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Jamieson C, Canuso CM, Ionescu DF, Lane R, Qiu X, Rozjabek H, Molero P, Fu DJ. Effects of esketamine on patient-reported outcomes in major depressive disorder with active suicidal ideation and intent: a pooled analysis of two randomized phase 3 trials (ASPIRE I and ASPIRE II). Qual Life Res 2023; 32:3053-3061. [PMID: 37439961 PMCID: PMC10522733 DOI: 10.1007/s11136-023-03451-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE To assess the effect of esketamine nasal spray on patient-reported outcomes (PROs) in patients with major depressive disorder having active suicidal ideation with intent (MDSI). METHODS Patient-level data from two phase 3 studies (ASPIRE I; ASPIRE II) of esketamine + standard of care (SOC) in patients (aged 18-64 years) with MDSI, were pooled. PROs were evaluated from baseline through end of the double-blind treatment phase (day 25). Outcome assessments included: Beck Hopelessness Scale (BHS), Quality of Life (QoL) in Depression Scale (QLDS), European QoL Group-5-Dimension-5-Level (EQ-5D-5L), and 9-item Treatment Satisfaction Questionnaire for Medication (TSQM-9). Changes in BHS and QLDS scores (baseline to day 25) were analyzed using a mixed-effects model for repeated measures (MMRM). RESULTS Pooled data for esketamine + SOC (n = 226; mean age: 40.5 years, 59.3% females) and placebo + SOC (n = 225; mean age: 39.6 years, 62.2% females) were analyzed. Mean ± SD change from baseline to day 25, esketamine + SOC vs placebo + SOC (least-square mean difference [95% CI] based on MMRM): BHS total score, - 7.4 ± 6.7 vs - 6.8 ± 6.5 [- 1.0 (- 2.23, 0.21)]; QLDS score, - 14.4 ± 11.5 vs - 12.2 ± 10.8 [- 3.1 (- 5.21, - 1.02)]. Relative risk (95% CI) of reporting perceived problems (slight to extreme) in EQ-5D-5L dimensions (day 25) in esketamine + SOC vs placebo + SOC: mobility [0.78 (0.50, 1.20)], self-care [0.83 (0.55, 1.27)], usual activities [0.87 (0.72, 1.05)], pain/discomfort [0.85 (0.69, 1.04)], and anxiety/depression [0.90 (0.80, 1.00)]. Mean ± SD changes from baseline in esketamine + SOC vs placebo + SOC for health status index: 0.23 ± 0.21 vs 0.19 ± 0.22; and for EQ-Visual Analogue Scale: 24.0 ± 27.2 vs 19.3 ± 24.4. At day 25, mean ± SD in domains of TSQM-9 scores in esketamine + SOC vs placebo + SOC were: effectiveness, 67.2 ± 25.3 vs 56.2 ± 26.8; global satisfaction, 69.9 ± 25.2 vs 56.3 ± 27.8; and convenience, 74.0 ± 19.4 vs 75.4 ± 18.7. CONCLUSION These PRO data support the patient perspective of the effect associated with esketamine + SOC in improving health-related QoL in patients with MDSI. TRIAL REGISTRATION ClinicalTrials.gov Identifier: ASPIRE I, NCT03039192 (Registration date: February 1, 2017); ASPIRE II, NCT03097133 (Registration date: March 31, 2017).
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Affiliation(s)
| | - Carla M Canuso
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | | | - Rosanne Lane
- Janssen Research & Development, LLC, Titusville, NJ, USA
| | - Xin Qiu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | | | - Patricio Molero
- Department of Psychiatry, Clinica Universidad de Navarra, Pamplona, Spain
| | - Dong-Jing Fu
- Janssen Research & Development, LLC, Titusville, NJ, USA
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Feeney A, Hoeppner BB, Freeman MP, Flynn M, Iosifescu DV, Trivedi MH, Sanacora G, Mathew SJ, DeBattista C, Ionescu DF, Cusin C, Papakostas GI, Jha MK, Fava M. Effect of Concomitant Benzodiazepines on the Antidepressant Effects of Ketamine: Findings From the RAPID Intravenous Ketamine Study. J Clin Psychiatry 2022; 84. [PMID: 36383742 DOI: 10.4088/jcp.22m14491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Ketamine is a novel and rapidly acting treatment for major depressive disorder (MDD). Benzodiazepines are commonly coprescribed with antidepressants in MDD. This study sought to examine data from a randomized clinical trial that compared a single infusion of intravenous (IV) ketamine to midazolam placebo in treatment-resistant depression (DSM-IV-TR MDD) and to assess whether the use of concomitant oral benzodiazepines differentially affected treatment response to ketamine versus midazolam. Methods: This trial ran from December 2015 to December 2016. Subjects who were taking oral benzodiazepines (n = 44) were compared to those who were not (n = 55). A significant treatment-by-benzodiazepine effect could be interpreted as a possible moderator of differential treatment response to ketamine versus midazolam. Benzodiazepine use was examined as both a binary and a continuous predictor, to assess the impact of dosage. Results: Benzodiazepine users did not differ from non-users on the original study's primary outcome measure, score on the 6-item Hamilton Depression Rating Scale (HDRS-6), at baseline, but the former had more severe anxiety. When oral benzodiazepine use was modeled as a binary predictor, benzodiazepine use did not impact differential treatment response. However, when benzodiazepine dosage was considered, there was a significant impact of benzodiazepine use on differential treatment response. Oral benzodiazepines significantly impacted HDRS-6 (P = .018) and Clinical Global Impressions-Severity of Illness scale (CGI-S; P = .008) scores at day 1 (24 hours post treatment); effects were nonsignificant for all day 3 outcomes. Among ketamine subjects, higher doses of benzodiazepines were associated with less improvement in depression scores at day 1. Conclusions: Concomitant oral benzodiazepines at higher doses may attenuate the antidepressant effects of IV ketamine at day 1 but not day 3 post-infusion. Trial Registration: ClinicalTrials.gov identifier: NCT01920555.
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Affiliation(s)
- Anna Feeney
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Corresponding author: Anna Feeney, MD, Clinical Trials Network and Institute, Massachusetts General Hospital, One Bowdoin Sq, 9th Floor, Boston, MA 02114
| | - Bettina B Hoeppner
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Marlene P Freeman
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Center for Women's Mental Health, Massachusetts General Hospital, Boston, Massachusetts
| | - Martina Flynn
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Dan V Iosifescu
- Clinical Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, New York.,Department of Psychiatry, New York University School of Medicine, New York, New York
| | - Madhukar H Trivedi
- Center for Depression Research and Clinical Care, UT Southwestern Medical Center, Dallas, Texas
| | | | - Sanjay J Mathew
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, Texas.,Michael E. Debakey VA Medical Center Mental Health Care Line, Houston, Texas
| | | | | | - Cristina Cusin
- Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - George I Papakostas
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Manish K Jha
- Center for Depression Research and Clinical Care, UT Southwestern Medical Center, Dallas, Texas
| | - Maurizio Fava
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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3
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Daly EJ, Turkoz I, Salvadore G, Fedgchin M, Ionescu DF, Starr HL, Borentain S, Trivedi MH, Thase ME, Singh JB. The effect of esketamine in patients with treatment-resistant depression with and without comorbid anxiety symptoms or disorder. Depress Anxiety 2021; 38:1120-1130. [PMID: 34293233 PMCID: PMC9291524 DOI: 10.1002/da.23193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/23/2021] [Accepted: 06/11/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Comorbid anxiety is generally associated with poorer response to antidepressant treatment. This post hoc analysis explored the efficacy of esketamine plus an antidepressant in patients with treatment-resistant depression (TRD) with or without comorbid anxiety. METHODS TRANSFORM-2, a double-blind, flexible-dose, 4-week study (NCT02418585), randomized adults with TRD to placebo or esketamine nasal spray, each with a newly-initiated oral antidepressant. Comorbid anxiety was defined as clinically noteworthy anxiety symptoms (7-item Generalized Anxiety Disorder scale [GAD-7] score ≥10) at screening and baseline or comorbid anxiety disorder diagnosis at screening. Treatment effect based on change in Montgomery-Åsberg Depression Rating Scale (MADRS) total score, and response and remission were examined by presence/absence of comorbid anxiety using analysis of covariance and logistic regression models. RESULTS Approximately 72% (162/223) of patients had baseline comorbid anxiety. Esketamine-treated patients with and without anxiety demonstrated significant reductions in MADRS (mean [SD] change from baseline at day 28: -21.0 [12.51] and -22.7 [11.98], respectively). Higher rates of response and remission, and a significantly greater decrease in MADRS score at day 28 were observed compared to antidepressant/placebo, regardless of comorbid anxiety (with anxiety: difference in LS means [95% CI] -4.2 [-8.1, -0.3]; without anxiety: -7.5 [-13.7, -1.3]). There was no significant interaction of treatment and comorbid anxiety (p = .371). Notably, in the antidepressant/placebo group improvement was similar in those with and without comorbid anxiety. CONCLUSION Post hoc data support efficacy of esketamine plus an oral antidepressant in patients with TRD, regardless of comorbid anxiety.
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Affiliation(s)
- Ella J. Daly
- Department of Neuroscience Medical AffairsJanssen Scientific Affairs, LLCTitusvilleNew JerseyUSA
| | - Ibrahim Turkoz
- Department of Statistics & Decision SciencesJanssen Research & Development, LLCTitusvilleNew JerseyUSA
| | - Giacomo Salvadore
- Department of NeuroscienceJanssen Research & Development, LLCTitusvilleNew JerseyUSA
| | - Maggie Fedgchin
- Department of NeuroscienceJanssen Research & Development, LLCTitusvilleNew JerseyUSA
| | - Dawn F. Ionescu
- Department of NeuroscienceJanssen Research & Development, LLCSan DiegoCaliforniaUSA
| | - H. Lynn Starr
- Department of Neuroscience Medical AffairsJanssen Scientific Affairs, LLCTitusvilleNew JerseyUSA
| | - Stephane Borentain
- Department of Neuroscience Medical AffairsJanssen Scientific Affairs, LLCTitusvilleNew JerseyUSA
| | - Madhukar H. Trivedi
- Department of PsychiatryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of MedicineUniversity of Pennsylvania and the Corporal Michael J. Crescenz VAMCPhiladelphiaPennsylvaniaUSA
| | - Jaskaran B. Singh
- Department of NeuroscienceJanssen Research & Development, LLCSan DiegoCaliforniaUSA
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Canuso CM, Ionescu DF, Li X, Qiu X, Lane R, Turkoz I, Nash AI, Lopena TJ, Fu DJ. Esketamine Nasal Spray for the Rapid Reduction of Depressive Symptoms in Major Depressive Disorder With Acute Suicidal Ideation or Behavior. J Clin Psychopharmacol 2021; 41:516-524. [PMID: 34412104 PMCID: PMC8407443 DOI: 10.1097/jcp.0000000000001465] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/30/2021] [Accepted: 05/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Numerous health authority approvals of esketamine nasal spray, combined with oral antidepressant, to treat depressive symptoms in adults with major depressive disorder and acute suicidal ideation or behavior were based on 2 identically designed, double-blind, phase 3 studies. METHODS/PROCEDURES Across both ASPIRE studies (NCT03039192, NCT03097133), patients (N = 456) were randomized to esketamine 84 mg or placebo nasal spray twice weekly for 4 weeks plus comprehensive standard of care, including hospitalization and newly initiated or optimized antidepressant(s). In post hoc analyses of pooled data, changes from baseline at 24 hours after the first dose in Montgomery-Åsberg Depression Rating Scale total score and Clinical Global Impression-Severity of Suicidality-Revised, in the full cohort and in subgroups, were analyzed using analysis of covariance. FINDINGS/RESULTS Esketamine plus standard of care demonstrated significantly greater improvement in Montgomery-Åsberg Depression Rating Scale total score versus placebo plus standard of care at 24 hours (least square mean difference [95% confidence interval], -3.8 [-5.75 to -1.89]) and at earlier (4 hours: -3.4 [-5.05 to -1.71]) and later time points (day 25: -3.4 [-5.36 to -1.36]). The between-group difference (95% confidence interval) for change in Clinical Global Impression-Severity of Suicidality-Revised at 24 hours was -0.20 (-0.43 to 0.04) for all patients and -0.31 (-0.61 to -0.01) for those with a history of suicide attempt. Common adverse events (≥20%) during esketamine treatment were dizziness, dissociation, nausea, somnolence, and headache. IMPLICATIONS/CONCLUSIONS Esketamine plus comprehensive standard of care rapidly reduces depressive symptoms in patients with major depressive disorder who have acute suicidal ideation or behavior, especially in those with a history of suicide attempt, providing a new treatment option for this particularly ill and vulnerable population.
