Treatment-resistant depression: therapeutic trends, challenges, and future directions

Self-criticism predicts antidepressant effects of intermittent theta-burst stimulation in Major Depressive Disorder

BACKGROUND

Self-criticism is a risk factor for depression and depressive symptom persistence, however higher degrees of self-criticism have been associated with greater antidepressant benefits from repetitive transcranial magnetic stimulation (rTMS), suggesting that self-criticism may act as a proxy for function of the targeted circuit. We test this hypothesis using secondary data from an rTMS treatment trial where an NMDA receptor agonist (D-Cycloserine) was used to enhance TMS synaptic plasticity to improve efficacy. We hypothesized that self-criticism would be more strongly associated with treatment outcome when stimulation was paired with D-Cycloserine than with a placebo.

METHODS

In a 4-week single-site double-blind randomized placebo-controlled trial, fifty adults with Major Depressive Disorder (MDD) (NCT03937596) were randomized to receive placebo or D-Cycloserine (100 mg) with daily intermittent theta-burst stimulation (iTBS) to the left dorsolateral prefrontal cortex (DLPFC). At baseline and after treatment, self-criticism was assessed using the Depressive Experiences Questionnaire as a secondary trial outcome and depressive symptoms were assessed using the clinician rated Montgomery Asberg Depression Rating scale (MADRS). Clinical response was defined as a ≥50 % decrease on the MADRS.

RESULTS

Self-criticism differentially predicted antidepressant effects when operationalized as both percent decrease on the MADRS and clinical response (≥50 % decrease), with a statistically significantly stronger association in the iTBS+D-Cycloserine group than the iTBS+Placebo condition. Self-criticism did not significantly change in either condition over the course of treatment.

CONCLUSIONS

Our data suggests that iTBS to the left DLPFC engages a circuit related to self-criticism. Higher levels of self-criticism predicted better response to iTBS with an adjuvant that enhances synaptic plasticity. This suggests that personality traits may be used to tailor non-invasive neurostimulation treatments.

Improvements in functioning and workplace productivity with esketamine nasal spray versus quetiapine extended release in patients with treatment resistant depression: Findings from a 32-week randomised, open-label, rater-blinded phase IIIb study

Patients with treatment resistant depression (TRD) experience a greater negative impact on their functioning and productivity at home and in the workplace versus treatment-responsive patients. Here, we report the effects of esketamine nasal spray (NS) versus quetiapine extended release (XR) on functioning, work productivity and activity impairment. ESCAPE‑TRD (NCT04338321) was a 32-week randomised, open‑label, rater‑blinded, active‑controlled phase IIIb study comparing the efficacy and safety of esketamine NS versus quetiapine XR, both alongside an ongoing selective serotonin reuptake inhibitor or serotonin norepinephrine reuptake inhibitor (SSRI/SNRI), in patients with TRD. Patient functioning was assessed via the Sheehan Disability Scale (SDS; functional remission ≤6). Absenteeism, presenteeism, work productivity loss and activity impairment over time were assessed using the Work Productivity and Activity Impairment: Depression (WPAI:D) questionnaire. Results were cumulated over the entire study duration. Esketamine NS-treated patients (N = 336) experienced 43.2 % more weeks with functional remission versus quetiapine XR-treated patients (N = 340) over the 32-week study period (difference: 2.0 weeks [95 % CI: 0.7, 3.3]; p = 0.0023 [ANCOVA models]). Up to Week 32, esketamine NS-treated patients experienced an 11.9 % reduction in productivity loss due to absenteeism (difference: -1.1 weeks [95 % CI: -2.9, 0.7]; p = 0.2285) and a 14.2 % reduction in overall work productivity loss (difference: -2.3 weeks, 95 % CI: [-3.9, -0.7] p = 0.0045) versus quetiapine XR-treated patients, based on mixed models for repeated measures. Patients receiving esketamine NS experienced greater improvements in functioning and productivity over 32 weeks versus quetiapine XR. These improvements demonstrate the clinical and functional benefit of treatment with esketamine NS for patients with TRD.

Association between the functional brain network and antidepressant responsiveness in patients with major depressive disorders: a resting-state EEG study

BACKGROUND

Recent neuroimaging studies have demonstrated that the heterogeneous antidepressant responsiveness in patients with major depressive disorder (MDD) is associated with diverse resting-state functional brain network (rsFBN) topology; however, only limited studies have explored the rsFBN using electroencephalography (EEG). In this study, we aimed to identify EEG-derived rsFBN-based biomarkers to predict pharmacotherapeutic responsiveness.

METHODS

The resting-state EEG signals were acquired for demography-matched three groups: 98 patients with treatment-refractory MDD (trMDD), 269 those with good-responding MDD (grMDD), and 131 healthy controls (HCs). The source-level rsFBN was constructed using 31 sources as nodes and beta-band power envelope correlation (PEC) as edges. The degree centrality (DC) and clustering coefficients (CCs) were calculated for various sparsity levels. Network-based statistic and one-way analysis of variance models were employed for comparing PECs and network indices, respectively. The multiple comparisons were controlled by the false discovery rate.

RESULTS

Patients with trMDD were characterized by the altered dorsal attention network and salience network. Specifically, they exhibited hypoconnection between eye fields and right parietal regions (p = 0.0088), decreased DC in the right supramarginal gyrus (q = 0.0057), and decreased CC in the reward circuit (qs < 0.05). On the other hand, both MDD groups shared increased DC but decreased CC in the posterior cingulate cortex.

CONCLUSIONS

We confirmed that network topology was more severely deteriorated in patients with trMDD, particularly for the attention-regulatory networks. Our findings suggested that the altered rsFBN topologies could serve as potential pathologically interpretable biomarkers for predicting antidepressant responsiveness.

Grape Seed Extract Pretreatment Prevents Mitochondrial Dysfunction and NLRP3 Inflammasome-Induced Inflammatory Response in Glial Cells Exposed to Paroxetine and Quinolinic Acid

Depression is a neuropsychiatric disorder that affects thousands of people around the world. Drug therapy is the main approach for treating this disease, but its use can cause side effects on cells. This study aimed to examine the impact of antidepressant drugs from different classes on glial (BV-2) cells in the presence or absence of grape seed extract (GSE) and quinolinic acid (QA; 1.5 mM). Cells were treated with GSE (50 μg/mL; 23 h) and then exposed to non-cytotoxic concentrations of bupropion, imipramine, paroxetine, trazodone, and venlafaxine (27-181 µM; 1 h). Principal Component Analysis (PCA) was conducted to demonstrate the best combination of drug and extract treatment. Cell viability, adenosine triphosphate (ATP) production, reactive oxygen species (ROS) and nitric oxide (NO) levels, oxidative damage to lipids (TBARS), superoxide dismutase (SOD) activity, apoptosis, and NLR family pyrin domain containing 3 (NLRP3) genetic expression were evaluated by spectrophotometry, qRT-PCR, or flow cytometry. Mitochondrial markers (CI: NADH-CoQ reductase and CIV: cytochrome c oxidase) were also studied. GSE prevented the increment in levels of ROS (13.73-72.11%), TBARS (44.1-92.77%), NO (9.5-16%), SOD (68.44-212.29%) activity, and apoptosis (10.06-17.3%) caused by antidepressant drugs. Furthermore, it prevented impairments in complexes I (22-71.5%) and IV (7.5-92.5%) activities and ATP production (8-46%). GSE also prevented the NLRP3 overexpression in BV-2 activated by QA (62%), and paroxetine (46%), defined by PCA. Our study evidences that GSE can restore redox equilibrium and prevent inflammation caused by antidepressants and/or QA in a glial microenvironment.

Antidepressive and anxiolytic effects of a combination of Saffron and Chamomile in rats and their relationship with serotonin using methods

OBJECTIVE

To explore the potential of combining natural herbs like chamomile and saffron for the management of anxiety and depression.

METHODS

A rodent model of Major Depressive Disorder (MDD) and anxiety, secondary to streptozotocin-induced diabetes mellitus was made. A total of 6 rat groups were chosen; healthy and diseased controls; and diseased test groups of fluoxetine, saffron, chamomile, and combined saffron and chamomile treated (n = 6/group). Activity by forced swim test (FST), elevated plus maze test (EPMT), and correlations with biochemical markers like serum glucose, tryptophan, C-reactive protein (CRP), brain derived neurotrophic factor (BDNF) and 5-hydrox-ytryptamine 2C receptor (5HT2CR) expression, were assessed at the end of the 3rd week of the treatment. A one-way analysis of variance with a post-hoc Tukey's test was applied.

RESULTS

The combined herbal treatment group showed significantly better (P <0.05) than all other groups in terms of anti-hyperglycemic effect. All treatments improved the CRP levels; however, the combination group was also significantly better than fluoxetine and the individual herb groups. Only the herb groups showed efficacy in the FST with added benefits of the combination group over the healthy controls and similar trends in the EPMT. However, expression of 5HT2CR was repressed while BDNF was elevated through treatment.

CONCLUSION

This study shows that in comparison to treatment with a SSRI, and individual herbs, the combination of chamomile and saffron showed overall improved outcomes.

Comparative impact of exercise variants on depressive symptoms in cancer patients: A systematic review and network meta-analysis

PURPOSE

The aim of this study was to conduct a network meta-analysis to assess the effectiveness of various forms of exercise as an intervention for post-cancer depression and to provide a guiding program based on evidence-based medicine for subsequent clinical practice.

