Emotional Blunting in Patients With Major Depressive Disorder: A Brief Non-systematic Review of Current Research

Perspectives on the impact of vortioxetine on the treatment armamentarium of major depressive disorder

INTRODUCTION

Major Depressive Disorder (MDD) is a mental health issue that significantly affects patients' quality of life and functioning. Despite available treatments, many patients continue to suffer due to incomplete symptom resolution and side effects.

AREAS COVERED

This manuscript examines Vortioxetine's role in Major Depressive Disorder (MDD) treatment, highlighting its potential to reshape therapeutic strategies due to its unique Multimodal action and proven broad-spectrum efficacy in multiple depressive domains. A detailed examination of Vortioxetine's pharmacological aspects, including indications, dosage, pharmacodynamics, and pharmacokinetics, is provided, emphasizing its safety and effectiveness. The discussion extends to Vortioxetine's role in acute-phase treatment and maintenance of MDD and its profound impact on specialized depression domains.

EXPERT OPINION

Vortioxetine is distinguished for its novel multimodal serotonin modulation mechanism, showcasing significant promise as an innovative treatment for MDD. Its efficacy, which is dose-dependent, along with a commendable tolerability profile, positions it as a potential leading option for initial treatment strategies. The discourse on dosage titration, particularly the strategy of initiating treatment at lower doses followed by gradual escalation, underscores the approach toward minimizing initial adverse effects while optimizing therapeutic outcomes, aligning with the principles of personalized medicine in psychiatric care.

Development of a multivariate prediction model for antidepressant resistant depression using reward-related predictors

Introduction

Individuals with depression who do not respond to two or more courses of serotonergic antidepressants tend to have greater deficits in reward processing and greater internalizing symptoms, yet there is no validated self-report method to determine the likelihood of treatment resistance based on these symptom dimensions.

Methods

This online case-control study leverages machine learning techniques to identify differences in self-reported anhedonia and internalizing symptom profiles of antidepressant non-responders compared to responders and healthy controls, as an initial proof-of-concept for relating these indicators to medication responsiveness. Random forest classifiers were used to identify a subset from a set of 24 reward predictors that distinguished among serotonergic medication resistant, non-resistant, and non-depressed individuals recruited online (N = 393). Feature selection was implemented to refine model prediction and improve interpretability.

Results

Accuracies for full predictor models ranged from .54 to .71, while feature selected models retained 3-5 predictors and generated accuracies of .42 to .70. Several models performed significantly above chance. Sensitivity for non-responders was greatest after feature selection when compared to only responders, reaching .82 with 3 predictors. The predictors retained from feature selection were then explored using factor analysis at the item level and cluster analysis of the full data to determine empirically driven data structures.

Discussion

Non-responders displayed 3 distinct symptom profiles along internalizing dimensions of anxiety, anhedonia, motivation, and cognitive function. Results should be replicated in a prospective cohort sample for predictive validity; however, this study demonstrates validity for using a limited anhedonia and internalizing self-report instrument for distinguishing between antidepressant resistant and responsive depression profiles.

Multimodal Mental Health Digital Biomarker Analysis From Remote Interviews Using Facial, Vocal, Linguistic, and Cardiovascular Patterns

OBJECTIVE

Psychiatric evaluation suffers from subjectivity and bias, and is hard to scale due to intensive professional training requirements. In this work, we investigated whether behavioral and physiological signals, extracted from tele-video interviews, differ in individuals with psychiatric disorders.

METHODS

Temporal variations in facial expression, vocal expression, linguistic expression, and cardiovascular modulation were extracted from simultaneously recorded audio and video of remote interviews. Averages, standard deviations, and Markovian process-derived statistics of these features were computed from 73 subjects. Four binary classification tasks were defined: detecting 1) any clinically-diagnosed psychiatric disorder, 2) major depressive disorder, 3) self-rated depression, and 4) self-rated anxiety. Each modality was evaluated individually and in combination.

RESULTS

Statistically significant feature differences were found between psychiatric and control subjects. Correlations were found between features and self-rated depression and anxiety scores. Heart rate dynamics provided the best unimodal performance with areas under the receiver-operator curve (AUROCs) of 0.68-0.75 (depending on the classification task). Combining multiple modalities provided AUROCs of 0.72-0.82.

CONCLUSION

Multimodal features extracted from remote interviews revealed informative characteristics of clinically diagnosed and self-rated mental health status.