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Affiliation(s)
- Carla M. Canuso
- From the Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ
| | - Dawn F. Ionescu
- Department of Neuroscience, Janssen Research & Development, LLC, San Diego, CA
| | - Xiang Li
- Department of Clinical Statistics, Janssen Research & Development, LLC, Raritan, NJ
| | - Xin Qiu
- Department of Clinical Statistics, Janssen Research & Development, LLC, Raritan, NJ
| | - Rosanne Lane
- Department of Clinical Statistics, Janssen Research & Development, LLC, Raritan, NJ
| | - Ibrahim Turkoz
- Department of Clinical Statistics, Janssen Research & Development, LLC, Raritan, NJ
| | | | - Tricia J. Lopena
- Medical Information, Janssen Scientific Affairs, LLC, Titusville, NJ
| | - Dong-Jing Fu
- From the Department of Neuroscience, Janssen Research & Development, LLC, Titusville, NJ
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5
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Feeney A, Hock RS, Freeman MP, Flynn M, Hoeppner B, Iosifescu DV, Trivedi MH, Sanacora G, Mathew SJ, Debattista C, Ionescu DF, Fava M, Papakostas GI. The effect of single administration of intravenous ketamine augmentation on suicidal ideation in treatment-resistant unipolar depression: Results from a randomized double-blind study. Eur Neuropsychopharmacol 2021; 49:122-132. [PMID: 34090255 PMCID: PMC8338746 DOI: 10.1016/j.euroneuro.2021.04.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/26/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022]
Abstract
This study aimed to assess the effect of a single infusion of intravenous (IV) ketamine on suicidal ideation in patients with treatment-resistant depression (TRD). Patients with TRD were randomized in a double-blind fashion to a single infusion of IV ketamine or IV midazolam placebo. Suicidal ideation was measured using the Montgomery-Asberg Depression Rating Scale (MADRS) suicide item at 3, 5, 7, 14 and 30 days post infusion. Clinically significant suicidal ideation was defined as a MADRS suicide item score ≥2. Forty patients who received IV ketamine and 16 who received IV midazolam had suicide item scores of ≥2 at baseline (IV ketamine group mean 2.90±0.74; IV midazolam group 2.69±0.70). The mean suicide scores of these groups differed significantly from each other on day 30; the IV ketamine group had a lower mean score than controls (2.03±1.59 vs. 3.00±1.41, t-test p = 0.049; Hedges' g 0.71). Among patients with a suicide score of ≥2 at baseline and <2 at day 3, the two groups did not differ significantly on mean scores changes at days 3, 5, 7, 14 or 30. Recurrence of suicidal ideation was extensive in both treatment groups. A single infusion of IV ketamine may reduce suicidal ideation in TRD out to 30 days post infusion, but early anti-suicidal effects appear to diminish rapidly. This post-hoc analysis was not powered to compare different doses of ketamine. A single infusion of IV ketamine might have a role as an adjunct to standard treatments in patients with TRD and suicidal ideation. Trial registration: NCT01920555.
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Affiliation(s)
- Anna Feeney
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Rebecca S Hock
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Marlene P Freeman
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Center for Women's Mental Health, Massachusetts General Hospital, Boston, MA
| | - Martina Flynn
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Bettina Hoeppner
- Psychiatry Department, Massachusetts General Hospital, Boston, MA
| | - Dan V Iosifescu
- Clinical Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, NY; Department of Psychiatry, New York University School of Medicine, New York, NY
| | - Madhukar H Trivedi
- Department of Psychiatry and Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Sanjay J Mathew
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX; Michael E. Debakey VA Medical Center Mental Health Care Line, Houston, TX
| | | | | | - Maurizio Fava
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - George I Papakostas
- Clinical Trials Network and Institute, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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6
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Wilcox M, McGee BA, Ionescu DF, Leonte M, LaCross L, Reps J, Wildenhaus K. Perinatal depressive symptoms often start in the prenatal rather than postpartum period: results from a longitudinal study. Arch Womens Ment Health 2021; 24:119-131. [PMID: 32016551 PMCID: PMC7929945 DOI: 10.1007/s00737-020-01017-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/02/2020] [Indexed: 11/21/2022]
Abstract
Depressive symptoms during and after pregnancy confer risks for adverse outcomes in both the mother and child. Postpartum depression is traditionally diagnosed after birth of the child. Perinatal depression is a serious, prevalent heterogeneous syndrome that can occur during the period from conception through several months after childbirth. Onset and course are not well understood. There is a paucity of longitudinal studies of the disorder that include the antenatal period in population-based samples. We used an Internet panel of pregnant women recruited in 2 cohorts; 858 ascertained in the first and 322 ascertained in the third trimesters of pregnancy. We recruited the second cohort in order to assure sufficient sample to examine depressive symptoms later in pregnancy and in the postpartum period. Assessments included standard psychometric measures, health history, and pregnancy experience. The Edinburgh Postnatal Depression Scale was used for the assessment of depressive symptoms. Nearly 10% of women entered the pregnancy with depressive symptoms. Prevalence was about the same at 4 weeks and 3 months postpartum. During pregnancy, prevalence increased to 16% in the third trimester. Among incident cases, 80% occurred during pregnancy, with 1/3 occurring in the first trimester. We describe predictors of incident depressive symptoms and covariates associated with time-to-onset which include health history (psychiatric and medical) and social support covariates. The majority of incident depressive symptoms occur during pregnancy rather than afterward. This finding underscores the mandate for mental health screening early in pregnancy and throughout gestation. It will be important to find safe and effective interventions that prevent, mitigate, or delay the onset of depressive symptoms that can be implemented during pregnancy.
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Affiliation(s)
- Marsha Wilcox
- Janssen Research & Development, Titusville, NJ, USA.
| | | | | | | | | | - Jenna Reps
- Janssen Research & Development, Titusville, NJ, USA
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Sydnor VJ, Lyall AE, Cetin-Karayumak S, Cheung JC, Felicione JM, Akeju O, Shenton ME, Deckersbach T, Ionescu DF, Pasternak O, Cusin C, Kubicki M. Studying pre-treatment and ketamine-induced changes in white matter microstructure in the context of ketamine's antidepressant effects. Transl Psychiatry 2020; 10:432. [PMID: 33319774 PMCID: PMC7738670 DOI: 10.1038/s41398-020-01122-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/23/2020] [Accepted: 11/16/2020] [Indexed: 12/28/2022] Open
Abstract
Ketamine is increasingly being used as a therapeutic for treatment-resistant depression (TRD), yet the effects of ketamine on the human brain remain largely unknown. This pilot study employed diffusion magnetic resonance imaging (dMRI) to examine relationships between ketamine treatment and white matter (WM) microstructure, with the aim of increasing the current understanding of ketamine's neural mechanisms of action in humans. Longitudinal dMRI data were acquired from 13 individuals with TRD two hours prior to (pre-infusion), and four hours following (post-infusion), an intravenous ketamine infusion. Free-water imaging was employed to quantify cerebrospinal fluid-corrected mean fractional anisotropy (FA) in 15 WM bundles pre- and post-infusion. Analyses revealed that higher pre-infusion FA in the left cingulum bundle and the left superior longitudinal fasciculus was associated with greater depression symptom improvement 24 h post-ketamine. Moreover, four hours after intravenous administration of ketamine, FA rapidly increased in numerous WM bundles in the brain; this increase was significantly associated with 24 h symptom improvement in select bundles. Overall, the results of this preliminary study suggest that WM properties, as measured by dMRI, may have a potential impact on clinical improvement following ketamine. Ketamine administration additionally appears to be associated with rapid WM diffusivity changes, suggestive of rapid changes in WM microstructure. This study thus points to pre-treatment WM structure as a potential factor associated with ketamine's clinical efficacy, and to post-treatment microstructural changes as a candidate neuroimaging marker of ketamine's cellular mechanisms.
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Affiliation(s)
- Valerie J. Sydnor
- Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Amanda E. Lyall
- Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Suheyla Cetin-Karayumak
- Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Joey C. Cheung
- grid.32224.350000 0004 0386 9924Depression Clinical and Research Program (DCRP), Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Julia M. Felicione
- grid.32224.350000 0004 0386 9924Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Boston, MA USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Martha E. Shenton
- Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,grid.410370.10000 0004 4657 1992VA Boston Healthcare System, Brockton Division, Brockton, MA USA
| | - Thilo Deckersbach
- grid.32224.350000 0004 0386 9924Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Dawn F. Ionescu
- grid.32224.350000 0004 0386 9924Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924Depression Clinical and Research Program (DCRP), Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Ofer Pasternak
- Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Cristina Cusin
- grid.32224.350000 0004 0386 9924Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA ,grid.32224.350000 0004 0386 9924Depression Clinical and Research Program (DCRP), Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Marek Kubicki
- Psychiatry Neuroimaging Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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8
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Ionescu DF, Fu DJ, Qiu X, Lane R, Lim P, Kasper S, Hough D, Drevets WC, Manji H, Canuso CM. Esketamine Nasal Spray for Rapid Reduction of Depressive Symptoms in Patients With Major Depressive Disorder Who Have Active Suicide Ideation With Intent: Results of a Phase 3, Double-Blind, Randomized Study (ASPIRE II). Int J Neuropsychopharmacol 2020; 24:22-31. [PMID: 32861217 PMCID: PMC7816667 DOI: 10.1093/ijnp/pyaa068] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/10/2020] [Accepted: 08/26/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Patients with major depressive disorder (MDD) having active suicidal ideation with intent require immediate treatment. METHODS This double-blind study (ASPIRE II) randomized adults (aged 18-64 years) with MDD having active suicidal ideation with intent to esketamine 84 mg or placebo nasal spray twice weekly for 4 weeks, given with comprehensive standard of care (hospitalization ≥5 days and newly initiated or optimized oral antidepressant[s]). Change from baseline to 24 hours post-first dose in Montgomery-Asberg Depression Rating Scale total score (primary efficacy endpoint) was analyzed using ANCOVA. Clinical Global Impression-Severity of Suicidality-revised (key secondary endpoint) was analyzed using ANCOVA on ranks of change. RESULTS Of 230 patients who were randomized (115 per arm), 227 received study drug and were included in efficacy/safety analyses; 184 (80.0%) completed double-blind treatment. Greater improvement in Montgomery-Asberg Depression Rating Scale total score was observed with esketamine (mean [SD]: -15.7 [11.56]) vs placebo (-12.4 [10.43]), each with standard of care, at 24 hours (least-squares mean difference [SE]: -3.9 [1.39], 95% CI: -6.60, -1.11; 2-sided P = .006). This was also noted at the earlier (4-hour) timepoint (least-squares mean difference -4.2, 95% CI: -6.38, -1.94). Patients in both treatment groups experienced rapid reduction in Clinical Global Impression-Severity of Suicidality-revised score; the between-group difference was not statistically significant. The most common adverse events among esketamine-treated patients were dizziness, dissociation, nausea, dysgeusia, somnolence, headache, and paresthesia. CONCLUSION This study confirmed rapid and robust reduction of depressive symptoms with esketamine nasal spray in severely ill patients with MDD who have active suicidal ideation with intent. Trial Registration: Clinical Trials.gov identifier: NCT03097133.
