend in withdrawal symptoms was observed to associate long-term use of esketamine with withdrawal syndrome. There were no reports of drug seeking, abuse, or overdose. Improvements in symptoms, functioning and quality of life, occurred during in the induction phase and were generally maintained through the optimization/maintenance phases of the study. Conclusion The safety and efficacy of esketamine in the Asian subgroup was generally consistent with the total SUSTAIN-2 population. There was no new safety signal and no indication of a high potential for abuse with the long-term (up to one year) use of esketamine in the Asian subgroup. Most of the benefits of esketamine occurred early during the induction phase.
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Affiliation(s)
- Hong Jin Jeon
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Korea Psychological Autopsy Center (KPAC), Seoul, Korea.,Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Seoul, Korea
| | - Po-Chung Ju
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Department of Psychiatry, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ahmad Hatim Sulaiman
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Salina Abdul Aziz
- Department of Psychiatry and Mental Health, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Jong-Woo Paik
- Department of Psychiatry, Kyung Hee University College of Medicine, Seoul, Korea
| | - Wilson Tan
- Regional Medical Affairs, Janssen Pharmaceutical Companies of Johnson and Johnson, Singapore
| | - Daisy Bai
- Statistics & Decision Sciences, Janssen Research & Development, LLC, Shanghai, China
| | - Cheng-Ta Li
- Division of Community & Rehabilitation Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan.,Functional Neuroimaging and Brain Stimulation Lab, National Yang Ming Chiao Tung University, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Sapkota A, Khurshid H, Qureshi IA, Jahan N, Went TR, Sultan W, Alfonso M. Efficacy and Safety of Intranasal Esketamine in Treatment-Resistant Depression in Adults: A Systematic Review. Cureus 2021; 13:e17352. [PMID: 34447651 PMCID: PMC8381465 DOI: 10.7759/cureus.17352] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/21/2021] [Indexed: 12/28/2022] Open
Abstract
Intranasal form of esketamine, the S-enantiomer of racemic ketamine, was approved by the US FDA in 2019 for treatment-resistant depression (TRD) in adults. Since intranasal esketamine is a newly approved drug with a novel mechanism of action, much still remains unknown in regard to its use in TRD. The objective of this study is to systematically review the latest existing evidence on intranasal esketamine, and provide a better insight into its safety and efficacy in TRD in adults. PubMed, MEDLINE (through PubMed), and Google Scholar were systematically searched from 2016 to 2021, using automation tools. After removal of duplicates and screening on the basis of title/abstract, eligibility criteria were applied and quality appraisal was done independently by two reviewers. A total of 10 studies were selected for the final review which included five clinical trials (three short-term trials, one withdrawal design relapse prevention study, and one long-term study), three post hoc studies, one case/non-case study, and one review article. Out of three short-term clinical trials, only one demonstrated a statistically significant difference between treatment with esketamine plus oral antidepressant (OAD) vs placebo plus OAD. The result of the relapse prevention study showed significantly delayed relapse of depressive symptoms in esketamine plus OAD arm when compared to placebo plus OAD arm. Similarly, the result of the long-term clinical trial showed that the improvement in depressive symptoms was found to be sustained in those using esketamine. The most common adverse effects of esketamine included nausea, dizziness, dissociation, headache, vertigo, somnolence, and dysgeusia (altered sense of taste); most were mild-moderate in severity. One case/non-case study reported rare adverse effects including panic attacks, mania, ataxia, akathisia, self-harm ideation, increased loquacity (talkativeness), and autoscopy. Intranasal esketamine has shown efficacy in reducing depressive symptoms in clinical trials, but the clinical meaningfulness of the treatment effect in the real-world population still needs to be explored. Although the safety profile of esketamine appears to be favorable in most clinical trials, some serious side effects are being reported to the FDA Adverse Event Reporting System, and therefore requires further investigation. More robust clinical trials, especially long-term randomized controlled trials are needed which can help provide a better assessment on the efficacy and safety of intranasal esketamine in the treatment of TRD.
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Affiliation(s)
- Alisha Sapkota
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hajra Khurshid
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Israa A Qureshi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nasrin Jahan
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Terry R Went
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Waleed Sultan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Michael Alfonso
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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