SIGNIFICANCE

The proposed multimodal approach has the potential to facilitate scalable, remote, and low-cost assessment for low-burden automated mental health services.

A Delphi consensus on clinical features, diagnosis and treatment of major depressive disorder patients with anhedonia amongst psychiatrists in the Asia-Pacific

Background

Anhedonia, a core diagnostic feature for major depressive disorder (MDD), is defined as the loss of pleasure and interest in daily activities. Its prevalence in MDD patients vary from 35 to 70%. Anhedonia in MDD negatively impacts functioning and is associated with treatment resistance and poorer prognosis for various clinical outcomes. Owing to its complexity, there remains considerable heterogeneity in the conceptualization, diagnosis and clinical management of anhedonia in MDD.

Methods

This modified Delphi panel was conducted to elicit expert opinion and establish consensus on concepts relating to clinical features, diagnosis and treatment of MDD with anhedonia (MDDwA) amongst psychiatrists in the Asia-Pacific region. Seven themes were covered. A three-stage process was adopted for consensus generation (two online survey rounds, followed by a moderated consensus meeting). Statements were developed based on a literature review and input from a steering committee of six regional experts. The panel included 12 psychiatrists practicing in Australia, China, Hong Kong, Japan, South Korea and Taiwan with ≥5 years of specialist clinical experience, including assessment or management of patients with MDDwA.

Results

Overall, consensus was achieved (median ≥8) on 89/103 statements (86%). About half of the statements (55/103, 53%) achieved consensus in Round 1, and 29/36 modified statements achieved consensus in Round 2. At the moderated consensus meeting, five modified statements were discussed by the steering committee and consensus was achieved on all statements (5/5). The findings highlighted a lack of clear and practical methods in clinical practice for assessing anhedonia in MDD patients and limited physician awareness of anhedonia in Asia-Pacific.

Conclusion

Insights from this Delphi consensus provide a reference point for psychiatrists in Asia-Pacific to optimize their strategies for personalized diagnosis and management of patients with MDDwA. Identification of distinct and clinically relevant subtypes in MDD may be valuable for guiding personalized diagnosis and management approaches, including type-specific therapies.

Efficacy of functional magnetic resonance imaging-guided personalized repetitive transcranial magnetic stimulation (fMRI-rTMS) in depressive patients with emotional blunting: study protocol for a randomized controlled trial

BACKGROUND

Emotional blunting is a symptom that has always been present in depressed patients. Repetitive transcranial magnetic stimulation (rTMS) is a safe and effective supplementary therapy for treating depression. However, the effectiveness and brain imaging processes of functional magnetic resonance imaging-guided personalized rTMS (fMRI-rTMS) in the treatment of depression with emotional blunting have not been observed in randomized controlled trials.

METHODS

This study is a randomized, controlled, double-blind, and single-center clinical trial in which 80 eligible depressed patients with emotional blunting will be randomly assigned to two groups: a functional magnetic resonance imaging-guided personalized rTMS (fMRI-rTMS) group and a control group. Individuals in the fMRI-rTMS group (n = 40) will receive high-frequency rTMS (10 Hz, 120% MT). The main target of stimulation will be the area most relevant to the functional connectivity of the right medial prefrontal cortex (mPFC) and amygdala. The control group (n = 40) will receive sham stimulation, with a coil flipped to 90 degrees relative to the vertical scalp. All patients will receive 15 consecutive days of treatment, with each session lasting half an hour per day, followed by 8 weeks of follow-up. The primary outcome is the comparison of Oxford Depression Questionnaire (ODQ) scores between these two groups at different time points. The secondary outcomes include evaluating other clinical scales and assessing the differences in brain imaging changes between the two groups before and after treatment.

DISCUSSION

This trial aims to examine the effects of functional magnetic resonance imaging-guided personalized rTMS (fMRI-rTMS) intervention on depressed patients experiencing emotional blunting and to elucidate the potential mechanism behind it. The results will provide new evidence for using fMRI-rTMS in treating depression with emotional blunting in the future.

TRIAL REGISTRATION

ClinicalTrials.gov INCT05555940. Registered on 13 September 2022 at http://clinicaltrials.gov .