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Affiliation(s)
- Dawn F Ionescu
- Department of Neuroscience, Janssen Research and Development, LLC, San Diego, CA,Correspondence: Dawn Ionescu, MD, Senior Director, Neuroscience Clinical Development, Janssen Research and Development, LLC, 3210 Merryfield Row, San Diego, CA 92121 ()
| | - Dong-Jing Fu
- Department of Neuroscience, Janssen Research and Development, LLC, Titusville, NJ
| | - Xin Qiu
- Department of Statistics, Janssen Research and Development, LLC, Raritan, NJ
| | - Rosanne Lane
- Department of Statistics, Janssen Research and Development, LLC, Titusville, NJ
| | - Pilar Lim
- Department of Statistics, Janssen Research and Development, LLC, Titusville, NJ
| | - Siegfried Kasper
- Center of Brain Research, Medical University of Vienna, Vienna, Austria
| | - David Hough
- Department of Neuroscience, Janssen Research and Development, LLC, Titusville, NJ
| | - Wayne C Drevets
- Department of Neuroscience, Janssen Research and Development, LLC, San Diego, CA
| | - Husseini Manji
- Department of Neuroscience, Janssen Research and Development, LLC, Titusville, NJ
| | - Carla M Canuso
- Department of Neuroscience, Janssen Research and Development, LLC, Titusville, NJ
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9
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Fu DJ, Ionescu DF, Li X, Lane R, Lim P, Sanacora G, Hough D, Manji H, Drevets WC, Canuso CM. Esketamine Nasal Spray for Rapid Reduction of Major Depressive Disorder Symptoms in Patients Who Have Active Suicidal Ideation With Intent: Double-Blind, Randomized Study (ASPIRE I). J Clin Psychiatry 2020; 81. [PMID: 32412700 DOI: 10.4088/jcp.19m13191] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/14/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare esketamine to placebo, each in addition to standard-of-care treatment, for rapidly reducing major depressive disorder symptoms, including suicidal ideation. METHODS This phase 3, double-blind, multicenter study (ASPIRE I), conducted between June 2017 and December 2018, enrolled 226 adults having major depressive disorder based on Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) criteria, active suicidal ideation with intent, and need for psychiatric hospitalization. Patients were randomized 1:1 to esketamine 84 mg or placebo nasal spray twice-weekly for 4 weeks, each with comprehensive standard-of-care treatment (initial psychiatric hospitalization and newly initiated or optimized oral antidepressant[s] therapy). Change from baseline to 24 hours post-first dose in Montgomery-Asberg Depression Rating Scale (MADRS) total score (primary endpoint) was analyzed using analysis of covariance (ANCOVA), and change in Clinical Global Impression of Severity of Suicidality Revised version (CGI-SS-r; key secondary endpoint) score was analyzed using ANCOVA on ranks with treatment difference estimated using the Hodges-Lehmann estimate. RESULTS Greater improvement in MADRS total score was observed with esketamine + standard-of-care versus placebo + standard-of-care at 24 hours (least-squares mean difference [SE]: -3.8 [1.39]; 95% CI, -6.56 to -1.09; 2-sided P = .006), as well as at earlier (4 hours) and later time points during 4-week double-blind treatment. The difference between groups in the severity of suicidality was not statistically significant (median of treatment difference [95% CI]: 0.0 [-1.00 to 0.00]; 2-sided P = .107). The most common adverse events among esketamine-treated patients were dizziness, dissociation, headache, nausea, and somnolence. CONCLUSIONS These findings demonstrate rapid and robust efficacy of esketamine nasal spray in reducing depressive symptoms in severely ill patients with major depressive disorder who have active suicidal ideation with intent. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03039192.
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Affiliation(s)
- Dong-Jing Fu
- Director, Neuroscience Clinical Development, Janssen Research and Development, LLC, 1125 Trenton-Harbourton Rd, Titusville, NJ 08560. .,Neuroscience Clinical Development, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Dawn F Ionescu
- Neuroscience Clinical Development, Janssen Research & Development, LLC, San Diego, California, USA
| | - Xiang Li
- Department of Quantitative Sciences, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Rosanne Lane
- Department of Quantitative Sciences, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Pilar Lim
- Department of Quantitative Sciences, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Gerard Sanacora
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - David Hough
- Neuroscience Clinical Development, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Husseini Manji
- Neuroscience Clinical Development, Janssen Research & Development, LLC, Titusville, New Jersey, USA
| | - Wayne C Drevets
- Neuroscience Clinical Development, Janssen Research & Development, LLC, San Diego, California, USA
| | - Carla M Canuso
- Neuroscience Clinical Development, Janssen Research & Development, LLC, Titusville, New Jersey, USA
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10
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Fava M, Freeman MP, Flynn M, Judge H, Hoeppner BB, Cusin C, Ionescu DF, Mathew SJ, Chang LC, Iosifescu DV, Murrough J, Debattista C, Schatzberg AF, Trivedi MH, Jha MK, Sanacora G, Wilkinson ST, Papakostas GI. Correction: Double-blind, placebo-controlled, dose-ranging trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD). Mol Psychiatry 2020; 25:1604. [PMID: 30617276 PMCID: PMC8329695 DOI: 10.1038/s41380-018-0311-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Supplementary Figure 1 and Supplementary Tables 1-4 have been re-uploaded so as to reflect the versions supplied during proofs stage. The publisher apologizes for the error in versioning. The HTML version of the paper has been updated.
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Affiliation(s)
| | - Marlene P. Freeman
- 0000 0004 0386 9924grid.32224.35Massachusetts General Hospital, Boston, MA USA
| | - Martina Flynn
- 0000 0004 0386 9924grid.32224.35Massachusetts General Hospital, Boston, MA USA
| | - Heidi Judge
- 0000 0004 0386 9924grid.32224.35Massachusetts General Hospital, Boston, MA USA
| | - Bettina B. Hoeppner
- 0000 0004 0386 9924grid.32224.35Massachusetts General Hospital, Boston, MA USA
| | - Cristina Cusin
- 0000 0004 0386 9924grid.32224.35Massachusetts General Hospital, Boston, MA USA
| | - Dawn F. Ionescu
- 0000 0004 0386 9924grid.32224.35Massachusetts General Hospital, Boston, MA USA
| | - Sanjay J. Mathew
- 0000 0001 2160 926Xgrid.39382.33Baylor College of Medicine/Michael E. Debakey VA Medical Center, Houston, TX USA
| | - Lee C. Chang
- 0000 0001 2160 926Xgrid.39382.33Baylor College of Medicine/Michael E. Debakey VA Medical Center, Houston, TX USA
| | - Dan V. Iosifescu
- 0000 0001 0670 2351grid.59734.3cIcahn School of Medicine at Mount Sinai, New York, NY USA
| | - James Murrough
- 0000 0001 0670 2351grid.59734.3cIcahn School of Medicine at Mount Sinai, New York, NY USA
| | - Charles Debattista
- 0000000419368956grid.168010.eStanford University School of Medicine, Stanford, CA USA
| | - Alan F. Schatzberg
- 0000000419368956grid.168010.eStanford University School of Medicine, Stanford, CA USA
| | - Madhukar H. Trivedi
- 0000 0000 9482 7121grid.267313.2University of Texas Southwestern, Dallas, TX USA
| | - Manish K. Jha
- 0000 0000 9482 7121grid.267313.2University of Texas Southwestern, Dallas, TX USA
| | - Gerard Sanacora
- 0000000419368710grid.47100.32Yale University, New Haven, CT USA
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11
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Salloum NC, Fava M, Hock RS, Freeman MP, Flynn M, Hoeppner B, Cusin C, Iosifescu DV, Trivedi MH, Sanacora G, Mathew SJ, Debattista C, Ionescu DF, Papakostas GI. Time to relapse after a single administration of intravenous ketamine augmentation in unipolar treatment-resistant depression. J Affect Disord 2020; 260:131-139. [PMID: 31494365 PMCID: PMC6803106 DOI: 10.1016/j.jad.2019.09.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/27/2019] [Accepted: 09/02/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To examine the rate and time to relapse for remitters and responders to ketamine in treatment-resistant depression (TRD). METHODS Subjects with TRD were randomized to a single infusion of one of several doses of intravenous ketamine, or midazolam. Using Kaplan-Meier survival function, the current report examines the rate and time to relapse, defined as MADRS ≥ 22, over a period of 30 days, in subjects who achieved remission (MADRS ≤ 10) or response (≥ 50% reduction in MADRS) on day three post-infusion of intravenous ketamine 0.1, 0.5, or 1.0 mg/kg. RESULTS Of the 60 randomized participants who received a single ketamine (0.1, 0.5, or 1.0 mg/kg) infusion, 19 (34%) met criteria for remission and 27 (48%) for response, on day 3 post-infusion. A numerical dose-response relationship was observed, with remitters/responders on ketamine 1.0 mg/kg having the lowest relapse rate, followed by ketamine 0.5 mg/kg and 0.1 mg/kg, respectively (% of remitters who relapsed by day 14: 38% with 1.0 mg/kg, 50% with 0.5 mg/kg, 100% with 0.1 mg/kg;% of responders who relapsed by day 14: 30% with 1.0 mg/kg, 50% with 0.5 mg/kg, 80% with 0.1 mg/kg). LIMITATIONS The sample size was small. No MADRS measurements at day one post-infusion. The study was not powered to assess differences in relapse prevention between different doses of ketamine. CONCLUSION Time to relapse after successful treatment with a single infusion of ketamine appears to follow a dose-response relationship, where higher dosage leads to increased time to relapse.