METHODS

This review was registered on the PROSPERO website with ID CRD42023485407. Pubmed, Embase, Cochrane Library, and Web of Science were comprehensively searched to obtain published articles from the establishment of the database until October 7, 2023. Bayesian network meta-analysis was conducted. Statistical analysis was conducted using R4.3.2 and Stata 15.1.

RESULTS

This study ultimately included 51 articles and 4956 samples. Aerobic exercise (SMD = -0.33, 95%CI: 0.58, -0.08), combined exercise (SMD = -0.48, 95%CI: 0.71, -0.26), and mind-body exercise (SMD = -0.35, 95%CI: 0.6, -0.09) significantly improved depression compared with usual care (UC). According to the SUCRA value and cumulative probability, the rank of depression improvement effect of various sports interventions is as follows: combined exercise (90.71%), mind-body exercise (69.64%), aerobic exercise (65.81%), resistance training (35.86%).

CONCLUSION

Exercise intervention can significantly improve post-cancer depression, but there is no significant difference in the effectiveness of various forms of exercise in improving post-cancer depression.

Ketamine and Esketamine in Clinical Trials: FDA-Approved and Emerging Indications, Trial Trends With Putative Mechanistic Explanations

Ketamine has a long and very eventful pharmacological history. Its enantiomer, esketamine ((S)-ketamine), was approved by the US Food and Drug Administration (FDA) and EMA for patients with treatment-resistant depression (TRD) in 2019. The number of approved indications for ketamine and esketamine continues to increase, as well as the number of clinical trials. This analysis provides a quantitative overview of the use of ketamine and its enantiomers in clinical trials during 2014-2024. A total of 363 trials were manually assessed from clinicaltrial.gov with the search term "Ketamine." The highest number of trials were found for the FDA-approved indications: anesthesia (~22%) and pain management (~28%) for ketamine and TRD for esketamine (~29%). Clinical trials on TRD for both ketamine and esketamine also comprised a large proportion of these trials, and interestingly, have reached phase III and phase IV status. Combinatorial treatment of psychiatric disorders and non-psychiatric conditions with pharmacological and non-pharmacological combinations (electroconvulsive therapy, psychotherapeutic techniques, virtual reality, and transcranial magnetic stimulation) is prevalent. Sub-anesthetic doses of ketamine may represent novel therapeutic avenues in neuropsychiatric conditions, that is, major depression, schizophrenia, and bipolar disorder, where glutamate excitotoxicity and oxidative stress are likely to be involved. The study suggests that the number of ketamine studies will continue to grow and possible ketamine variants can be approved for treatment of additional indications.

Combination of rTMS and oxytocin agonist attenuate depression-like behavior after postpartum depression in mice

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) categorizes postpartum depression (PPD) as a subtype of Major Depressive Disorder (MDD) with peripartum onset, generally arising within the initial trimester following delivery. This acute psychiatric condition is characterized by feelings of worthlessness, insomnia, extreme anxiety, or maternal neglect. Intranasal oxytocin (OT) and transcranial magnetic stimulation (TMS) have the potential to address impaired social cognition; nonetheless, their neuronal underpinnings, along with their safety and efficacy, are little comprehended. This study examines the effects of rTMS stimulation with an oxytocin agonist or antagonist in a PPD model. We employed the maternal separation with early weaning (MSEW) strategy for 21 days to attain our objective. Oxytocin acetate (agonist) and atosiban (antagonist) were administered by injection twice daily for three consecutive days following the model according to the established protocol. A single session of rTMS involved the application of high-frequency stimulation (20 Hz) one hour following the final injection. Behavioral testing and brain collection were conducted 12 h post-rTMS. The results indicated that treatment with OT followed by rTMS stimulation decreased neuronal cell death and microglial activation, meanwhile enhancing synaptic plasticity through the upregulation of PSD95, Synapsin I, and Synaptophysin. Simultaneously, both OT therapy and repetitive transcranial magnetic stimulation demonstrated a significant capacity to alter autophagy activity and astrocyte function. Nonetheless, OTA therapy followed by rTMS did not exhibit the same pattern of outcomes. Our findings indicate that the combination of rTMS stimulation and an oxytocin agonist in a PPD model may mitigate depression-like behavior.

Examining memory reconsolidation as a mechanism of nitrous oxide's antidepressant action

There is an ongoing need to identify novel pharmacological agents for the effective treatment of depression. One emerging candidate, which has demonstrated rapid-acting antidepressant effects in treatment-resistant groups, is nitrous oxide (N2O)-a gas commonly used for sedation and pain management in clinical settings and with a range of pharmacological effects, including antagonism of NMDA glutamate receptors. A growing body of evidence suggests that subanaesthetic doses of N2O (50%) can interfere with the reconsolidation of maladaptive memories in healthy participants and across a range of disorders. Negative biases in memory play a key role in the onset, maintenance, and recurrence of depressive episodes, and the disruption of affective memory reconsolidation is one plausible mechanism through which N2O exerts its therapeutic effects. Understanding N2O's mechanisms of action may facilitate future treatment development in depression. In this narrative review, we introduce the evidence supporting an antidepressant profile of N2O and evaluate its clinical use compared to other treatments. With a focus on the specific memory processes that are thought to be disrupted in depression, we consider the effects of N2O on memory reconsolidation and propose a memory-based mechanism of N2O antidepressant action.

Effects of an acute maximal exercise bout on serum insulin-like growth factor-1 in adults with MDD

Exercise has acute, positive effects on mood and can lead to antidepressant effects over time when repeated regularly. The mechanisms underlying the antidepressant effects of exercise training are not well known, limiting the prescription of exercise training for depression. Serum Insulin-Like Growth Factor-1 (IGF-1) appears dysregulated in those with Major Depressive Disorder (MDD), suggesting MDD could inhibit or alter the IGF-1 response to exercise. In healthy individuals, exercise has been shown to acutely increase serum IGF-1, which may act positively on the dysregulated IGF-1 system in MDD. Therefore, the purpose of this study was to examine the sensitivity of serum IGF-1 levels to an acute maximal exercise bout in adults with MDD and healthy controls. Additionally, clinical and behavioral factors of MDD are likely to affect this system, such as depression severity, antidepressant usage and physical activity habits. Baseline data were used from a larger trial in Germany (SPeED Study) collected from individuals with mild to moderate MDD (n=113) and healthy controls (n=34) that were matched for age, sex, and education. Demographics, depression severity (Hamilton Depression Rating Scale-17), self-reported antidepressant usage, MVPA (International Physical Activity Questionnaire-Short Form), and blood draws before and after a maximal exercise test were collected. Multiple linear regressions were conducted to determine relationships between depression severity, antidepressant usage, and physical activity with peripheral IGF-1 levels following acute exercise. Covariates included demographic factors and IGF-1 pre-exercise (baseline levels). Acute IGF-1 changes occurred similarly in depression (mean ± SD; 11.3 ± 12.9) as well as healthy adults (11.3 ± 20.4: p>0.05). Neither depression severity, antidepressant use, nor regular physical activity were significant predictors of peripheral IGF-1 levels at baseline or following exercise. Individuals with MDD are likely to have favorable exercise-induced IGF-1 changes regardless of clinical and behavioral differences. Acute exercise increases peripheral IGF-1 briefly, and in response to repeated exercise bouts, the IGF-1 system could normalize over time. The normalization of the IGF-1 system might be a possible mechanism underlying mood increases that occur during exercise with exercise training research warranted.

Functional connectivity analyses of individual hippocampal subregions in major depressive disorder with electroconvulsive therapy

Background

The hippocampus has been widely reported to be involved in the neuropathology of major depressive disorder (MDD). All the previous researches adopted group-level hippocampus subregions atlas to investigate abnormal functional connectivities in MDD in absence of capturing individual variability. In addition, the molecular basis of functional impairments of hippocampal subregions in MDD remains elusive.

Objective

We aimed to reveal functional disruptions and recovery of individual hippocampal subregions in MDD patients before and after ECT and linked these functional connectivity differences to transcriptomic profiles to reveal molecular mechanism.

Methods

we used group guided individual functional parcellation approach to define individual subregions of hippocampus for each participant. Resting-state functional connectivity (FC) analysis of individual hippocampal subregions was conducted to investigate functional disruptions and recovery in MDD patients before and after ECT. Spatial association between functional connectivity differences and transcriptomic profiles was employed to reveal molecular mechanism.

Results

MDD patients showed increased FCs of the left tail part of hippocampus with dorsolateral prefrontal cortex and middle temporal gyrus while decreased FC with primary visual cortex. These abnormal FCs in MDD patients were normalized after ECT. In addition, we found that functional disruptions of the left tail part of hippocampus in MDD were mainly related to synaptic signaling and transmission, ion transport, cell-cell signaling and neurogenesis.

Conclusion

Our findings provide initial evidence for functional connectome disruption of individual hippocampal subregions and their molecular basis in MDD.

Treatment with combined exercise in patients with resistant major depression (TRACE-RMD): study protocol for a randomised controlled trial

BACKGROUND

Around 40% of people with major depressive disorder (MDD) experience moderate remission, with the remainder meeting the criteria for resistant major depression (RMD). It has been shown that exercise has a low-to-moderate effect on MDD, but there is a lack of evidence on exercise interventions in RMD patients. The primary purpose of the proposed study will be to investigate the effect of a 12-week supervised combined exercise program on depressive symptoms in people with RMD compared to a treatment-as-usual (TAU) group.