Negative emotionality downregulation affects moral choice but not moral judgement of harm: a pharmacological study

Previous neuroscientific research has expounded on the fundamental role played by emotion during moral decision-making. Negative emotionality has been observed to exert a general inhibitory effect towards harmful behaviors against others. Nevertheless, the downregulation of negative affects at different levels of moral processing (e.g. impersonal versus personal moral dilemmas) alongside its possible interactions with other factors (e.g. perspective taking) hasn't been directly assessed; both of which can assist in predicting future moral decision-making. In the present research, we empirically test (Study 1, N = 41) whether downregulating negative emotionality through pharmacological interventions using lorazepam (a GABA receptor agonist), modulate the permissibility of harm to others -i.e. if participants find it more morally permissible to harm others when harm is unavoidable (inevitable harm moral dilemmas), than when it may be avoided (evitable harm moral dilemmas). Furthermore, using another sample (Study 2, N = 31), we assess whether lorazepam's effect is modulated by different perspective-taking conditions during a moral dilemma task -e.g. "is it morally permissible for you to […]?" (1st person perspective), relative to "is it morally permissible for [x individual] to […]?" (3rd person perspective)-, where the outcome of the different scenarios is controlled. The results of both studies converge, revealing an emotion-dependent, rather than an outcome-dependent, pharmacological modulation. Lorazepam only influenced interpersonal moral judgments when not modulated by the evitable/inevitable condition. Furthermore, there was a significant interaction between perspective-taking and drug administration, as lorazepam exerted a larger effect in modulating moral choices rather than moral judgements.

Adverse Childhood Experiences and Depression among Homeless Young Adults: A Social Determinants of Health Perspective

Homelessness is a pervasive issue in the United States that presents significant challenges to public health. Homeless young adults (HYAs) are at particular risk for increased incidence and severity of depression. Using primary survey data (n = 205) collected in the Phoenix Metropolitan Area, Arizona, from June to August 2022, this study aims to examine the relationship between adverse childhood experiences (ACEs) and depression among HYAs. We adopted the ACEs 10-item scale to measure childhood traumatic experiences, whereas depression was measured by using a PHQ-4 depression scale and diagnosed depression. Regression models were conducted to test the relationships between ACEs and depression outcomes while controlling for the covariates at the individual, interpersonal, and socioeconomic/living environment levels. The average PHQ-4 score was 5.01 (SD = 3.59), and 59.69% of HYAs reported being diagnosed previously with depression. The mean ACEs score was 5.22 out of 10. Other things being equal, for every one unit increase in ACEs scores, the odds of being diagnosed with depression increased by 11.5%, yet it was not statistically significant, while the PHQ-4 score increased by 0.445 (p < 0.001). Overall, HYAs were disproportionately affected by depression. This study elucidates the complex relationship between ACEs and depression among HYAs.

The antidepressant drugs vortioxetine and duloxetine differentially and sex-dependently affect animal well-being, cognitive performance, cardiac redox status and histology in a model of osteoarthritis

Osteoarthritis represents a leading cause of disability with limited treatment options. Furthermore, it is frequently accompanied by cardiovascular and cognitive disorders, which can be exacerbated by osteoarthritis or drugs used for its treatment. Here, we examined the behavioral and cardiac effects of the novel antidepressant vortioxetine in an osteoarthritis model, and compared them to duloxetine (an established osteoarthritis treatment). Osteoarthritis was induced in male and female rats with an intraarticular sodium-monoiodoacetate injection. Antidepressants were orally administered for 28 days following induction. During this period the acetone, burrowing and novel-object-recognition tests (NORT) were used to assess the effects of antidepressants on pain hypersensitivity (cold allodynia), animal well-being and cognitive performance, respectively. Following behavioral experiments, heart muscles were collected for assessment of redox status/histology. Antidepressant treatment dose-dependently reduced cold allodynia in rats with osteoarthritis. Duloxetine (but not vortioxetine) depressed burrowing behavior in osteoarthritic rats in a dose-related manner. Osteoarthritis induction reduced cognitive performance in NORT, which was dose-dependently alleviated by vortioxetine (duloxetine improved performance only in female rats). Furthermore, duloxetine (but not vortioxetine) increased oxidative stress parameters in the heart muscles of female (but not male) rats and induced histological changes in cardiomyocytes indicative of oxidative damage. Vortioxetine displayed comparable efficacy to duloxetine in reducing pain hypersensitivity. Furthermore, vortioxetine (unlike duloxetine) dose-dependently improved cognitive performance and had no adverse effect on burrowing behavior (animal surrogate of well-being) and cardiac redox status/histology. Our results indicate that vortioxetine could be a potential osteoarthritis treatment (with better characteristics compared to duloxetine).