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Affiliation(s)
- Naji C Salloum
- Massachusetts General Hospital, Harvard Medical School, USA; Clinical Trials Network and Institute, Massachusetts General Hospital, USA.
| | - Maurizio Fava
- Massachusetts General Hospital, Harvard Medical School, USA; Clinical Trials Network and Institute, Massachusetts General Hospital, USA
| | - Rebecca S Hock
- Massachusetts General Hospital, Harvard Medical School, USA
| | - Marlene P Freeman
- Massachusetts General Hospital, Harvard Medical School, USA; Clinical Trials Network and Institute, Massachusetts General Hospital, USA
| | - Martina Flynn
- Massachusetts General Hospital, Harvard Medical School, USA; Clinical Trials Network and Institute, Massachusetts General Hospital, USA
| | | | - Cristina Cusin
- Massachusetts General Hospital, Harvard Medical School, USA
| | - Dan V Iosifescu
- New York University School of Medicine, Nathan Kline Institute, USA
| | | | | | - Sanjay J Mathew
- Baylor College of Medicine and Michael E. Debakey VA Medical Center, Houston, TX, USA
| | | | - Dawn F Ionescu
- Massachusetts General Hospital, Harvard Medical School, USA
| | - George I Papakostas
- Massachusetts General Hospital, Harvard Medical School, USA; Clinical Trials Network and Institute, Massachusetts General Hospital, USA
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12
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Pedrelli P, Fedor S, Ghandeharioun A, Howe E, Ionescu DF, Bhathena D, Fisher LB, Cusin C, Nyer M, Yeung A, Sangermano L, Mischoulon D, Alpert JE, Picard RW. Monitoring Changes in Depression Severity Using Wearable and Mobile Sensors. Front Psychiatry 2020; 11:584711. [PMID: 33391050 PMCID: PMC7775362 DOI: 10.3389/fpsyt.2020.584711] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/13/2020] [Indexed: 12/14/2022] Open
Abstract
Background: While preliminary evidence suggests that sensors may be employed to detect presence of low mood it is still unclear whether they can be leveraged for measuring depression symptom severity. This study evaluates the feasibility and performance of assessing depressive symptom severity by using behavioral and physiological features obtained from wristband and smartphone sensors. Method: Participants were thirty-one individuals with Major Depressive Disorder (MDD). The protocol included 8 weeks of behavioral and physiological monitoring through smartphone and wristband sensors and six in-person clinical interviews during which depression was assessed with the 17-item Hamilton Depression Rating Scale (HDRS-17). Results: Participants wore the right and left wrist sensors 92 and 94% of the time respectively. Three machine-learning models estimating depressive symptom severity were developed-one combining features from smartphone and wearable sensors, one including only features from the smartphones, and one including features from wrist sensors-and evaluated in two different scenarios. Correlations between the models' estimate of HDRS scores and clinician-rated HDRS ranged from moderate to high (0.46 [CI: 0.42, 0.74] to 0.7 [CI: 0.66, 0.74]) and had moderate accuracy with Mean Absolute Error ranging between 3.88 ± 0.18 and 4.74 ± 1.24. The time-split scenario of the model including only features from the smartphones performed the best. The ten most predictive features in the model combining physiological and mobile features were related to mobile phone engagement, activity level, skin conductance, and heart rate variability. Conclusion: Monitoring of MDD patients through smartphones and wrist sensors following a clinician-rated HDRS assessment is feasible and may provide an estimate of changes in depressive symptom severity. Future studies should further examine the best features to estimate depressive symptoms and strategies to further enhance accuracy.
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Affiliation(s)
- Paola Pedrelli
- The Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Szymon Fedor
- The Media Lab, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Asma Ghandeharioun
- The Media Lab, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Esther Howe
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
| | - Dawn F Ionescu
- Janssen Research and Development, San Diego, CA, United States
| | - Darian Bhathena
- The Media Lab, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Lauren B Fisher
- The Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Cristina Cusin
- The Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Maren Nyer
- The Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Albert Yeung
- The Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Lisa Sangermano
- The Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - David Mischoulon
- The Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA, United States
| | - Johnathan E Alpert
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, United States
| | - Rosalind W Picard
- The Media Lab, Massachusetts Institute of Technology, Cambridge, MA, United States
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13
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Abstract
Major depressive disorder (MDD) is one of the most prevalent conditions in psychiatry. Patients who do not respond to traditional monoaminergic antidepressant treatments have an especially difficult-to-treat type of MDD termed treatment-resistant depression. Subanesthetic doses of ketamine-a glutamatergic modulator-have shown great promise for rapidly treating patients with the most severe forms of depression. As such, ketamine represents a promising probe for understanding the pathophysiology of depression and treatment response. Through neuroimaging, ketamine's mechanism may be elucidated in humans. Here, we review 47 articles of ketamine's effects as revealed by neuroimaging studies. Some important brain areas emerge, especially the subgenual anterior cingulate cortex. Furthermore, ketamine may decrease the ability to self-monitor, may increase emotional blunting, and may increase activity in reward processing. Further studies are needed, however, to elucidate ketamine's mechanism of antidepressant action.
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Affiliation(s)
- Dawn F. Ionescu
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Aishwarya Gosai
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Cristina Cusin
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philip Shin
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Benjamin G. Shapero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Athinoula A. Martinos Center for Biomedical Imaging, Boston, MA
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14
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Salloum NC, Fava M, Freeman MP, Flynn M, Hoeppner B, Hock RS, Cusin C, Iosifescu DV, Trivedi MH, Sanacora G, Mathew SJ, Debattista C, Ionescu DF, Papakostas GI. Efficacy of intravenous ketamine treatment in anxious versus nonanxious unipolar treatment-resistant depression. Depress Anxiety 2019; 36:235-243. [PMID: 30597688 DOI: 10.1002/da.22875] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/03/2018] [Accepted: 12/01/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To examine the effect of high baseline anxiety on response to ketamine versus midazolam (active placebo) in treatment-resistant depression (TRD). METHODS In a multisite, double-blind, placebo-controlled trial, 99 subjects with TRD were randomized to one of five arms: a single dose of intravenous ketamine 0.1, 0.2, 0.5, 1.0 mg/kg, or midazolam 0.045 mg/kg. The primary outcome measure was change in the six-item Hamilton Rating Scale for Depression (HAMD6). A linear mixed effects model was used to examine the effect of anxious depression baseline status (defined by a Hamilton Depression Rating Scale Anxiety-Somatization score ≥7) on response to ketamine versus midazolam at 1 and 3 days postinfusion. RESULTS N = 45 subjects had anxious TRD, compared to N = 54 subjects without high anxiety at baseline. No statistically significant interaction effect was found between treatment group assignment (combined ketamine treatment groups versus midazolam) and anxious/nonanxious status on HAMD6 score at either days 1 or 3 postinfusion (Day 1: F(1, 84) = 0.02, P = 0.88; Day 3: F(1, 82) = 0.12, P = 0.73). CONCLUSION In contrast with what is observed with traditional antidepressants, response to ketamine may be similar in both anxious and nonanxious TRD subjects. These pilot results suggest the potential utility of ketamine in the treatment of anxious TRD.
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Affiliation(s)
- Naji C Salloum
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts.,Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts.,Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Marlene P Freeman
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts.,Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Martina Flynn
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts.,Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Bettina Hoeppner
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - Rebecca S Hock
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - Cristina Cusin
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - Dan V Iosifescu
- Department of Psychiatry, Nathan Kline Institute, New York University School of Medicine, New York, New York
| | - Madhukar H Trivedi
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gerard Sanacora
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Sanjay J Mathew
- Michael E. Debakey VA Medical Center, Baylor College of Medicine, Houston, Texas
| | - Charles Debattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Dawn F Ionescu
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts
| | - George I Papakostas
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts.,Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, Massachusetts
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15
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Mischoulon D, Hylek L, Yeung AS, Clain AJ, Baer L, Cusin C, Ionescu DF, Alpert JE, Soskin DP, Fava M. Corrigendum to "Randomized, proof-of-concept trial of low dose naltrexone for patients with breakthrough symptoms of major depressive disorder on antidepressants" [J. Affect. Disord. 208 (2017, Jan. 15) 6-14, doi: 10.1016/j.jad.2016.08.029, Epub 2016 Oct. 1]. J Affect Disord 2018; 227:198. [PMID: 29100152 DOI: 10.1016/j.jad.2017.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- D Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States.
| | - L Hylek
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - A S Yeung
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - A J Clain
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - L Baer
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - C Cusin
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - D F Ionescu
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - J E Alpert
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - D P Soskin
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - M Fava
- Depression Clinical and Research Program, Department of Psychiatry, The Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
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16
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Niciu MJ, Iadarola ND, Banerjee D, Luckenbaugh DA, Park M, Lener M, Park L, Ionescu DF, Ballard ED, Brutsche NE, Akula N, McMahon FJ, Machado-Vieira R, Nugent AC, Zarate CA. The antidepressant efficacy of subanesthetic-dose ketamine does not correlate with baseline subcortical volumes in a replication sample with major depressive disorder. J Psychopharmacol 2017; 31:1570-1577. [PMID: 29039254 PMCID: PMC5863225 DOI: 10.1177/0269881117732514] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study sought to reproduce, in a larger sample, previous findings of a correlation between smaller raw 3-Tesla (3T) hippocampal volumes and improved antidepressant efficacy of ketamine in individuals with major depressive disorder (MDD). A secondary analysis stratified subjects according to functional BDNF rs6265 (val66met) genotype. METHODS Unmedicated subjects with treatment-resistant MDD ( n=55) underwent baseline structural 3T MRI. Data processing was conducted with FSL/FIRST and Freesurfer software. The amygdala, hippocampus, and thalamus were selected a priori for analysis. All subjects received a single 0.5mg/kg × 40-minute ketamine infusion. Pearson correlations were performed with subcortical volumes and percent change in MADRS score (from baseline to 230 minutes, 1 day, and 1 week post-infusion). RESULTS Raw and corrected subcortical volumes did not correlate with antidepressant response at any timepoint. In val/val subjects ( n=23), corrected left and right thalamic volume positively correlated with antidepressant response to ketamine at 230 minutes post-infusion but did not reach statistical significance. In met carriers ( n=14), corrected left and right thalamic volume negatively correlated with antidepressant response to ketamine. CONCLUSION Baseline subcortical volumes implicated in MDD did not correlate with ketamine's antidepressant efficacy. Baseline thalamic volume and BDNF genotype may be a combinatorial rapid antidepressant response biomarker.