METHOD

This randomised, single-blind, controlled experimental trial will include 70 adults (≥ 18 years old) with RMD. Participants randomised to an exercise intervention, or a TAU group will be assessed at baseline and after a three-month intervention period. The primary variable will be participants' depressive symptoms measured with the Montgomery-Asberg Depression Rating Scale. Secondary outcome variables will include cardiorespiratory fitness (peak oxygen uptake through peak cardiopulmonary exercise test), body composition (bioimpedance and anthropometric variables), physical activity level (the International Physical Activity Questionnaire), health-related quality of life (the Short Form-36 Health Survey), functional outcome (the Sheehan Disability Scale and Quality of Life in Depression Scale), overall disease severity (the Clinical Global Impression Scale-Severity of Illness), and biochemical variables (a fasting blood sample).

DISCUSSION

This study will try to answer whether a supervised co-adjuvant combined (aerobic and resistance training) exercise program will help the prognosis of this population with RMD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136027. Last public release on 12/13/2023.

Effects of electroconvulsive shock on the function, circuitry, and transcriptome of dentate gyrus granule neurons

Therapeutic use of electroconvulsive shock (ECS) is particularly effective for treatment-resistant depression. Like other more common forms of antidepressant treatment such as SSRIs, ECS has been shown to increase neurogenesis in the hippocampal dentate gyrus of rodent models. Yet the question of how ECS-induced neurogenesis supports improvement of depressive symptoms remains unknown. Here, we show that ECS-induced neurogenesis is necessary to improve depressive-like behavior of mice exposed to chronic corticosterone (Cort). We then use slice electrophysiology to show that optogenetic stimulation of adult-born neurons produces a greater hyperpolarization in mature granule neurons after ECS vs Sham treatment. We identify that this hyperpolarization requires the activation of group II metabotropic glutamate receptors. Consistent with this finding, we observe reduced expression of the immediate early gene cFos in the granule cell layer of ECS vs Sham subjects. Using single nucleus RNA sequencing, we reveal major transcriptomic shifts in granule neurons after treatment with ECS+Cort or fluoxetine+Cort vs Cort alone. We identify a population of immature cells which has greater representation in both ECS+Cort and fluoxetine+Cort treated samples vs Cort alone. We also find global differences in ECS-vs fluoxetine-induced transcriptomic shifts. Together, these findings highlight a critical role for immature granule cells in the antidepressant action of ECS.

Drug metabolizing enzymes pharmacogenetic variation-informed antidepressant therapy approach for common mental disorders: A systematic review and meta-analysis

IMPORTANCE

Currently, 30-50 % of individuals with depression and 40 % with anxiety-collectively referred to as common mental disorders (CMDs), exhibit inadequate responses to antidepressant treatments.

OBJECTIVE

To assess the effectiveness and safety of drug-metabolizing enzyme pharmacogenetic variation informed treatment (PGxIT) versus usual antidepressant treatment (UT) in patients with CMDs.

DATA SOURCES

A literature search was conducted in the MEDLINE, Scopus, and Cochrane Library databases from inception until January 30, 2024.

STUDY SELECTION

Studies were selected based on CMD diagnoses, reporting on the genetic variations of drug-metabolizing enzyme (DME) genes in relation to antidepressants, involving PGxIT and UT groups with human subjects, and published in English.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment were performed independently by two authors. A pooled risk ratio (RR) with 95 % CI was estimated using both random and fixed-effect models, and heterogeneity was assessed using Cochran's Q test and the I2 statistic. The publication bias of eligible studies was assessed using post hoc Doi plots and the LFK index.

RESULTS

This systematic review included 18 studies (n = 7021). The PGxIT demonstrated greater efficacy in the remission of symptoms of depressive disorder at 8 weeks (RR 1.523 [95 % CI: 1.255-1.843]; I2 = 48 %) and 12 weeks (RR 1.631 [95 % CI: 1.001-2.657]; I2 = 86 %; p < 0.01), and symptoms of anxiety disorder compared to UT. Additionally, the risk of adverse drug events (ADEs) was significantly lower in the PGxIT group (RR = 0.65 [95 % CI: 0.52-0.82]; I2 = 0 %) than in the UT group. The certainty of evidence for both outcomes was moderate.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis suggest that pharmacogenetically guided antidepressant treatment, based on genetic variation in drug-metabolizing enzymes, is associated with superior efficacy in the remission of symptoms for patients with depressive disorders and a reduction in ADEs compared to usual treatment and the findings of the systematic review for remission in anxiety disorders indicate that, PGx guided treatment is also associated with increased remission of symptoms in anxiety disorders compared to usual treatment.

Escin ameliorates CUMS-induced depressive-like behavior via BDNF/TrkB/CREB and TLR4/MyD88/NF-κB signaling pathways in rats

Major depressive disorder (MDD) is a prevalent psychiatric disorder associated with brain inflammation and neuronal damage. Derived from the Aesculus chinensis Bunge fruit, escin has shown anti-inflammatory and neuroprotective effects. However, its potential as a treatment for MDD is unclear. This study investigates the antidepressant properties of escin using in vivo experimentation. The chronic unpredictable mild stress (CUMS) model was used to analyze the potential antidepressant effects and underlying mechanisms of escin. Wistar rats were exposed to CUMS for 35 consecutive days to induce MDD. The rats were then given either escin (1, 3, and 10 mg/kg) or fluoxetine (2 mg/kg) on a daily basis. Notably, escin significantly alleviated the depressive behaviors induced by CUMS, as evaluated through a series of behavioral assessments. Moreover, escin administration reduced TNF-α, IL-1β, and IL-6 levels in the hippocampus. It also decreased serum adrenal cortical hormone (ACTH) and corticosterone (CORT) levels while increasing 5-HT and Brain-derived neurotrophic factor (BDNF) levels in the CUMS rats, as measured by the enzyme-linked immunosorbent assay (ELISA). Pathological changes in the hippocampal regions were identified through Nissl staining, and Western blotting was used to quantify the protein levels of BDNF, TrkB, CREB, TLR4, MyD88, and NF-κB. Escin mitigated neuronal injury, elevated TrkB, BDNF, and CREB, and reduced TLR4, MyD88, and NF-κB protein levels in CUMS rats. The data from this study suggest that escin holds the potential for alleviating depression-like symptoms induced by CUMS. This effect may be mediated through the modulation of two signaling pathways, BDNF/TrkB/CREB and TLR4/MyD88/NF-κB.

Efficacy and tolerability of monoamine oxidase inhibitors for the treatment of depressive episodes in mood disorders: A systematic review and network meta-analysis

BACKGROUND

Monoamine oxidase inhibitors (MAOIs) are considered third-line treatments for treatment resistant depression; however, they are underused in clinical practice.

AIMS

This study aimed to assess the efficacy, tolerability, and acceptability of MAOIs for the treatment of depression in comparison with other antidepressant treatments.

METHODS

A systematic review and network meta-analysis of randomised clinical trials was performed to compare the efficacy, tolerability and acceptability between MAOIs and other antidepressant treatments for the treatment of depressive episodes.

RESULTS

A total of 83 double-blinded, randomised controlled trials were included in the analysis, with 7765 participants assigned to an active treatment and 1844 assigned to placebo. Several MAOIs, including isocarboxazid, phenelzine, tranylcypromine and moclobemide, showed significantly higher efficacy compared with placebo. The tolerability and acceptability of MAOIs was comparable to other antidepressants.

LIMITATIONS

A disproportionate number of studies investigating the most commonly used MAOIs, such as moclobemide and phenelzine, and a lack of specific studies focusing on treatment-resistant and atypical depression.

CONCLUSIONS

MAOIs are similar in efficacy to other antidepressants for the treatment of depression. However, more studies are needed comparing MAOI treatment in people with treatment-resistant, atypical and bipolar depression.

Concept article: Antidepressant-induced destabilization in bipolar illness mediated by serotonin 3 receptor (5HT3)

OBJECTIVES

Antidepressants used by patients with bipolar disorder have been associated with destabilization with an increase in mania, depression, and cycling. The most commonly proposed mechanism, that antidepressants 'overshoot' their antidepressant effect to create a manic or mixed state, is unlikely since antidepressants have actually been found to be ineffective in treating bipolar depression. Beginning with known bipolar-specific pathophysiologic abnormalities provides the greatest likelihood of insight.

METHODS

PubMed was queried with 'bipolar', 'sodium', 'intracellular sodium', 'serotonin 3', '5HT3', '5-hydroxytryptamine type 3 receptors', and 'antidepressant' either individually or in combination.

RESULTS

Pathologic mood states (both mania and depression) are associated with increased intracellular sodium (Na) concentrations that depolarize the resting membrane potential to increase cellular excitability (mania) or cause depolarization block (depression). Stimulation of the serotonin (5HT) receptors depolarizes the post-synaptic neuron. Stimulation of 5HT3 may be of particular importance since it is coupled to a cation channel that directly depolarizes the membrane. These effects directly impact the physiology of patients with bipolar disorder to alter neuronal excitability in a fashion that worsens both mania and depression.

PROPOSED CONCEPT

The most consistently observed biological abnormality in individuals going through mania or bipolar depression involves a decline in Na pump activity, with consequent elevation of intracellular Na levels. Antidepressant treatment potentiates this, particularly by activation of 5HT3. This hypothesis can be tested by coadministering a 5HT3 antagonist (e.g., vortioxetine or ondansetron) to achieve blockade of that receptor while treating bipolar depression with a serotoninergic antidepressant.