Multimodal mental health assessment with remote interviews using facial, vocal, linguistic, and cardiovascular patterns

Objective

The current clinical practice of psychiatric evaluation suffers from subjectivity and bias, and requires highly skilled professionals that are often unavailable or unaffordable. Objective digital biomarkers have shown the potential to address these issues. In this work, we investigated whether behavioral and physiological signals, extracted from remote interviews, provided complimentary information for assessing psychiatric disorders.

Methods

Time series of multimodal features were derived from four conceptual modes: facial expression, vocal expression, linguistic expression, and cardiovascular modulation. The features were extracted from simultaneously recorded audio and video of remote interviews using task-specific and foundation models. Averages, standard deviations, and hidden Markov model-derived statistics of these features were computed from 73 subjects. Four binary classification tasks were defined: detecting 1) any clinically-diagnosed psychiatric disorder, 2) major depressive disorder, 3) self-rated depression, and 4) self-rated anxiety. Each modality was evaluated individually and in combination.

Results

Statistically significant feature differences were found between controls and subjects with mental health conditions. Correlations were found between features and self-rated depression and anxiety scores. Visual heart rate dynamics achieved the best unimodal performance with areas under the receiver-operator curve (AUROCs) of 0.68-0.75 (depending on the classification task). Combining multiple modalities achieved AUROCs of 0.72-0.82. Features from task-specific models outperformed features from foundation models.

Conclusion

Multimodal features extracted from remote interviews revealed informative characteristics of clinically diagnosed and self-rated mental health status.

Significance

The proposed multimodal approach has the potential to facilitate objective, remote, and low-cost assessment for low-burden automated mental health services.

Individuals with and without child maltreatment experiences are evaluated similarly and do not differ in facial affect display at zero- and first-acquaintance

BACKGROUND

Individuals with a history of child maltreatment (CM) are more often disliked, rejected and victimized compared to individuals without such experiences. However, contributing factors for these negative evaluations are so far unknown.

OBJECTIVE

Based on previous research on adults with borderline personality disorder (BPD), this preregistered study assessed whether negative evaluations of adults with CM experiences, in comparison to unexposed controls, are mediated by more negative and less positive facial affect display. Additionally, it was explored whether level of depression, severity of CM, social anxiety, social support, and rejection sensitivity have an influence on ratings.

METHODS

Forty adults with CM experiences (CM +) and 40 non-maltreated (CM-) adults were filmed for measurement of affect display and rated in likeability, trustworthiness, and cooperativeness by 100 independent raters after zero-acquaintance (no interaction) and 17 raters after first-acquaintance (short conversation).

RESULTS

The CM + and the CM- group were neither evaluated significantly different, nor showed significant differences in affect display. Contrasting previous research, higher levels of BPD symptoms predicted higher likeability ratings (p = .046), while complex post-traumatic stress disorder symptoms had no influence on ratings.

CONCLUSIONS

The non-significant effects could be attributed to an insufficient number of participants, as our sample size allowed us to detect effects with medium effect sizes (f² = .16 for evaluation; f² = .17 for affect display) with a power of .95. Moreover, aspects such as the presence of mental disorders (e.g., BPD or post-traumatic stress disorder), might have a stronger impact than CM per se. Future research should thus further explore conditions (e.g., presence of specific mental disorders) under which individuals with CM are affected by negative evaluations as well as factors that contribute to negative evaluations and problems in social relationships.

Can antidepressant use be associated with emotional blunting in a subset of patients with depression? A scoping review of available literature

INTRODUCTION

Despite frequent recognition of emotional blunting in the published literature, either as a primary symptom of depression or as an adverse effect of antidepressants, there is no systematic synthesis on this topic to our knowledge. We undertook this scoping review to assess the prevalence, clinical features, implicated causes and management of emotional blunting, outlining the phenomenological and clinical gaps in research.

METHOD

A systematic search was done until March 15, 2022, to include all original studies (i.e., interventional trials, cohort & cross-sectional studies, case reports, and case series). All reviewed data were delineated to answer pertinent clinical, phenomenological, and management questions related to the phenomenon of emotional blunting.