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Affiliation(s)
- Mark J Niciu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Nicolas D Iadarola
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Dipavo Banerjee
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - David A Luckenbaugh
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Minkyung Park
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Marc Lener
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Lawrence Park
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Dawn F Ionescu
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, USA
| | - Elizabeth D Ballard
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Nancy E Brutsche
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Nirmala Akula
- Human Genetics Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Francis J McMahon
- Human Genetics Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Rodrigo Machado-Vieira
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Allison C Nugent
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, USA
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17
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Abstract
Ketamine, a molecule of many faces, has contributed immeasurably to numerous realms of clinical practice and scientific inquiry. From anesthesia and analgesia to depression and schizophrenia, it continues to shed light on the molecular underpinnings of pain, consciousness, and the pathophysiology of neuropsychiatric disorders. In particular, research on ketamine's mechanism of action is providing new hope in the search for therapies for treatment-resistant depression and affords insights into disorders of glutamatergic dysfunction. In this Review, we will cover aspects of ketamine's synthesis, manufacturing, metabolism, pharmacology, approved and off-label indications, and adverse effects. We will also discuss the captivating history of this molecule, its influence on neuropsychiatry, and its potential to advance the fields of chemical neuroscience and neuropharmacology.
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Affiliation(s)
- Marshall W. Tyler
- Chemical Neurobiology Laboratory, Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Chemical Biology Program, Boston, Massachusetts 02114, United States
| | - Harmony B. Yourish
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, United States
| | - Dawn F. Ionescu
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Stephen J. Haggarty
- Chemical Neurobiology Laboratory, Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Chemical Biology Program, Boston, Massachusetts 02114, United States
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18
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Fujita M, Richards EM, Niciu MJ, Ionescu DF, Zoghbi SS, Hong J, Telu S, Hines CS, Pike VW, Zarate CA, Innis RB. cAMP signaling in brain is decreased in unmedicated depressed patients and increased by treatment with a selective serotonin reuptake inhibitor. Mol Psychiatry 2017; 22:754-759. [PMID: 27725657 PMCID: PMC5388600 DOI: 10.1038/mp.2016.171] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/03/2016] [Accepted: 08/01/2016] [Indexed: 01/10/2023]
Abstract
Basic studies exploring the importance of the cyclic adenosine monophosphate (cAMP) cascade in major depressive disorder (MDD) have noted that the cAMP cascade is downregulated in MDD and upregulated by antidepressant treatment. We investigated cAMP cascade activity by using 11C-(R)-rolipram to image phosphodiesterase-4 (PDE4) in unmedicated MDD patients and after ~8 weeks of treatment with a selective serotonin reuptake inhibitor (SSRI). 11C-(R)-rolipram positron emission tomographic (PET) scans were performed in 44 unmedicated patients during a major depressive episode and 35 healthy controls. Twenty-three of the 44 patients had a follow-up 11C-(R)-rolipram PET scan ~8 weeks after treatment with an SSRI. Patients were moderately depressed (Montgomery-Åsberg Depression Rating Scale=30±6) and about half were treatment naïve. 11C-(R)-rolipram binding was measured using arterial sampling to correct for individual differences in radioligand metabolism. We found in unmedicated MDD patients widespread, ~20% reductions in 11C-(R)-rolipram binding compared with controls (P=0.001). SSRI treatment significantly increased rolipram binding (12%, P<0.001), with significantly greater increases observed in older patients (P<0.001). Rolipram binding did not correlate with severity of baseline symptoms, and increased rolipram binding during treatment did not correlate with symptom improvement. In brief, consistent with the results of basic studies, PDE4 was decreased in unmedicated MDD patients and increased after SSRI treatment. The lack of correlation between PDE4 binding and depressive symptoms could reflect the heterogeneity of the disease and/or the heterogeneity of the target, given that PDE4 has four subtypes. These results suggest that PDE4 inhibitors, which increase cAMP cascade activity, may have antidepressant effects.
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Affiliation(s)
- Masahiro Fujita
- Molecular Imaging Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Erica M. Richards
- Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Mark J. Niciu
- Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Dawn F. Ionescu
- Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Sami S. Zoghbi
- Molecular Imaging Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Jinsoo Hong
- Molecular Imaging Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Sanjay Telu
- Molecular Imaging Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Christina S. Hines
- Molecular Imaging Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Victor W. Pike
- Molecular Imaging Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Carlos A. Zarate
- Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
| | - Robert B. Innis
- Molecular Imaging Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, United States
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19
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Ionescu DF, McAdams CJ, O'Donovan A, Philip NS. Becoming an Academic Researcher in Psychiatry: A View From the Trenches. Acad Psychiatry 2017; 41:293-296. [PMID: 26983418 PMCID: PMC5026548 DOI: 10.1007/s40596-016-0514-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 02/09/2016] [Indexed: 06/05/2023]
Affiliation(s)
- Dawn F Ionescu
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carrie J McAdams
- University of Texas at Southwestern Medical Center, Dallas, TX, USA.
| | - Aoife O'Donovan
- University of California San Francisco, San Francisco, CA, USA
| | - Noah S Philip
- Alpert Medical School of Brown University, Providence, RI, USA
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20
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Abstract
Depression is one of the most common psychiatric conditions. Symptoms can lead to significant disability, which result in impairments in overall quality of life. Though there are many approved antidepressant treatments for depression-including selective serotonin reuptake inhibitors, tricyclic antidepressants and monoamine oxidase inhibitors-about a third of patients do not respond to these medications. Therefore, it is imperative for drug discovery to continue towards the development of novel and rapidly acting compounds, especially for patients with treatment-resistant depression. After a brief review of the efficacy of approved antidepressant therapies, we will discuss experimental medication treatments for depression. Specifically, we examine novel medications that are thought to primarily modulate the glutamatergic, cholinergic and opioid systems to achieve antidepressant efficacy. We also give examples of anti-inflammatories, neurokinin-1 modulators, vasopressin antagonists and neurogenesis enhancers that may have a therapeutic role in treatment-resistant depression. The current pipeline of antidepressant treatments is shifting towards medications with novel mechanisms, which may lead to important, life-changing discoveries for patients with severe disease.
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Affiliation(s)
- D F Ionescu
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - G I Papakostas
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, MA, USA
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21
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Ross RA, Foster SL, Ionescu DF. The Role of Chronic Stress in Anxious Depression. Chronic Stress (Thousand Oaks) 2017; 1:2470547016689472. [PMID: 32440578 PMCID: PMC7219927 DOI: 10.1177/2470547016689472] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/22/2016] [Accepted: 12/26/2016] [Indexed: 02/04/2023]
Abstract
Depression is a heterogeneous disease with many different subtypes. Patients with the anxious depression-a common subtype of major depression-are at an increased risk for treatment-resistance to standard antidepressants, with resultant increases in morbidity. However, the underlying pathophysiology of anxious depression remains unknown. Without such knowledge, the development of targeted treatments towards this specific depression subtype will likely remain elusive. One method by which research into the neurobiology of anxious depression may prove fruitful is with the research domain criteria (RDoC). RDoC provides a framework for investigation into the underlying pathophysiology of mental illness. By studying disorders in terms of RDoC constructs-such as the sustained threat construct of the negative valence system-new insights may be gained into neurobiological mechanisms of disease. These mechanisms may be useful for the development of novel antidepressants that are based on specific brain targets. Specifically, we review the impact that sustained threat-or chronic stress-has on the eventual development of depression (especially anxious depression) through pathological changes to molecules, cells, neurocircuitry, physiology, and behavior.
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Affiliation(s)
- Rachel A Ross
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA.,Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, USA.,Harvard Medical School, Boston, USA
| | - Simmie L Foster
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA.,Harvard Medical School, Boston, USA
| | - Dawn F Ionescu
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA.,Harvard Medical School, Boston, USA
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22
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Ionescu DF, Cusin C. Drs Ionescu and Cusin Reply. J Clin Psychiatry 2017; 78:e72. [PMID: 28129501 DOI: 10.4088/jcp.16lr11210a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Dawn F Ionescu
- .,Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Cristina Cusin
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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23
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Abstract
Previously, we found an anxiolytic effect of ziprasidone augmentation to escitalopram (compared with placebo augmentation) in patients with depression in an 8-week, randomized, double-blind, parallel-group, placebo-controlled trial. Here, we carried out a post-hoc analysis, comparing changes in the Hamilton Depression and Anxiety Rating Scales between patients with anxious depression versus nonanxious depression, using a moderator analysis. Hamilton Depression Rating Scales total change scores from baseline and endpoint were not significantly different (interaction term P=0.91) in patients with anxious depression on ziprasidone augmentation (n=19; -9.1±4.9) or placebo (n=19; -6.1±8.9) versus patients without anxious depression on ziprasidone (n=52; -5.5±6.7) or placebo (n=49; -2.3±4.5). There was a trend toward statistical significance (interaction term P=0.1) in favor of patients without anxious depression for a difference in Hamilton Anxiety Rating Scale total change scores from baseline to endpoint [patients with anxious depression on ziprasidone augmentation (n=19; -2.7±5.3) or placebo (n=19; -3.3±5.8) versus patients without anxious depression on ziprasidone (n=51; -3.9±6.6) or placebo (n=44; -0.9±4.7)]. Ziprasidone augmentation was equally efficacious in treating depression in patients with versus without anxious depression. However, the observed anxiolytic effect for patients with higher anxiety was not clinically significant.
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Affiliation(s)
- Dawn F. Ionescu
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA, USA 02114,Harvard Medical School, 1 Bowdoin Square, 6th Floor, Boston, MA, 02114 USA
| | - Richard C. Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Office of Psychiatric Clinical Research, 1720 7th Avenue South, Sparks Building 10th Floor, Birmingham, AL, USA 35294
| | - Lee Baer
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA, USA 02114,Harvard Medical School, 1 Bowdoin Square, 6th Floor, Boston, MA, 02114 USA
| | - Kathryn H. Meade
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA, USA 02114
| | - Michaela B. Swee
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA, USA 02114
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA, USA 02114,Harvard Medical School, 1 Bowdoin Square, 6th Floor, Boston, MA, 02114 USA
| | - George I. Papakostas
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA, USA 02114,Harvard Medical School, 1 Bowdoin Square, 6th Floor, Boston, MA, 02114 USA
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24
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Berg HE, Ballard ED, Luckenbaugh DA, Nugent AC, Ionescu DF, Zarate CA. Recognition of emotional facial expressions in anxious and nonanxious depression. Compr Psychiatry 2016; 70:1-8. [PMID: 27624417 PMCID: PMC5023953 DOI: 10.1016/j.comppsych.2016.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/10/2016] [Accepted: 06/11/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Anxiety and depression have each been independently associated with impairments in emotional face recognition. However, little is known about the nature of these impairments when anxiety and depression co-occur. METHODS This post-hoc analysis evaluated the relationship between anxiety status and performance on the Emotional Expression Multimorph Task within a clinical sample of individuals with major depressive disorder (MDD). RESULTS Participants with anxious depression (n=14) and nonanxious depression (n=14) completed the Emotional Expression Multimorph Task. Those with anxious depression required greater intensity of emotion to identify both happy (p=.01) and sad (p=.04) facial expressions than those with nonanxious depression. Severity of anxiety also correlated with greater intensity of emotion required to detect sad faces. Contrary to prediction, hypervigilance to angry and fearful facial expressions was not observed in anxious depression. LIMITATIONS The present study did not include an anxiety-only group for comparison, and did not assess state anxiety at time of administration. In addition, the extent to which the experimental task correlates with social functioning is not fully understood. CONCLUSIONS These findings suggest a diminished sensitivity to happy and sad facial expressions specific to anxious depression, but not a hypervigilance toward threatening facial expressions. Further research on the nature of emotion recognition in anxiety and depression may inform improved clinical interventions.