Longitudinal trajectories of symptom change during antidepressant treatment among managed care patients with depression and anxiety

Despite the high correlation between anxiety and depression, little remains known about the course of each condition when presenting concurrently. This study aimed to identify longitudinal patterns during antidepressant treatment in patients with depression and anxiety, and evaluate related factors associated with these patterns. By analyzing longitudinal self-report Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) scores that tracked courses of depression and anxiety over a three-month window among the 577 adult participants, six depression and six anxiety trajectory subgroups were computationally derived using group-based trajectory modeling. Three depression subgroups showed symptom improvement, while three showed nonresponses. Similar patterns were observed in the six anxiety subgroups. Multinomial regression was used to associate patient characteristics with trajectory subgroup membership. Compared to patients in the remission group, factors associated with depressive symptom nonresponse included older age and lower depression severity.

Psychotherapeutic treatments for depression in older adults

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of psychotherapeutic interventions in the treatment of older adults with depression and whether the effects of different types of psychotherapeutic treatments vary for older adults with depression.

Liquid Biopsy-Based Detection and Response Prediction for Depression

Proactively predicting antidepressant treatment response before medication failures is crucial, as it reduces unsuccessful attempts and facilitates the development of personalized therapeutic strategies, ultimately enhancing treatment efficacy. The current decision-making process, which heavily depends on subjective indicators, underscores the need for an objective, indicator-based approach. This study developed a method for detecting depression and predicting treatment response through deep learning-based spectroscopic analysis of extracellular vesicles (EVs) from plasma. EVs were isolated from the plasma of both nondepressed and depressed groups, followed by Raman signal acquisition, which was used for AI algorithm development. The algorithm successfully distinguished depression patients from healthy individuals and those with panic disorder, achieving an AUC accuracy of 0.95. This demonstrates the model's capability to selectively diagnose depression within a nondepressed group, including those with other mental health disorders. Furthermore, the algorithm identified depression-diagnosed patients likely to respond to antidepressants, classifying responders and nonresponders with an AUC accuracy of 0.91. To establish a diagnostic foundation, the algorithm applied explainable AI (XAI), enabling personalized medicine for companion diagnostics and highlighting its potential for the development of liquid biopsy-based mental disorder diagnosis.

Comorbid anxiety, loneliness, and chronic pain as predictors of intervention outcomes for subclinical depressive symptoms in older adults: evidence from a large community-based study in Hong Kong

BACKGROUND

Depression is among the leading causes of the global burden of disease and is associated with substantial morbidity in old age. The importance of providing timely intervention, particularly those with subclinical symptoms, has thus increasingly been emphasised. Despite their overall effectiveness, a small but notable subgroup tends to be less responsive to interventions. Identifying predictors of non-remission and non-response is critical to inform future strategies for optimising intervention outcomes.

METHODS

A total of 4153 older adults aged 60 years and above with subclinical depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] = 5-19) were recruited from JC JoyAge, a large-scale collaborative stepped-care intervention service across Hong Kong. A wide range of clinical and modifiable risk and protective factors at baseline were assessed, including depressive symptoms, anxiety symptoms, loneliness, suicidal ideation, cognitive capacity, multimorbidity, chronic pain, need for informal care due to mental health reasons, history of abuse, and sociodemographic characteristics. Separate multivariable logistic regression models were applied to identify predictors of non-remission (PHQ-9 ≥ 5) and non-response (< 50% reduction in PHQ-9) following intervention.

RESULTS

The rates of non-remission and non-response were 18.9% (n = 784) and 23.0% (n = 956), respectively. Comorbid anxiety symptoms (adjusted odds ratio [aOR] = 2.08, CI = 1.72-2.51; 1.28, 1.05-1.57), loneliness (2.00, 1.66-2.42; 1.67, 1.38-2.01), need for informal care (1.86, 1.49-2.33; 1.48, 1.18-1.85), lower cognitive capacity (0.95, 0.93-0.97; 0.94, 0.92-0.96), and absence of chronic pain (0.59, 0.48-0.72; 0.76, 0.64-0.91) predicted both non-remission and non-response. Meanwhile, moderate-to-severe depressive symptoms predicted higher odds of non-remission (1.41, 1.18-1.69) and lower odds of non-response (0.28, 0.23-0.34), respectively. Subgroup analyses conducted separately in older adults with mild and moderate-to-severe depressive symptoms at baseline revealed that comorbid anxiety, loneliness, need for informal care, and absence of chronic pain were consistent predictors of non-remission. Those with non-remission and non-response showed more depression-related functional impairments and poorer health-related quality of life post-intervention.

CONCLUSIONS

Older adults with subclinical depressive symptoms showing comorbid anxiety, higher loneliness, need for informal care, and chronic pain may be offered more targeted interventions in future services. A personalised risk-stratification approach may be helpful.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers: NCT03593889 (registered 29 May 2018), NCT04863300 (registered 23 April 2021).

Early-Life Stress Influences the Transcriptional Activation of Alpha-2A Adrenergic Receptor and Associated Protein Kinase A Signaling Molecules in the Frontal Cortex of Rats

Early life is a highly sensitive period associated with profound changes in brain structure and function. Adverse experiences of early-life stress (ELS) are prominent risk factors for the precipitation of major depressive disorder (MDD). In recent years, dysfunction of the central noradrenergic (NA) system and subsequent deficits in norepinephrine (NE) signaling have gained increasing attention in the pathophysiology of MDD. However, the role of the α-2A adrenergic receptor and its downstream second messenger signaling system has not been investigated in connection to early-life stress-induced depression, limiting valuable insights into neurobiological mechanisms underlying this disorder. In this study, we used maternal separation (MS) as a rodent model of ELS to investigate whether ELS-induced depressive behavior is related to the α-2A adrenergic receptor and its associated second messenger signaling cascade. To do so, we studied expression levels of the α-2A adrenergic receptor (Adra2a), G alpha proteins (stimulatory subunit-Gαs [Gnas] and inhibitory subunit-Gαi [Gnai1 and Gnai2]), and downstream protein kinase A (PKA) catalytic [Prkarcα and Prkarcβ] and regulatory subunits [Prkar1α, Prkar1β, Prkar2α, and Prkar2β]) in the frontal cortex (FC) of MS rats. We found reduced sucrose preference in MS animals, along with reduced transcript levels of Adra2a, Gnai2, Prkar1β, and Prkarcβ. These findings suggest that ELS exposure may contribute to depression symptomatology via alterations in the expression of key genes involved in the NA system, highlighting potential mechanisms underlying ELS-induced depressive behavior.

Integrated Long Noncoding RNA and Messenger RNA Expression Analysis Identifies Molecules Specifically Associated With Resiliency and Susceptibility to Depression and Antidepressant Response

Background

Depression involves maladaptive processes impairing an individual's ability to interface with the environment appropriately. Long noncoding RNAs (lncRNAs) are gaining traction for their role in higher-order brain functioning. Recently, we reported that lncRNA coexpression modules may underlie abnormal responses to stress in rats showing depression-like behavior. The current study explored the global expression regulation of lncRNAs and messenger RNAs (mRNAs) in the hippocampus of rats showing susceptibility (learned helplessness [LH]) or resiliency (non-LH) to depression and fluoxetine response to LH (LH+FLX).

Methods

Multiple comparison analysis was performed with an analysis of variance via the aov and summary function in the R platform to identify the differential expression of mRNAs and lncRNAs among LH, non-LH, tested control, and LH+FLX groups. Weighted gene coexpression network analysis was used to identify distinctive modules and pathways associated with each phenotype. A machine learning analysis was conducted to screen the critical target genes. Based on the combined analysis, the regulatory effects of lncRNAs on mRNA expression were explored.

Results

Multiple comparison analyses revealed differentially expressed mRNAs and lncRNAs with each phenotype. Integrated bioinformatics analysis identified novel transcripts, specific modules, and regulatory pairs of mRNA-lncRNA in each phenotype. In addition, the machine learning approach predicted lncRNA-regulated Spp2 and Olr25 genes in developing LH behavior, whereas joint analysis of mRNA-lncRNA pairs identified Mboat7, Lmod1, I l 18, and Rfx5 genes in depression-like behavior and Adam6 and Tpra1 in antidepressant response.

Conclusions

The study shows a novel role for lncRNAs in the development of specific depression phenotypes and in identifying newer targets for therapeutic development.

Recent advances in the synthesis of antidepressant derivatives: pharmacologic insights for mood disorders

Mood disorders, including depression, remain a significant global health concern, necessitating continuous efforts to develop novel and more effective antidepressant therapies. Although there have been significant advancements in comprehending the biology of Major Depressive Disorder (MDD), a considerable number of people suffering from depression do not exhibit positive responses to the pharmacologic treatments now available. This study specifically examines emerging targets and potential future approaches for pharmaceutical interventions in the treatment of MDD. The discussion revolves around novel therapeutic agents and their effectiveness in treating depression. The focus is on the specific pathophysiological pathways targeted by these agents and the amount of evidence supporting their use. While conventional antidepressants are anticipated to continue being the primary treatment for MDD in the foreseeable future, there is currently extensive research being conducted on numerous new compounds to determine their effectiveness in treating MDD. Many of these compounds have shown encouraging results. This review highlighted the recent advances in the synthesis of antidepressant derivatives and explores their pharmacologic insights for the treatment of mood disorders.