RESULTS

A total of 25 original studies were included in our scoping review. Emotional blunting was described as a persistent diminution in both positive and negative feelings in depressed patients, who could subjectively differentiate it from their acute symptoms. However, the literature lacked the distinction between emotional blunting as a primary symptom of depression or an adverse effect of antidepressants. Common clinical strategies to manage antidepressant-induced emotional blunting included dose reduction or switching to a different antidepressant.

CONCLUSION

Emotional blunting was a significant patient-reported concern with antidepressants. Future research should clarify phenomenological and neurobiological constructs underlying emotional blunting to improve diagnostic and management skills.

Considerations when selecting an antidepressant: a narrative review for primary care providers treating adults with depression

Major depressive disorder (MDD) is a debilitating mental disorder that can be treated with a number of different antidepressant therapies, each with its own unique prescribing considerations. Complicating the selection of an appropriate antidepressant for adults with MDD is the heterogeneity of clinical profiles and depression subtypes. Additionally, patient comorbidities, preferences, and likelihood of adhering to treatment must all be considered when selecting an appropriate therapy. With the majority of prescriptions being written by primary care practitioners, it is appropriate to review the unique characteristics of all available antidepressants, including safety considerations. Prior to initiating antidepressant treatment and when patients do not respond adequately to initial therapy and/or exhibit any hypomanic or manic symptoms, bipolar disorder must be ruled out, and evaluation for psychiatric comorbidities must be considered as well. Patients with an inadequate response may then require a treatment switch to another drug with a different mechanism of action, combination, or augmentation strategy. In this narrative review, we propose that careful selection of the most appropriate antidepressant for adult patients with MDD based on their clinical profile and comorbidities is vital for initial treatment selection.Strategies must be considered for addressing partial and inadequate responses as well to help patients achieve full remission and sustained functional recovery. This review also highlights data for MDD clinical outcomes for which gaps in the literature have been identified, including the effects of antidepressants on functional outcomes, sleep disturbances, emotional and cognitive blunting, anxiety, and residual symptoms of depression.

Distinguishing apathy from depression: A review differentiating the behavioral, neuroanatomic, and treatment-related aspects of apathy from depression in neurocognitive disorders

OBJECTIVES

This narrative review describes the clinical features of apathy and depression in individuals with neurocognitive disorders (NCDs), with the goal of differentiating the two syndromes on the basis of clinical presentation, diagnostic criteria, neuropathological features, and contrasting responses to treatments.

METHODS

Literature was identified using PubMed, with search terms to capture medical conditions of interest; additional references were also included based on our collective experience and knowledge of the literature.

RESULTS

Evidence from current literature supports the distinction between the two disorders; apathy and depression occur with varying prevalence in individuals with NCDs, pose different risks of progression to dementia, and have distinct, if overlapping, neurobiological underpinnings. Although apathy is a distinct neuropsychiatric syndrome, distinguishing apathy from depression can be challenging, as both conditions may occur concurrently and share several overlapping features. Apathy is associated with unfavorable outcomes, especially those with neurodegenerative etiologies (e.g., Alzheimer's disease) and is associated with an increased burden for both patients and caregivers. Diagnosing apathy is important not only to serve as the basis for appropriate treatment, but also for the development of novel targeted interventions for this condition. Although there are currently no approved pharmacologic treatments for apathy, the research described in this review supports apathy as a distinct neuropsychiatric condition that warrants specific treatments aimed at alleviating patient disability.

CONCLUSIONS

Despite differences between these disorders, both apathy and depression pose significant challenges to patients, their families, and caregivers; better diagnostics are needed to develop more tailored treatment and support.

VGF: A prospective biomarker and therapeutic target for neuroendocrine and nervous system disorders

Neuroendocrine regulatory polypeptide VGF (nerve growth factor inducible) was firstly found in the rapid induction of nerve growth factor on PC12 cells. It was selectively distributed in neurons and many neuroendocrine tissues. This paper reviewed the latest literatures on the gene structure, transcriptional regulation, protein processing, distribution and potential receptors of VGF. The neuroendocrine roles of VGF and its derived polypeptides in regulating energy, water electrolyte balance, circadian rhythm and reproductive activities were also summarized. Furthermore, based on the experimental evidence in vivo and in vitro, dysregulation of VGF in different neuroendocrine diseases and the possible mechanism mediated by VGF polypeptides were discussed. We next discussed the potential as the clinical diagnosis and therapy for VGF related diseases in the future.