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Affiliation(s)
- Hannah E Berg
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Elizabeth D Ballard
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.
| | - David A Luckenbaugh
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Allison C Nugent
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Dawn F Ionescu
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Carlos A Zarate
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
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25
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Ionescu DF, Swee MB, Pavone KJ, Taylor N, Akeju O, Baer L, Nyer M, Cassano P, Mischoulon D, Alpert JE, Brown EN, Nock MK, Fava M, Cusin C. Rapid and Sustained Reductions in Current Suicidal Ideation Following Repeated Doses of Intravenous Ketamine: Secondary Analysis of an Open-Label Study. J Clin Psychiatry 2016; 77:e719-25. [PMID: 27232360 DOI: 10.4088/jcp.15m10056] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/10/2015] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ketamine rapidly reduces thoughts of suicide in patients with treatment-resistant depression who are at low risk for suicide. However, the extent to which ketamine reduces thoughts of suicide in depressed patients with current suicidal ideation remains unknown. METHODS Between April 2012 and October 2013, 14 outpatients with DSM-IV-diagnosed major depressive disorder were recruited for the presence of current, stable (≥ 3 months) suicidal thoughts. They received open-label ketamine infusions over 3 weeks (0.5 mg/kg over 45 minutes for the first 3 infusions; 0.75 mg/kg over 45 minutes for the last 3). In this secondary analysis, the primary outcome measures of suicidal ideation (Columbia-Suicide Severity Rating Scale [C-SSRS] and the Suicide Item of the 28-item Hamilton Depression Rating Scale [HDRS₂₈-SI]) were assessed at 240 minutes postinfusion and for 3 months thereafter in a naturalistic follow-up. RESULTS Over the course of the infusions (acute treatment phase), 7 of 14 patients (50%) showed remission of suicidal ideation on the C-SSRS Ideation scale (even among patients whose depression did not remit). There was a significant linear decrease in this score over time (P < .001), which approached significance even after controlling for severity of 6-item Hamilton Depression Rating Scale (HDRS₆) core depression items (P = .05). Similarly, there were significant decreases in the C-SSRS Intensity (P < .01) and HDRS₂₈-SI (P < .001) scores during the acute treatment phase. Two of the 7 patients who achieved remission during the acute treatment phase (29%) maintained their remission throughout a 3-month naturalistic follow-up. CONCLUSIONS In this preliminary study, repeated doses of open-label ketamine rapidly and robustly decreased suicidal ideation in pharmacologically treated outpatients with treatment-resistant depression with stable suicidal thoughts; this decrease was maintained for at least 3 months following the final ketamine infusion in 2 patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01582945.
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Affiliation(s)
- Dawn F Ionescu
- Massachusetts General Hospital, Depression Clinical and Research Program, 1 Bowdoin Sq, 6th Floor, Boston, MA 02114. .,Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Michaela B Swee
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Kara J Pavone
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston
| | - Norman Taylor
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston.,Department of Psychology, Harvard University, Cambridge, Massachusetts, USA
| | - Lee Baer
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Maren Nyer
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Paolo Cassano
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - David Mischoulon
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan E Alpert
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Emery N Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew K Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Maurizio Fava
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
| | - Cristina Cusin
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts, USA
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26
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Abstract
Although monoaminergic antidepressants revolutionized the treatment of Major Depressive Disorder (MDD) over a half-century ago, approximately one third of depressed patients experience treatment-resistant depression (TRD). Such patients account for a disproportionately large burden of disease, as evidenced by increased disability, cost, human suffering, and suicide. This review addresses the definition, causes, evaluation, and treatment of unipolar TRD, as well as the major treatment strategies, including optimization, augmentation, combination, and switch therapies. Evidence for these options, as outlined in this review, is mainly focused on large-scale trials or meta-analyses. Finally, we briefly review emerging targets for antidepressant drug discovery and the novel effects of rapidly acting antidepressants, with a focus on ketamine.
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Affiliation(s)
- Dawn F Ionescu
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jerrold F Rosenbaum
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan E Alpert
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
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27
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Richards EM, Mathews DC, Luckenbaugh DA, Ionescu DF, Machado-Vieira R, Niciu MJ, Duncan WC, Nolan NM, Franco-Chaves JA, Hudzik T, Maciag C, Li S, Cross A, Smith MA, Zarate CA. A randomized, placebo-controlled pilot trial of the delta opioid receptor agonist AZD2327 in anxious depression. Psychopharmacology (Berl) 2016; 233:1119-30. [PMID: 26728893 PMCID: PMC5103283 DOI: 10.1007/s00213-015-4195-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/14/2015] [Indexed: 12/20/2022]
Abstract
RATIONALE Patients with anxious major depressive disorder (AMDD) have more severe symptoms and poorer treatment response than patients with non-AMDD. Increasing evidence implicates the endogenous opioid system in the pathophysiology of depression. AZD2327 is a selective delta opioid receptor (DOR) agonist with anxiolytic and antidepressant activity in animal models. OBJECTIVE This double-blind, parallel group design, placebo-controlled pilot study evaluated the safety and efficacy of AZD2327 in a preclinical model and in patients with AMDD. METHODS We initially tested the effects of AZD2327 in an animal model of AMDD. Subsequently, 22 subjects with AMDD were randomized to receive AZD2327 (3 mg BID) or placebo for 4 weeks. Primary outcome measures included the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A). We also evaluated neurobiological markers implicated in mood and anxiety disorders, including vascular endothelial growth factor (VEGF) and electroencephalogram (EEG). RESULTS Seven (54 %) patients responded to active drug and three (33 %) responded to placebo. No significant main drug effect was found on either the HAM-D (p = 0.39) or the HAM-A (p = 0.15), but the HAM-A had a larger effect size. Levels of AZ12311418, a major metabolite of AZD2327, were higher in patients with an anti-anxiety response to treatment compared to nonresponders (p = 0.03). AZD2327 treatment decreased VEGF levels (p = 0.02). There was a trend (p < 0.06) for those with an anti-anxiety response to have higher EEG gamma power than nonresponders. CONCLUSION These results suggest that AZD2327 has larger potential anxiolytic than antidepressant efficacy. Additional research with DOR agonists should be considered.
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Affiliation(s)
- Erica M Richards
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA.
| | - Daniel C Mathews
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
- Lundbeck LLC, Chicago, IL, USA
| | - David A Luckenbaugh
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
| | - Dawn F Ionescu
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
- Massachusetts General Hospital, Boston, MA, USA
| | - Rodrigo Machado-Vieira
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
| | - Mark J Niciu
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
| | - Wallace C Duncan
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
| | - Neal M Nolan
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
| | - Jose A Franco-Chaves
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
- Veteran Affairs Caribbean Healthcare System, San Juan, Puerto Rico
| | - Thomas Hudzik
- AstraZeneca Neuroscience Innovative Medicines, Cambridge, MA, USA
- AbbVie, Chicago, IL, USA
| | - Carla Maciag
- AstraZeneca Neuroscience Innovative Medicines, Cambridge, MA, USA
- Sage Therapeutics, Cambridge, MA, USA
| | - Shuang Li
- AstraZeneca Neuroscience Innovative Medicines, Cambridge, MA, USA
| | - Alan Cross
- AstraZeneca Neuroscience Innovative Medicines, Cambridge, MA, USA
| | - Mark A Smith
- AstraZeneca Neuroscience Innovative Medicines, Cambridge, MA, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive CRC, Room 7-5545, Bethesda, MD, 20892, USA
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28
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Ionescu DF, Fava M, Kim DJH, Baer L, Shelton RC, Cusin C. A placebo-controlled crossover study of iloperidone augmentation for residual anger and irritability in major depressive disorder. Ther Adv Psychopharmacol 2016; 6:4-12. [PMID: 26913173 PMCID: PMC4749740 DOI: 10.1177/2045125315618621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Even when patients experience remission with antidepressants, many continue to report anger attacks and excessive irritability despite continued treatment. Iloperidone antagonizes 5-HT-2a, D2, and alpha-1 receptors, which can have anti-aggressive effects. We examined iloperidone's safety and efficacy as an augmentation agent in outpatients with partially remitted major depressive disorder (MDD) with residual symptoms of anger and irritability. METHODS A total of 13 outpatients with partially remitted MDD [currently treated with selective serotonin reuptake inhibitors (SSRIs)] received four weeks of iloperidone or placebo, followed by one week of washout. Patients were then crossed over to the other treatment arm for 4 weeks. Treatment arms were randomized and double blind; and two sites were used for the study. Analyses compared treatment response using the Symptom Questionnaire (SQ) Anger/Hostility Subscale as the primary outcome measure. RESULTS There was no significant differential effect of iloperidone × weeks on the SQ Anger/Hostility Subscore over the course of the study, compared with placebo × weeks, regardless of administration order (p = 0.77). CONCLUSIONS Iloperidone did not significantly outperform placebo on measures of anger or irritability in patients with partially remitted MDD and residual anger/irritability.
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Affiliation(s)
- Dawn F Ionescu
- Massachusetts General Hospital, Depression Clinical and Research Program, Boston, MA, USA Harvard Medical School, Boston, MA
| | - Maurizio Fava
- Massachusetts General Hospital, Depression Clinical and Research Program, Harvard Medical School, 55 Fruit Street, Bulfinch 351, Boston, MA 02114, USA
| | - Daniel Ju Hyung Kim
- Massachusetts General Hospital, Depression Clinical and Research Program, Boston, MA, USA
| | - Lee Baer
- Massachusetts General Hospital, Depression Clinical and Research Program, Boston, MA, USA Harvard Medical School, Boston, MA
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cristina Cusin
- Massachusetts General Hospital, Depression Clinical and Research Program, Boston, MA, USA Harvard Medical School, Boston, MA
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29
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Ionescu DF, Luckenbaugh DA, Niciu MJ, Richards EM, Zarate CA. A single infusion of ketamine improves depression scores in patients with anxious bipolar depression. Bipolar Disord 2015; 17:438-43. [PMID: 25400146 PMCID: PMC4431955 DOI: 10.1111/bdi.12277] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 10/06/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patents with anxious bipolar disorder have worse clinical outcomes and are harder to treat with traditional medication regimens compared to those with non-anxious bipolar disorder. Ketamine has been shown to rapidly and robustly decrease symptoms of depression in depressed patients with bipolar disorder. We sought to determine whether baseline anxiety status reduced ketamine's ability to decrease symptoms of depression. METHODS Thirty-six patients with anxious (n = 21) and non-anxious (n = 15) treatment-resistant bipolar depression (types I and II; concurrently treated with either lithium or valproate) received a single infusion of ketamine (0.5 mg/kg) over 40 min. Post-hoc analyses compared changes in the Montgomery-Åsberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale (HDRS) in anxious versus non-anxious depressed patients with bipolar disorder through 14 days post-infusion. Anxious bipolar depression was defined as DSM-IV bipolar depression plus a HDRS Anxiety/Somatization Factor score of ≥ 7. RESULTS A linear mixed model revealed a significant effect of anxiety group on the MADRS (p = 0.04) and HDRS (p = 0.04). Significant drug effects (all p < 0.001) suggested that both anxious and non-anxious groups had an antidepressant response to ketamine. The drug-by-anxiety interactions were not significant (all p > 0.28). CONCLUSIONS Both anxious and non-anxious patients with bipolar depression had significant antidepressant responses to ketamine, although the anxious depressed group did not show a clear antidepressant response disadvantage over the non-anxious group. Given that anxiety has been shown to be a predictor of poor treatment response in bipolar depression when traditional treatments are used, our findings suggest a need for further investigations into ketamine's novel role in the treatment of anxious bipolar depression.