The Effectiveness of Emotional Freedom Techniques for Depressive Symptoms: A Meta-Analysis

Background: Emotional Freedom Techniques (EFT) have gained attention as a potential therapy for reducing depressive symptoms. However, the evidence remains inconsistent. This meta-analysis aims to assess the overall efficacy of EFT in treating depressive symptoms and explore moderators influencing its effectiveness. Methods: A meta-analysis of 18 randomized controlled trials (RCTs) was conducted, with depressive symptom reduction as the primary outcome. Meta-regression explored moderators such as the EFT format, duration, age, and depression severity. Results: The analysis showed a significant overall effect size of 1.268 for EFT in reducing depressive symptoms. A moderator analysis revealed that group-based EFT interventions were more effective than individual ones, and participants with moderate depression experienced the greatest benefits. Additionally, shorter interventions were found to be highly effective. Conclusions: EFT effectively reduces depressive symptoms, particularly in group settings and for those with moderate depression. Shorter, well-structured interventions may enhance treatment efficiency. Further studies should explore long-term effects and broader applications.

Ketamine and chronic treatment-resistant depression: real-world practice and after relapse

BACKGROUND

Chronic treatment-resistant depression (TRD) poses a major challenge for clinicians. Ketamine has shown a rapid but short-lived antidepressant effect in several studies involving TRD patients with different demographic and clinical profiles. Our study aimed to assess the antidepressant effect of serial infusion sessions of ketamine in patients with chronic TRD and evaluate the severity of symptoms after relapse and the general psychiatric health of the responding patients.

METHODS

In this single arm open-label study, six infusions of ketamine at 0.5 mg/kg were administered to chronic TRD patients for approximately two weeks. Response and remission rates, side effects, adverse events and after-relapse symptoms were evaluated, and patients were followed for three months.

RESULTS

23 patients underwent at least one infusion session, and 18 patients completed the six sessions. Twelve (66.67%) patients responded to the treatment at some point, and 11 (61.11%) patients maintained response after the end of the treatment protocol. One infusion was not sufficient to achieve a response (P > 0.9999, z = 1.81), and more than half of the responders met the response criteria after the third infusion. Only one patient (5.56%) achieved remission at the end of the infusion phase. All but one ketamine responders relapsed within one month after the end of the treatment. There was no statistical difference between baseline and after-relapse MADRS scores (P = 0.7886, 95% CI=-5.512-4.312, R2 = 0,008411). However, a high incidence of serious adverse events related to suicidality was evident; one of the non-responding patients attempted suicide and several attempts to sedate this patient with benzodiazepines failed. Two responding patients ended up with a suicidal attempt or severe suicidal thoughts.

CONCLUSIONS

Introducing rapid-acting antidepressant to manage TRD patients in clinical practice demands further investigation, and the benefit-to-harm ratio should be assessed in the light of the increased risk of suicidality.

Preclinical models for evaluating psychedelics in the treatment of major depressive disorder

Psychedelic drugs have seen a resurgence in interest as a next generation of psychiatric medicines with potential as rapid-acting antidepressants (RAADs). Despite promising early clinical trials, the mechanisms which underlie the effects of psychedelics are poorly understood. For example, key questions such as whether antidepressant and psychedelic effects involve related or independent mechanisms are unresolved. Preclinical studies in relevant animal models are key to understanding the pharmacology of psychedelics and translating these findings to explain efficacy and safety in patients. Understanding the mechanisms of action associated with the behavioural effects of psychedelic drugs can also support the identification of novel drug targets and more effective treatments. Here we review the behavioural approaches currently used to quantify the psychedelic and antidepressant effects of psychedelic drugs. We discuss conceptual and methodological issues, the importance of using clinically relevant doses and the need to consider possible sex differences in preclinical psychedelic studies.

Prediction of pharmacological treatment efficacy using electroencephalography-based salience network in patients with major depressive disorder

Introduction

Recent resting-state electroencephalogram (EEG) studies have consistently reported an association between aberrant functional brain networks (FBNs) and treatment-resistant traits in patients with major depressive disorder (MDD). However, little is known about the changes in FBNs in response to external stimuli in these patients. This study investigates whether changes in the salience network (SN) could predict responsiveness to pharmacological treatment in resting-state and external stimuli conditions.

Methods

Thirty-one drug-naïve patients with MDD (aged 46.61 ± 10.05, female 28) and twenty-one healthy controls (aged 43.86 ± 14.14, female 19) participated in the study. After 8 weeks of pharmacological treatment, the patients were divided into non-remitted MDD (nrMDD, n = 14) and remitted-MDD (rMDD, n = 17) groups. EEG data under three conditions (resting-state, standard, and deviant) were analyzed. The SN was constructed with three cortical regions as nodes and weighted phase-lag index as edges, across alpha, low-beta, high-beta, and gamma bands. A repeated measures analysis of the variance model was used to examine the group-by-condition interaction. Machine learning-based classification analyses were also conducted between the nrMDD and rMDD groups.

Results

A notable group-by-condition interaction was observed in the high-beta band between nrMDD and rMDD. Specifically, patients with nrMDD exhibited hypoconnectivity between the dorsal anterior cingulate cortex and right insula (p = 0.030). The classification analysis yielded a maximum classification accuracy of 80.65%.

Conclusion

Our study suggests that abnormal condition-dependent changes in the SN could serve as potential predictors of pharmacological treatment efficacy in patients with MDD.

Estimating the benefit of esketamine nasal spray versus real-world treatment on patient-reported functional remission: results from the ICEBERG study

Introduction

Treatment resistant depression (TRD) affects approximately 10-30% of patients with major depressive disorder, and most patients with TRD do not respond to real-world treatments (RWT). Treatment with esketamine nasal spray (NS) plus a selective serotonin or serotonin norepinephrine reuptake inhibitor (SSRI/SNRI) has significant long-term clinical benefit over RWT in patients with TRD. However, the impact on patient-reported function remains to be determined.

Methods

The ICEBERG analysis was an indirect treatment comparison performed using data from two studies of patients with TRD: SUSTAIN-2 (esketamine NS; NCT02497287) and the European Observational TRD Cohort (EOTC; RWT; NCT03373253; clinicaltrials.gov). Here, patient-reported functional remission, assessed using the Sheehan Disability Scale (SDS), was defined as SDS ≤6 at Month 6. Analyses were conducted using propensity score re-weighting and multivariable models based on 18 covariates.

Results

At Month 6, the probability of functional remission in esketamine NS-treated patients from SUSTAIN-2 (n=512) was 25.6% (95% confidence interval [CI] 21.8-29.4), while the adjusted probability for RWT patients from the EOTC (n=184) was 11.5% (95% CI 6.9-16.1; relative risk: 2.226 [95% CI 1.451-3.416]; p=0.0003). In the total combined population (N=696), patients who did not achieve clinical response or remission had a low probability of achieving functional remission (5.84% and 8.76%, respectively). However, for patients who did achieve clinical response or remission, the probability of achieving functional remission was greater (43.38% and 54.15%, respectively), although many still did not achieve this status.

Conclusions

For patients with TRD, esketamine NS had a significant functional benefit versus RWT after 6 months of treatment. Irrespective of treatment, achievement of clinical response or remission was insufficient to attain functional remission. Nevertheless, clinical remission increased the likelihood of achieving functional remission, further supporting an important role for clinical remission in for the path towards functional recovery.

Endocannabinoids and Stress-Related Neurospsychiatric Disorders: A Systematic Review and Meta-Analysis of Basal Concentrations and Response to Acute Psychosocial Stress

Background: Dysregulation of the endocannabinoid (eCB) system is implicated in various stress-related neuropsychiatric disorders (SRDs), including anxiety, depression, and post-traumatic stress disorder (PTSD). In this systematic review and meta-analysis, our objectives were to characterize circulating anandamide (AEA) and 2-arachidonoylglycerol (2-AG) concentrations at rest and in response to acute laboratory-based psychosocial stress in individuals with SRDs and without (controls). Our primary aims were to assess the effects of acute psychosocial stress on eCB concentrations in controls (Aim 1), compare baseline (prestress) eCB concentrations between individuals with SRDs and controls (Aim 2), and explore differential eCB responses to acute psychosocial stress in individuals with SRDs compared with controls (Aim 3). Methods: On June 8, 2023, a comprehensive review of the MEDLINE (PubMed) database was conducted to identify original articles meeting inclusion criteria. A total of 1072, 1341, and 400 articles were screened for inclusion in Aims 1, 2, and 3, respectively. Results: Aim 1, comprised of seven studies in controls, revealed that most studies reported stress-related increases in AEA (86%, with 43% reporting statistical significance) and 2-AG (83%, though none were statistically significant except for one study in saliva). However, meta-analyses did not support these patterns (p's>0.05). Aim 2, with 20 studies, revealed that most studies reported higher baseline concentrations of both AEA (63%, with 16% reporting statistical significance) and 2-AG (60%, with 10% reporting statistical significance) in individuals with SRDs compared with controls. Meta-analyses confirmed these findings (p's<0.05). Aim 3, which included three studies, had only one study that reported statistically different stress-related changes in 2-AG (but not AEA) between individuals with PTSD (decrease) and controls (increase), which was supported by the meta-analysis (p<0.001). Meta-analyses showed heterogeneity across studies and aims (I2=14-97%). Conclusion: Despite substantial heterogeneity in study characteristics, samples, and methodologies, consistent patterns emerged, including elevated baseline AEA and 2-AG in individuals with SRDs compared with controls, as well as smaller stress-related increases in 2-AG in individuals with SRDs compared with controls. To consider eCBs as reliable biomarkers and potential intervention targets for SRDs, standardized research approaches are needed to clarify the complex relationships between eCBs, SRDs, and psychosocial stress.