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Affiliation(s)
- Dawn F Ionescu
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA
,Harvard Medical School, Boston, MA
| | - David A Luckenbaugh
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Mark J Niciu
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Erica M Richards
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Ionescu DF, Rosenbaum JF, Alpert JE. Pharmacological approaches to the challenge of treatment-resistant depression. Dialogues Clin Neurosci 2015; 17:111-26. [PMID: 26246787 PMCID: PMC4518696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Although monoaminergic antidepressants revolutionized the treatment of Major Depressive Disorder (MDD) over a half-century ago, approximately one third of depressed patients experience treatment-resistant depression (TRD). Such patients account for a disproportionately large burden of disease, as evidenced by increased disability, cost, human suffering, and suicide. This review addresses the definition, causes, evaluation, and treatment of unipolar TRD, as well as the major treatment strategies, including optimization, augmentation, combination, and switch therapies. Evidence for these options, as outlined in this review, is mainly focused on large-scale trials or meta-analyses. Finally, we briefly review emerging targets for antidepressant drug discovery and the novel effects of rapidly acting antidepressants, with a focus on ketamine.
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Affiliation(s)
- Dawn F Ionescu
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jerrold F Rosenbaum
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan E Alpert
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
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Niciu MJ, Luckenbaugh DA, Ionescu DF, Richards EM, Vande Voort JL, Ballard ED, Brutsche NE, Furey ML, Zarate CA. Ketamine's antidepressant efficacy is extended for at least four weeks in subjects with a family history of an alcohol use disorder. Int J Neuropsychopharmacol 2014; 18:pyu039. [PMID: 25539512 PMCID: PMC4303351 DOI: 10.1093/ijnp/pyu039] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND A single subanesthetic infusion of the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine has rapid and potent antidepressant properties in treatment-resistant major depressive disorder (TRD). As a family history of an alcohol use disorder is a positive predictor of ketamine's antidepressant response and the strength of the association increases over time, we hypothesized that depressed subjects with a family history of an alcohol use disorder would have greater antidepressant durability and that riluzole would augment and/or extend ketamine's antidepressant efficacy. METHODS Fifty-two TRD subjects received an open-label infusion of ketamine (0.5mg/kg over 40 minutes), and, four to six hours post-infusion, were randomized to either flexible-dose (100-200mg/day) riluzole or placebo in the following proportions: Family History Positive (FHP) riluzole (n = 10), FHP placebo (n = 9), Family History Negative (FHN) riluzole (n = 16), and FHN placebo (n = 17). RESULTS FHP subjects randomized to placebo had a greater antidepressant response than FHN subjects; however, contrary to our initial hypothesis, there was no significant difference in antidepressant efficacy with riluzole. Although potentially underpowered, there was no difference in overall time-to-relapse based on randomization status (riluzole responders: n = 15, placebo responders: n = 17). Yet, time-to-relapse was longer in FHP placebo responders (n = 8) compared to FHN placebo responders (n = 9) with, again, no significant difference in time-to-relapse in FHP riluzole responders (n = 6) compared to FHN riluzole responders (n = 9). CONCLUSIONS Ketamine's extended antidepressant durability in FHP TRD should be considered in the design and analysis of ketamine depression trials.
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Affiliation(s)
- Mark J Niciu
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche).
| | - David A Luckenbaugh
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
| | - Dawn F Ionescu
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
| | - Erica M Richards
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
| | - Jennifer L Vande Voort
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
| | - Elizabeth D Ballard
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
| | - Nancy E Brutsche
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
| | - Maura L Furey
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
| | - Carlos A Zarate
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Bethesda, MD (Drs Niciu, Ionescu, Richards, Vande Voort, Ballard, Furey, and Zarate, Mr Luckenbaugh, and Ms Brutsche)
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Abstract
Mental illness accounts for 7.4% of the total disease burden worldwide-more than HIV/AIDS, tuberculosis, or diabetes-making it the leading cause of years lost to disability. Depressive disorders make up 40.5% of that disability, the most of all mental illnesses. Despite the devastating global effects of depression, a report on approval trends by the US Food and Drug Administration (FDA) found that new molecular entities (NMEs) approved for targeting psychiatric illness peaked in the 1960s and have been declining since.
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Affiliation(s)
- George I Papakostas
- Massachusetts General Hospital, Clinical Trials Network and Institute and Depression Clinical and Research Program, 1 Bowdoin Square, 6th Fl, Boston, MA 02114
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Ballard ED, Ionescu DF, Vande Voort JL, Niciu MJ, Richards EM, Luckenbaugh DA, Brutsche NE, Ameli R, Furey M, Zarate CA. Improvement in suicidal ideation after ketamine infusion: relationship to reductions in depression and anxiety. J Psychiatr Res 2014; 58:161-6. [PMID: 25169854 PMCID: PMC4163501 DOI: 10.1016/j.jpsychires.2014.07.027] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/09/2014] [Accepted: 07/31/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Suicide is a psychiatric emergency. Currently, there are no approved pharmacologic treatments for suicidal ideation. Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist that rapidly reduces suicidal ideation as well as depression and anxiety, but the dynamic between these symptoms is not known. The aim of this analysis was to evaluate whether ketamine has an impact on suicidal thoughts, independent of depressive and anxiety symptoms. METHODS 133 patients with treatment-resistant depression (major depressive disorder or bipolar I/II disorder) received a single subanesthetic infusion of ketamine (0.5 mg/kg over 40 min). Post-hoc correlations and linear mixed models evaluated the relationship between suicidal ideation and depression and anxiety symptoms using the Hamilton Depression Rating Scale (HAMD), Scale for Suicidal Ideation (SSI), Beck Depression Inventory (BDI), and Hamilton Anxiety Rating Scale (HAMA) focusing on 230 min post-infusion. RESULTS At 230 min post-infusion, correlations between changes in suicidal ideation and depression ranged from 0.23 to 0.44 (p < .05), accounting for up to 19% in the variance of ideation change. Correlations with anxiety ranged from 0.23 to 0.40 (p < .05), accounting for similar levels of variance. Ketamine infusion was associated with significant reductions in suicidal ideation compared to placebo, when controlling for the effects of ketamine on depression (F1,587 = 10.31, p = .001) and anxiety (F1,567 = 8.54, p = .004). CONCLUSIONS Improvements in suicidal ideation after ketamine infusion are related to, but not completely driven by, improvements in depression and anxiety. Investigation of the specific effects of ketamine on suicidal thoughts is warranted.
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Affiliation(s)
- Elizabeth D. Ballard
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Dawn F. Ionescu
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Jennifer L. Vande Voort
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Mark J. Niciu
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Erica M. Richards
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - David A. Luckenbaugh
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Nancy E. Brutsche
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Rezvan Ameli
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Maura Furey
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
| | - Carlos A. Zarate
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, 20892
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Niciu MJ, Luckenbaugh DA, Ionescu DF, Richards EM, Vande Voort JL, Ballard ED, Brutsche NE, Furey ML, Zarate CA. Riluzole likely lacks antidepressant efficacy in ketamine non-responders. J Psychiatr Res 2014; 58:197-9. [PMID: 25139008 PMCID: PMC4300112 DOI: 10.1016/j.jpsychires.2014.07.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/30/2014] [Accepted: 07/24/2014] [Indexed: 01/25/2023]
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Svenningsson P, Berg L, Matthews D, Ionescu DF, Richards E, Niciu M, Malinger A, Toups M, Manji H, Trivedi MH, Zarate CA, Greengard P. Preliminary evidence that early reduction in p11 levels in natural killer cells and monocytes predicts the likelihood of antidepressant response to chronic citalopram. Mol Psychiatry 2014; 19:962-4. [PMID: 24614495 PMCID: PMC4161667 DOI: 10.1038/mp.2014.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The prediction of treatment response in many neuropsychiatric disorders would be facilitated by easily accessible biomarkers. Using flow cytometry, we herein demonstrate correlations between early reductions of p11 levels in Natural Killer (NK) cells and monocytes and antidepressant response to citalopram in patients with major depressive disorder (MDD).
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Affiliation(s)
- P Svenningsson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - L Berg
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - D Matthews
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, USA
| | - DF Ionescu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, USA
| | - E Richards
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, USA
| | - M Niciu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, USA
| | - A Malinger
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, USA
| | - M Toups
- Department of Psychiatry and the Mood Disorders Research Program and Clinic, University of Texas Southwestern Medical Center, Dallas, USA
| | - H Manji
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, USA
| | - MH Trivedi
- Department of Psychiatry and the Mood Disorders Research Program and Clinic, University of Texas Southwestern Medical Center, Dallas, USA
| | - CA Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Bethesda, USA
| | - P Greengard
- Laboratory of Molecular and Cellular Neuroscience, The Rockefeller University, New York, USA
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Ionescu DF, Luckenbaugh DA, Niciu MJ, Richards EM, Slonena EE, Vande Voort JL, Brutsche NE, Zarate CA. Effect of baseline anxious depression on initial and sustained antidepressant response to ketamine. J Clin Psychiatry 2014; 75:e932-8. [PMID: 25295436 DOI: 10.4088/jcp.14m09049] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/05/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Patients with anxious depression are typically more difficult to treat with monoaminergic antidepressants compared to those with nonanxious depression. Although novel research has shown that the N-methyl-D-aspartate (NMDA) receptor antagonist ketamine has rapidly acting, relatively sustained effects in treating depression, we predicted that, consistent with the existent literature on traditional antidepressants, patients with anxious depression would have a poorer antidepressant response. METHOD Twenty-six inpatients with treatment-resistant major depressive disorder (MDD) (DSM-IV criteria) received a single infusion of ketamine (0.5 mg/kg over 40 minutes) from January 2006-March 2013 and were followed for 28 days. A post hoc analysis compared treatment response and relapse using the Montgomery-Asberg Depression Rating Scale (MADRS) in patients with anxious versus nonanxious depression. Anxious depression was defined as MDD plus a Hamilton Depression Rating Scale anxiety/somatization factor score ≥ 7. RESULTS Both anxious and nonanxious depressed patients responded positively to ketamine. A linear mixed model controlling for baseline with the MADRS revealed a significant group main effect (P = .03) and group-by-time interaction (P = .01). Post hoc tests indicated that patients with anxious depression had significantly fewer depression symptoms compared to those with nonanxious depression at days 1 through 5, 9 through 12, 15 through 17, and 25, with no significant group differences in dissociative (P = .62) or psychotic (P = .41) side effects. Regarding responders, patients with anxious depression relapsed significantly later than those with nonanxious depression (median ± SE = 19.0 ± 17.9 vs 1.0 ± 0.0 days to relapse, respectively; χ² = 9.30; P = .002). CONCLUSIONS Unexpectedly, patients with anxious depression responded better to ketamine than those with nonanxious depression, with longer time to relapse and no side effect differences. This finding gives promise for the role of novel glutamatergic medications for the treatment of those with anxious depression, a traditionally difficult-to-treat subgroup of depressed patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00088699.