Neuroimaging signatures and a deep learning modeling for early diagnosing and predicting non-pharmacological therapy success for subclinical depression comorbid sleep disorders in college students

Objective

College students with subclinical depression often experience sleep disturbances and are at high risk of developing major depressive disorder without early intervention. Clinical guidelines recommend non-pharmacotherapy as the primary option for subclinical depression with comorbid sleep disorders (sDSDs). However, the neuroimaging mechanisms and therapeutic responses associated with these treatments are poorly understood. Additionally, the lack of an early diagnosis and therapeutic effectiveness prediction model hampers the clinical promotion and acceptance of non-pharmacological interventions for subclinical depression.

Methods

This study involved pre- and post-treatment resting-state functional Magnetic Resonance Imaging (rs-fMRI) and clinical data from a multicenter, single-blind, randomized clinical trial. The trial included 114 first-episode, drug-naïve university students with subclinical depression and comorbid sleep disorders (sDSDs; Mean age=22.8±2.3 years; 73.7% female) and 93 healthy controls (HCs; Mean age=22.2±1.7 years; 63.4% female). We examined altered functional connectivity (FC) and brain network connective mode related to subregions of Default Mode Network (sub-DMN) using seed-to-voxel analysis before and after six weeks of non-pharmacological antidepressant treatment. Additionally, we developed an individualized diagnosing and therapeutic effect predicting model to realize early recognition of subclinical depression and provide objective suggestions to select non-pharmacological therapy by using the newly proposed Hierarchical Functional Brain Network (HFBN) with advanced deep learning algorithms within the transformer framework.

Results

Neuroimaging responses to non-pharmacologic treatments are characterized by alterations in functional connectivity (FC) and shifts in brain network connectivity patterns, particularly within the sub-DMN. At baseline, significantly increased FC was observed between the sub-DMN and both Executive Control Network (ECN) and Dorsal Attention Network (DAN). Following six weeks of non-pharmacologic intervention, connectivity patterns primarily shifted within the sub-DMN and ECN, with a predominant decrease in FCs. The HFBN model demonstrated superior performance over traditional deep learning models, accurately predicting therapeutic outcomes and diagnosing subclinical depression, achieving cumulative scores of 80.47% for sleep quality prediction and 84.67% for depression prediction, along with an overall diagnostic accuracy of 82.34%.

Conclusions

Two-scale neuroimaging signatures related to the sub-DMN underlying the antidepressant mechanisms of non-pharmacological treatments for subclinical depression. The HFBN model exhibited supreme capability in early diagnosing and predicting non-pharmacological treatment outcomes for subclinical depression, thereby promoting objective clinical psychological treatment decision-making.

Comparative Side-Effects of Neurosurgical Treatment of Treatment-Resistant Depression

INTRODUCTION

Treatment-resistant depression (TRD) is a condition in which patients suffering from depression no longer respond to common methods of treatment, such as anti-depressant medication. Neurosurgical procedures such as ablative surgery, deep brain stimulation, and vagus nerve stimulation have been used in efforts to overcome TRD.

OBJECTIVES

This review aims to provide an overview of the side effects of neurosurgery performed in clinical studies related to depression.

METHODS

A literature search was conducted through PubMed, MEDLINE, EMBASE, Ovid, and ClinicalTrials.gov databases.

RESULTS

This review selected 10 studies for ablative surgery, 12 for deep brain stimulation, and 10 for vagus nerve stimulation, analyzing their side effect profiles of neurosurgery for TRD. The major side effects of each type of neurosurgery were identified, such as incontinence and confusion for ablative surgery, headaches and increased suicide ideation for deep brain stimulation, and voice hoarseness and dyspnea for vagus nerve stimulation.

CONCLUSION

The review discusses the merits and demerits of neurosurgery as a treatment option for TRD. It also suggests new insights into decreasing the burden of these neurosurgical side effects so that they can be a viable, high-efficacy treatment method for TRD.

The role of psilocybin in depressive disorders

Depression is a serious psychiatric disorder with a high incidence of morbidity and mortality and psilocybin with psychotherapy has emerged as a promising potential in the treatment of depressive disorders. A review of psilocybin use in patients with depressive disorders is presented.A search was conducted investigating the use of psilocybin in patients with depressive disorders and treatment resistant depression via PubMed/MEDLINE, EMBASE, and Google Scholar in October 2023; all publication types were permitted and limited for English-language. Keyword search terms included: "psilocybin" or "psychedelics" and "depression", or "major depressive disorder", or "treatment-resistant depression". Controlled and uncontrolled clinical trials utilizing psilocybin with psychological support for major depressive disorder and treatment-resistant depression, as well as in patients with depression and cancer related anxiety have demonstrated immediate and sustained antidepressant and anxiolytic effects. Psilocybin has a favorable safety profile and was well-tolerated in clinical trials. Psilocybin's abuse potential is low and clinical research suggests the potential of psilocybin to produce rapid and lasting antidepressant effects up to 12 months post-treatment. Psilocybin may offer a valuable contribution as an option to the currently available pharmacological and psychotherapeutic agents for patients with major depressive disorders, treatment-resistant depression as well as for patients with depression and comorbid terminal cancer. Future studies are needed to demonstrate these findings and any synergistic interaction between psilocybin and the psychological support offered to patients during sessions.

Current Perspectives on the Clinical Research and Medicalization of Psychedelic Drugs for Addiction Treatments: Safety, Efficacy, Limitations and Challenges

Mental health disorders and substance use disorders (SUDs) in particular, contribute greatly to the global burden of disease. Psychedelics, including entactogens and dissociative substances, are currently being explored for the treatment of SUDs, yet with less empirical clinical evidence than for other mental health disorders, such as depression or post-traumatic stress disorder (PTSD). In this narrative review, we discuss the current clinical research evidence, therapeutic potential and safety of psilocybin, lysergic acid diethylamide (LSD), ketamine, 3,4-methylenedioxymethamphetamine (MDMA) and ibogaine, particularly in the context of the SUD treatment. Our aim was to provide a balanced overview of the current research and findings on potential benefits and harms of psychedelics in clinical settings for SUD treatment. We highlight the need for more clinical research in this particular treatment area and point out some limitations and challenges to be addressed in future research.

SAL0114: a novel deuterated dextromethorphan-bupropion combination with improved antidepressant efficacy and safety profile

Background

Esketamine, the first Food and Drug Administration-approved fast-acting antidepressant, has limited use because of its addictive properties. Although the combination of dextromethorphan and bupropion partially addresses the limitations of esketamine, concerns remain regarding neurologic side effects related to dextromethorphan metabolites, and seizure risks associated with high-dose bupropion. SAL0114, a novel formulation combining deuterated dextromethorphan (in which hydrogen atoms are replaced with deuterium) with bupropion, seeks to enhance dextromethorphan stability through deuteration of its metabolic sites. This approach is expected to increase antidepressant efficacy, reduce metabolite-induced safety issues, and allow for lower bupropion dosages.

Methods

Radioligand competition binding assays were used to evaluate the impact of deuterium substitution on the in vitro activity of dextromethorphan and its metabolite, dextrorphan. In vitro hepatic microsomal stability and in vivo mouse pharmacokinetic assays were performed to assess the effects of deuteration on dextromethorphan stability. Two mouse models of behavioral despair were used to determine the antidepressant and synergistic effects of deuterated dextromethorphan and bupropion. Additionally, a reserpine-induced hypothermia rat model and an ammonia-induced cough mouse model were used to assess the in vivo effects from a pathological perspective.

Results

Deuterated dextromethorphan maintained the same in vitro activity as dextromethorphan while exhibiting twice the metabolic stability both in vitro and in vivo. Combination with bupropion further improved its in vivo stability, increasing the exposure by 2.4 times. The combination demonstrated efficacy and synergistic effects in all tested animal models, showing superior efficacy compared with the dextromethorphan-bupropion combination.

Conclusion

Deuteration improved dextromethorphan metabolic stability without altering its in vitro activity. Bupropion enhanced this stability and synergistically boosted the antidepressant effect by increasing deuterated dextromethorphan exposure in vivo. This enhanced metabolic stability suggests a reduction in dextromethorphan metabolites associated with clinical neurological side effects. Consequently, SAL0114 is hypothesized to offer improved efficacy and safety compared with the non-deuterated combination, potentially allowing for lower bupropion dosages. Further clinical studies are required to confirm these preclinical findings.

Therapeutic Protocols Using Ketamine and Esketamine for Depressive Disorders: A Systematic Review

Depression is one of the most prevalent mental health disorders globally, causing severe emotional suffering, reducing life expectancy and increasing the risk of suicide. Recently, the use of dissociative psychedelic substances such as ketamine and esketamine for depressive disorders has expanded treatment options. We sought to analyze, through a systematic review, the existing protocols for the treatment of depression with ketamine and esketamine. The search adopted PRISMA criteria and was performed using PubMed and Web of Science databases. Procedures in each study were compared, focusing on the sample recruited, therapeutic approaches, including the clinical team and professionals engaged in treatment, medical procedures, description of the setting (including music) and factors such as specific medication (ketamine or esketamine), route of administration and dosage employed. Results indicated the predominance of a medical approach, with a limited number of studies on ketamine assisted psychotherapy (KAP) and other modalities of psychedelic assisted therapy. Additionally, there is limited information on psychosocial elements such as preparation, psychological support during session and integration of experience. Altogether these findings suggest that treatment of depression with ketamine or esketamine diverges in relation to the practices employed with psychedelic substances. This is discussed considering future research directions in the field.

Understanding profiles of patients with treatment-resistant depression by stringency of health plan prior authorization criteria for approval of esketamine nasal spray

OBJECTIVES

In the United States (US), prescription drug coverage is subject to prior authorization (PA) criteria, which may vary between health plans and may exceed drug label requirements. This study aimed to characterize profiles and treatment history of patients with treatment-resistant depression (TRD) who initiated esketamine nasal spray, by stringency of their health plans' PA criteria relative to the esketamine label.

METHODS

Adults with evidence of TRD (≥2 antidepressant courses of adequate dose and duration) prior to initiating esketamine were identified using US insurance claims data (03/2016-02/2022). Based on health plan PA criteria for esketamine obtained from Managed Markets Insight & Technology data (05/2020-02/2022), patients were grouped into stringent (PA criteria exceeds label) and non-stringent (PA criteria less stringent or equal to label) cohorts. Patient treatment history before esketamine initiation was compared using Wilcoxon rank sum and Fisher's exact tests.

RESULTS

The stringent cohort included 168 patients (mean age: 45 years, 63% female) and the non-stringent cohort included 400 patients (mean age: 45 years, 70% female). During the ongoing major depressive episode before esketamine initiation, the stringent versus non-stringent cohort completed 3.9 versus 3.8 antidepressant treatment courses, on average (p = 0.217); 94.6% versus 96.8% used augmentation therapy (p = 0.240), including 59.3% versus 58.1% with an antipsychotic (p = 0.844), respectively.

CONCLUSIONS

Regardless of health plan stringency, on average, patients exceeded US label-mandated number of antidepressant trials before esketamine initiation, which questions the need for health insurance plans PA criteria above label.

Chronic ecologically relevant stress effects on reverse-translated touchscreen assays of reward responsivity and attentional processes in male rats: Implications for depression

Stagnation in the development of novel therapeutic strategies for treatment-resistant depression has encouraged continued interest in improving preclinical methods. One tactic prioritizes the reverse translation of behavioral tasks developed to objectively quantify depressive phenotypes in patient populations for their use in laboratory animals via touchscreen technology. After cross-species concordance in task outcomes under healthy conditions is confirmed, construct validity can be further enhanced by identifying environmental stressors that reliably produce deficits in task performance that resemble those in depressive participants. The present studies characterized in male rats the ability of two chronic ecologically relevant stressors, inescapable ice water or isolated restraint, to produce depressive-like behavioral phenotypes in the Probabilistic Reward Task (PRT) and Psychomotor Vigilance Task (PVT). These tasks previously have been reverse-translated using touchscreen technology for rodents and nonhuman primates to objectively quantify, respectively, reward responsivity (anhedonia) and attentional processes (impaired cognitive function), each of which are core features of major depressive disorder. In the PRT, both inescapable ice water and isolated restraint produced persistent anhedonic phenotypes compared to non-stressed control performance (i.e., significantly blunted response bias for the richly rewarded stimulus). In the PVT, both chronic stressors impaired attentional processing, revealed by increases in titrated reaction times; however, these deficits largely subsided by the end of the chronic condition. Taken together, these findings confirm the ability of reverse-translated touchscreen tasks to effectively generate behavioral phenotypes that exhibit expected deficits in performance outcomes following exposure to chronic ecologically relevant stress. In turn, this approach is well positioned to appraise the ability of candidate therapeutics to attenuate or reverse such behavioral deficits and, thereby, contribute to preclinical medications development for treatment-resistant depression.

A systematic review and meta-analysis of the preclinical and clinical results of low-field magnetic stimulation in cognitive disorders

Cognitive disorders such as major depressive disorder and bipolar disorder severely compromise brain function and neuronal activity. Treatments to restore cognitive abilities can have severe side effects due to their intense and excitatory nature, in addition to the fact that they are expensive and invasive. Low-field magnetic stimulation (LFMS) is a novel non-invasive proposed treatment for cognitive disorders. It repairs issues in the brain by altering deep cortical areas with treatments of low-intensity magnetic stimulation. This paper aims to summarize the current literature on the effects and results of LFMS in cognitive disorders. We developed a search strategy to identify relevant studies utilizing LFMS and systematically searched eight scientific databases. Our review suggests that LFMS could be a viable and effective treatment for multiple cognitive disorders, especially major depressive disorder. Additionally, longer, more frequent, and more personalized LFMS treatments tend to be more efficacious.

Challenges and prospects in bridging precision medicine and artificial intelligence in genomic psychiatric treatment

Precision medicine is transforming psychiatric treatment by tailoring personalized healthcare interventions based on clinical, genetic, environmental, and lifestyle factors to optimize medication management. This study investigates how artificial intelligence (AI) and machine learning (ML) can address key challenges in integrating pharmacogenomics (PGx) into psychiatric care. In this integration, AI analyzes vast genomic datasets to identify genetic markers linked to psychiatric conditions. AI-driven models integrating genomic, clinical, and demographic data demonstrated high accuracy in predicting treatment outcomes for major depressive disorder and bipolar disorder. This study also examines the pressing challenges and provides strategic directions for integrating AI and ML in genomic psychiatry, highlighting the importance of ethical considerations and the need for personalized treatment. Effective implementation of AI-driven clinical decision support systems within electronic health records is crucial for translating PGx into routine psychiatric care. Future research should focus on developing enhanced AI-driven predictive models, privacy-preserving data exchange, and robust informatics systems to optimize patient outcomes and advance precision medicine in psychiatry.

Unlocking new avenues for neuropsychiatric disease therapy: the emerging potential of Peroxisome proliferator-activated receptors as promising therapeutic targets

RATIONALE

Peroxisome proliferator-activated receptors (PPARs) are transcription factors that regulate various physiological processes such as inflammation, lipid metabolism, and glucose homeostasis. Recent studies suggest that targeting PPARs could be beneficial in treating neuropsychiatric disorders by modulating neuronal function and signaling pathways in the brain. PPAR-α, PPAR-δ, and PPAR-γ have been found to play important roles in cognitive function, neuroinflammation, and neuroprotection. Dysregulation of PPARs has been associated with neuropsychiatric disorders like bipolar disorder, schizophrenia, major depression disorder, and autism spectrum disorder. The limitations and side effects of current treatments have prompted research to target PPARs as a promising novel therapeutic strategy. Preclinical and clinical studies have shown the potential of PPAR agonists and antagonists to improve symptoms associated with these disorders.

OBJECTIVE

This review aims to provide an overview of the current understanding of PPARs in neuropsychiatric disorders, their potential as therapeutic targets, and the challenges and future directions for developing PPAR-based therapies.

METHODS

An extensive literature review of various search engines like PubMed, Medline, Bentham, Scopus, and EMBASE (Elsevier) databases was carried out with the keywords "PPAR, Neuropsychiatric disorders, Oxidative stress, Inflammation, Bipolar Disorder, Schizophrenia, Major depression disorder, Autism spectrum disorder, molecular pathway".

RESULT & CONCLUSION

Although PPARs present a hopeful direction for innovative therapeutic approaches in neuropsychiatric conditions, additional research is required to address obstacles and convert this potential into clinically viable and individualized treatments.

Depression-reminiscent Behavior Induced by Chronic Unpredictable Mild Stress Paradigm in Mice Substantially Abrogated by Diosmin

Background:

Diosmin has already been described and documented to be neuroprotective, antioxidant and anti-inflammatory. It may possess or hold depressionalleviating activity. Therefore, the purpose of the current research protocol is to investigate the depression-relieving proficiency of diosmin in stressed and unstressed mice.

Methods:

Male mice (Swiss albino) were imperiled to an unpredictable chronic stress paradigm every day for three sequential weeks, and depression-resembling behavioral despair was induced. Imipramine 15 mg/kg and diosmin (25, 50 and 100 mg/kg) were dispensed for 21 successive days to discrete groups of stressed and unstressed mice.

Results:

Both diosmin (100 mg/kg) and 15 mg/kg imipramine administration for 3 consecutive weeks substantially or significantly diminished the immobility period of mice imperiled to stress in comparison to stressed mice gauzed with the vehicle. Diosmin (25, 50 and 100 mg/kg) and imipramine considerably reinstated the diminished sucrose proclivity (sucrose preference percentage; %) in stressed mice, demonstrating their considerable or substantial depression-relieving effects. The locomotor activities of mice were not considerably altered by these drugs. Antidepressant-like activity of diosmin for immobility periods and preference for sucrose was observed to be analogous to imipramine. Diosmin (100 mg/kg) and imipramine substantially quashed CUMS- persuaded escalation of plasma corticosterone and nitrite levels, malondialdehyde levels and MAO-A activity in the brain of stressed mice. Both drugs also substantially reversed CUMS-prompted reduction in catalase activity and brain glutathione levels.

Conclusion:

Accordingly, diosmin revealed significant anti-depressive activity in mice imperiled to chronic mild unpredictable stress paradigm conceivably via mitigation of nitrosative and oxidative stress, reticence of brain MAO-A action, and sink drop of plasma corticosterone degrees.

New insights about the antidepressant-like effects of riparin A in a chronic murine model of depression

Riparin A is a synthetic form of natural riparins. Acute scale studies that take into consideration the structure-activity relationship have shown preliminary evidence of antidepressant and anxiolytic effects of riparin A, similar to that already known for other riparins. However, for better pharmacological characterization of this new compound, further studies are required. The aim of this work was to evaluate the effect of chronic treatment with riparin A (10 mg/kg; intraperitoneally) on depressive-like behavior in the forced swimming test and tail suspension test, as well as the reduction of anhedonia in the sucrose preference test, and on anxiety-like behavior in the open field and elevated plus maze apparatus, triggered in rats previously subjected to unpredictable chronic mild stress by 4 weeks. In addition, a pentobarbital-induced sleep time test was also used. Riparin A reduced the duration of immobility in both the forced swimming test and tail suspension test, as well as attenuated the anhedonia in the sucrose preference test. Furthermore, riparin A appears to produce anxiolytic effects in rats exposed to an open field and elevated plus maze, while increasing the alertness/vigilance in rats submitted to pentobarbital-induced sleep time test, without altering their locomotor integrity. Our results suggest that chronic riparin A appears to be a potential pharmacological target for new studies on the control of depression- and anxiety-like behaviors in stressed rats.

Enhancing Major Depressive Disorder Diagnosis With Dynamic-Static Fusion Graph Neural Networks

Major Depressive Disorder (MDD) is a debilitating, complex mental condition with unclear mechanisms hindering diagnostic progress. Research links MDD to abnormal brain connectivity using functional magnetic resonance imaging (fMRI). Yet, existing fMRI-based MDD models suffer from limitations, including neglecting dynamic network traits, lacking interpretability, and struggling with small datasets. We present DSFGNN, a novel graph neural network framework addressing these issues for improved MDD diagnosis. DSFGNN employs a graph isomorphism encoder to model static and dynamic brain networks, achieving effective fusion of temporal and spatial information through a spatiotemporal attention mechanism, thereby enhancing interpretability. Furthermore, we incorporate a causal disentangling module and orthogonal regularization module to augment the model's expressiveness. We evaluate DSFGNN on the Rest-meta-MDD dataset, yielding superior results compared to the best baseline. Besides, extensive ablation studies and interpretability analysis confirm DSFGNN's effectiveness and potential for biomarker discovery.

Depression clinical trials worldwide: a systematic analysis of the ICTRP and comparison with ClinicalTrials.gov

Major depressive disorder (MDD), commonly known as depression, affects over 300 million people worldwide as of 2018 and presents a wide range of clinical symptoms. The international clinical trials registry platform (ICTRP) introduced by WHO includes aggregated data from ClinicalTrials.gov and 17 other national registers, making it the largest clinical trial platform. Here we analysed data in ICTRP with the aim of providing comprehensive insights into clinical trials on depression. Applying a novel hidden duplicate identification method, 10,606 depression trials were identified in ICTRP, with ANZCTR being the largest non- ClinicalTrials.gov database at 1031 trials, followed by IRCT with 576 trials, ISRCTN with 501 trials, CHiCTR with 489 trials, and EUCTR with 351 trials. The top four most studied drugs, ketamine, sertraline, duloxetine, and fluoxetine, were consistent in both groups, but ClinicalTrials.gov had more trials for each drug compared to the non-ClinicalTrials.gov group. Out of 9229 interventional trials, 663 unique agents were identified, including approved drugs (74.5%), investigational drugs (23.2%), withdrawn drugs (1.8%), nutraceuticals (0.3%), and illicit substances (0.2%). Both ClinicalTrials.gov and non-ClinicalTrials.gov databases revealed that the largest categories were antidepressive agents (1172 in ClinicalTrials.gov and 659 in non-ClinicalTrials.gov) and nutrients, amino acids, and chemical elements (250 in ClinicalTrials.gov and 659 in non-ClinicalTrials.gov), indicating a focus on alternative treatments involving dietary supplements and nutrients. Additionally, 26 investigational antidepressive agents targeting 16 different drug targets were identified, with buprenorphine (opioid agonist), saredutant (NK2 antagonist), and seltorexant (OX2 antagonist) being the most frequently studied. This analysis addresses 40 approved drugs for depression treatment including new drug classes like GABA modulators and NMDA antagonists that are offering new prospects for treating MDD, including drug-resistant depression and postpartum depression subtypes.

Major challenges in youth psychopathology: treatment-resistant depression. A narrative review

Major depressive disorder (MDD) represents a major health issue in adolescents and young adults, leading to high levels of disability and profoundly impacting overall functioning. The clinical presentation of MDD in this vulnerable age group may slightly differ from what can be observed in adult populations, and psychopharmacological strategies do not always lead to optimal response. Resistance to antidepressant treatment has a prevalence estimated around 40% in youths suffering from MDD and is associated with higher comorbidity rates and suicidality. Several factors, encompassing biological, environmental, and clinical features, may contribute to the emergence of treatment-resistant depression (TRD) in adolescents and young adults. Furthermore, TRD may underpin the presence of an unrecognized bipolar diathesis, increasing the overall complexity of the clinical picture and posing major differential diagnosis challenges in the clinical practice. After summarizing current evidence on epidemiological and clinical correlates of TRD in adolescents and young adults, the present review also provides an overview of possible treatment strategies, including novel fast-acting antidepressants. Despite these pharmacological agents are promising in this population, their usage is expected to rely on risk-benefit ratio and to be considered in the context of integrated models of care.

Online mindfulness-based cognitive therapy for treatment-resistant depression: a parallel-arm randomized controlled feasibility trial

Introduction

Treatment-resistant depression (TRD) presents a significant challenge, affecting approximately 30% of individuals diagnosed with major depressive disorder and leading to poor treatment responses. Innovations in digital mental health, especially online mindfulness-based cognitive therapy (eMBCT), offer promising avenues for enhancing access to effective mental health care for individuals with TRD in a clinical setting.

Objective

The aim of this study was to examine the feasibility of eMBCT in an individual clinical context to decrease depressive symptoms for TRD.

Methods

Conducted at the Institute of Psychiatry of the Federal University of Rio de Janeiro, Brazil, this parallel-arm, randomized controlled feasibility trial involved outpatients diagnosed with TRD, aged 18 and above. Of the 39 outpatients invited, 28 were randomized into two groups: an intervention group receiving the eMBCT program (n = 15) and a control group (n = 13). The intervention, consisting of an 8-week course, was delivered via live video sessions. Following the assessment period, participants in the control group were offered the eMBCT intervention. Assessments using standardized questionnaires were conducted at the start and end of the study.

Results

Within the eMBCT group, improvements were observed in depression symptoms (Z = -3.423; p = 0.001; effect size r = 0.78), anxiety symptoms (Z = -3.361; p = 0.001; effect size r = 0.77), with no significant changes in the control group. Comparatively, the eMBCT group showed significant reductions in depression symptoms and improvements in clinical global impressions over the control group (BDI2: U = 30.5; p = 0.015; effect size r = 0.47, CGI1: U = 21.0; p = 0.004; effect size r = 0.56).

Conclusion

eMBCT in an individual format combined with medication, appears to be a feasible treatment for TRD, decreasing symptoms of depression. In a future trial the control group may have a manualized intervention.

Clinical trial registration

The Brazilian Clinical Trials Registry: (https://ensaiosclinicos.gov.br/rg/RBR-6zndpbv) and RBR-6zndpbv.

Vitamin-mediated interaction between the gut microbiome and mitochondria in depression: A systematic review-based integrated perspective

Depression is one of the world's most prevalent mental disorders and its treatment remains suboptimal. Depression is a systemic disease with highly complex biological mechanisms. Emerging evidence points towards the involvement of mitochondria, microbiome and vitamins in its pathophysiology. Mitochondrial energy production was shown to be lowered in patients with depression. Mitochondrial energy production depends on vitamins, which are available from food, but are also synthesized by the gut microbiota. Several studies reported altered vitamin levels as well as changes in the gut microbiome composition and its vitamin metabolism in patients with depression. Therefore, the question of a connection between mitochondria and gut microbiome and vitamins influencing the mental health arises. This review aims to systematically investigate a combination of the topics - depression, mitochondria, microbiome, and vitamins - to generate an overview of a novel yet extremely complex and interconnected research field. A systematic literature search yielded 34 articles, and the results were summarized and bundled to develop this new integrative perspective on mitochondrial function mediated by the microbiome and microbiome-derived vitamins in depression. Furthermore, by discussing the research gaps this review aims to encourage innovative research approaches to better understand the biology of depression, which could result in optimized therapeutic approaches.

Longitudinal Outcomes of Resilience, Quality of Life, and Community Integration in Treatment-Resistant Depression: A Two-Group Matched Controlled Trial

BACKGROUND

Current evidence of nonpharmacological intervention for patients with treatment-resistant depression (TRD) is lacking. AIMS: To examine whether an 8-week nurse-led cognitive-behavioral based group intervention would enhance resilient coping and life quality among community-based patients with TRD.

METHOD

The participants were randomly sampled from a cohort of TRD recruited from two general teaching hospitals. The two groups were assessed with multiple outcome measures at baseline (T0); 8-week post-baseline (T1); and at 3, 6, and 9 months after T1 (T2-4). Psychoeducation was nested in the cognitive behavioral group intervention to facilitate discussion.

RESULTS

Of the 23 participants (mean age 56 years, 69.6% female) in the experimental group, higher resilient coping and lower mental distress levels at T1 as well as later improved quality of life and community integration at T2-4 were observed compared to the controls across COVID-19 (T3). Overall, the scores of resilience and community integration were higher throughout the four follow-up points of observations for the experimental group.

CONCLUSION

The findings indicated that an 8-week nurse-led cognitive-behavioral based group intervention may enhance the TRD patients' resilient coping and mental distress levels while providing the potentials for community reintegration after mental health psychoeducation engagement. It is imperative for the nurses caring for patients with TRD to extend from clinical-based intervention to community-based self-care approach, with the importance of short-term stress management and healthy lifestyle development highlighted during the community reintegration trajectory.