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Affiliation(s)
- Dawn F Ionescu
- Bldg 10, CRC Room 7-5545, 10 Center Drive, MSC 1282, Bethesda, MD 20892
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Lundin NB, Niciu MJ, Luckenbaugh DA, Ionescu DF, Richards EM, Vande Voort JL, Brutsche NE, Machado-Vieira R, Zarate CA. Baseline vitamin B12 and folate levels do not predict improvement in depression after a single infusion of ketamine. Pharmacopsychiatry 2014; 47:141-4. [PMID: 24955551 DOI: 10.1055/s-0034-1377042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Deficiencies in both vitamin B12 and folate have been associated with depression. Recently, higher baseline vitamin B12 levels were observed in individuals with bipolar depression who responded to the antidepressant ketamine at 7 days post-infusion. This study sought to -replicate this result by correlating peripheral vitamin levels with ketamine's antidepressant efficacy in bipolar depression and major depressive disorder (MDD). METHODS Baseline vitamin B12 and folate levels were obtained in 49 inpatients with treatment-resistant MDD and 34 inpatients with treatment-resistant bipolar depression currently experiencing a major depressive episode. All subjects received a single intravenous ketamine infusion. Post-hoc Pearson correlations were performed between baseline vitamin B12 and folate levels, as well as antidepressant response assessed by percent change in Hamilton Depression Rating Scale (HDRS) scores from baseline to 230 min, 1 day, and 7 days post-infusion. RESULTS No significant correlation was observed between baseline vitamin B12 or folate and percent change in HDRS for any of the 3 time points in either MDD or bipolar depression. DISCUSSION Ketamine's antidepressant efficacy may occur independently of baseline peripheral vitamin levels.
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Affiliation(s)
- N B Lundin
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - M J Niciu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - D A Luckenbaugh
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - D F Ionescu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - E M Richards
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - J L Vande Voort
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - N E Brutsche
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - R Machado-Vieira
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
| | - C A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Intramural Research Program, Bethesda, MD
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Ballard ED, Ionescu DF, Vande Voort JL, Slonena EE, Franco-Chaves JA, Zarate CA, Grillon C. Increased fear-potentiated startle in major depressive disorder patients with lifetime history of suicide attempt. J Affect Disord 2014; 162:34-8. [PMID: 24767002 PMCID: PMC4040504 DOI: 10.1016/j.jad.2014.03.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/14/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Suicide is a common reason for psychiatric emergency and morbidity, with few effective treatments. Anxiety symptoms have emerged as potential modifiable risk factors in the time before a suicide attempt, but few studies have been conducted using laboratory measures of fear and anxiety. We operationally defined fear and anxiety as increased startle reactivity during anticipation of predictable (fear-potentiated startle) and unpredictable (anxiety-potentiated startle) shock. We hypothesized that a lifetime history of suicide attempt (as compared to history of no suicide attempt) would be associated with increased fear-potentiated startle. METHODS A post-hoc analysis of fear- and anxiety-potentiated startle was conducted in 28 medication-free patients with Major Depressive Disorder (MDD) divided according to suicide attempt history. RESULTS The magnitude of fear-potentiated startle was increased in depressed patients with lifetime suicide attempts compared to those without a lifetime history of suicide attempt (F(1,26)=5.629, p=.025). There was no difference in anxiety-potentiated startle by suicide attempt history. LIMITATIONS This is a post-hoc analysis of previously analyzed patient data from a study of depressed inpatients. Further replication of the finding with a larger patient sample is indicated. CONCLUSIONS Increased fear-potentiated startle in suicide attempters suggests the role of amygdala in depressed patients with a suicide attempt history. Findings highlight the importance of anxiety symptoms in the treatment of patients at increased suicide risk.
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Affiliation(s)
- Elizabeth D. Ballard
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Dawn F. Ionescu
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer L. Vande Voort
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth E. Slonena
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Jose A. Franco-Chaves
- Department of Psychiatry, VA Caribbean Health Network, Veterans Health Administration San Juan, Puerto Rico
| | - Carlos A. Zarate
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Christian Grillon
- Section on Neurobiology of Fear and Anxiety, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
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Ionescu DF, Niciu MJ, Richards EM, Zarate CA. Pharmacologic treatment of dimensional anxious depression: a review. Prim Care Companion CNS Disord 2014; 16:13r01621. [PMID: 25317369 DOI: 10.4088/pcc.13r01621] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/05/2014] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To review the pharmacologic treatment of dimensionally defined anxious depression. DATA SOURCES English-language, adult human research articles published between 1949 and February 2013 were identified via PUBMED and EMBASE. The search term was treatment of anxious depression. STUDY SELECTION We identified and reviewed 304 original articles. Of these, 31 studies of patients with anxious depression, who were treated with an antidepressant or antipsychotic, are included in this review. DATA EXTRACTION All studies explicitly used a dimensional definition of anxious depression. All patients were treated with either antidepressants or antipsychotic medications. RESULTS Of the 31 relevant psychopharmacologic studies identified, 7 examined patients receiving only 1 medication, 2 studied cotherapeutic strategies, 1 examined antipsychotic augmentation, and 21 compared multiple medications. Eleven were pooled analyses from several studies. All studies were of adults (18-92 years old). The Hamilton Depression Rating Scale Anxiety/Somatization Factor Score was used to define anxious depression in 71% of the studies, and 77.4% were post hoc analyses of previous datasets. Seventeen studies found selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and/or tricyclic antidepressants (TCAs) to be useful for successfully treating anxious depression. However, patients with anxious depression were less likely to experience sustained response or remission. Furthermore, baseline anxious depression puts patients at greater risk for side effect burden. CONCLUSIONS Despite achieving response with SSRIs, SNRIs, and TCAs, patients with dimensionally defined anxious depression do not maintain response or remission and often report a larger burden of side effects compared to nonanxious depressive patients, suggesting that it is a harder-to-treat subtype of major depressive disorder.
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Affiliation(s)
- Dawn F Ionescu
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Mark J Niciu
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Erica M Richards
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
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Niciu MJ, Luckenbaugh DA, Ionescu DF, Guevara S, Machado-Vieira R, Richards EM, Brutsche NE, Nolan NM, Zarate CA. Clinical predictors of ketamine response in treatment-resistant major depression. J Clin Psychiatry 2014; 75:e417-23. [PMID: 24922494 PMCID: PMC4310499 DOI: 10.4088/jcp.13m08698] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 10/07/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The N-methyl-D-aspartate receptor antagonist ketamine has rapid antidepressant effects in treatment-resistant major depressive disorder (MDD) and bipolar depression. Clinical predictors may identify those more likely to benefit from ketamine within clinically heterogeneous populations. METHOD Data were analyzed from 4 studies of treatment-resistant inpatients with DSM-IV-TR-diagnosed MDD or bipolar I or II depression. Patients who were currently experiencing a moderate-to-severe major depressive episode were enrolled between November 2004 and March 2013. All subjects received a single subanesthetic (0.5 mg/kg) ketamine infusion over 40 minutes. Patients were analyzed at the 230-minute postinfusion time point (n = 108), at day 1 (n = 82), and at day 7 (n = 71). Univariate Pearson correlations were performed for each variable with percent change from baseline in the 17-item Hamilton Depression Rating Scale (HDRS). Multivariate linear regression was then conducted for statistically significant predictors (P ≤ .05, 2-tailed). RESULTS Higher body mass index correlated with greater HDRS improvement at 230 minutes (standardized β = -0.30, P = .004) and at day 1 (standardized β = -0.37, P = .001), but not at day 7 (standardized β = -0.18, P = .10). Family history of an alcohol use disorder in a first-degree relative was associated with greater HDRS improvement at day 1 (standardized β = -0.27, P = .014) and day 7 (standardized β = -0.41, P < .001). No prior history of suicide attempt(s) was associated with greater improvement only at day 7 (standardized β = 0.28, P = .01). The overall statistical model explained 13%, 23%, and 36% of HDRS percent change variance at 230 minutes, day 1, and day 7, respectively. CONCLUSIONS Despite its post hoc nature, this study identified several clinical correlates of ketamine's rapid and durable antidepressant effects. Further investigation of these relationships is critical for individualized treatment of depression.
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Niciu MJ, Mathews DC, Nugent AC, Ionescu DF, Furey ML, Richards EM, Machado-Vieira R, Zarate CA. Developing biomarkers in mood disorders research through the use of rapid-acting antidepressants. Depress Anxiety 2014; 31:297-307. [PMID: 24353110 PMCID: PMC3984598 DOI: 10.1002/da.22224] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 11/18/2013] [Accepted: 11/20/2013] [Indexed: 01/10/2023] Open
Abstract
An impediment to progress in mood disorders research is the lack of analytically valid and qualified diagnostic and treatment biomarkers. Consistent with the National Institute of Mental Health (NIMH)'s Research Domain Criteria (RDoC) initiative, the lack of diagnostic biomarkers has precluded us from moving away from a purely subjective (symptom-based) toward a more objective diagnostic system. In addition, treatment response biomarkers in mood disorders would facilitate drug development and move beyond trial-and-error toward more personalized treatments. As such, biomarkers identified early in the pathophysiological process are proximal biomarkers (target engagement), while those occurring later in the disease process are distal (disease pathway components). One strategy to achieve this goal in biomarker development is to increase efforts at the initial phases of biomarker development (i.e. exploration and validation) at single sites with the capability of integrating multimodal approaches across a biological systems level. Subsequently, resultant putative biomarkers could then undergo characterization and surrogacy as these latter phases require multisite collaborative efforts. We have used multimodal approaches - genetics, proteomics/metabolomics, peripheral measures, multimodal neuroimaging, neuropsychopharmacological challenge paradigms and clinical predictors - to explore potential predictor and mediator/moderator biomarkers of the rapid-acting antidepressants ketamine and scopolamine. These exploratory biomarkers may then be used for a priori stratification in larger multisite controlled studies during the validation and characterization phases with the ultimate goal of surrogacy. In sum, the combination of target engagement and well-qualified disease-related measures are crucial to improve our pathophysiological understanding, personalize treatment selection, and expand our armamentarium of novel therapeutics.
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Affiliation(s)
- Mark J. Niciu
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Maryland
| | | | - Allison C. Nugent
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Maryland
| | - Dawn F. Ionescu
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Maryland
| | - Maura L. Furey
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Maryland
| | - Erica M. Richards
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Maryland
| | - Rodrigo Machado-Vieira
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Maryland
| | - Carlos A. Zarate
- Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Maryland
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Luckenbaugh DA, Niciu MJ, Ionescu DF, Nolan NM, Richards EM, Brutsche NE, Guevara S, Zarate CA. Do the dissociative side effects of ketamine mediate its antidepressant effects? J Affect Disord 2014; 159:56-61. [PMID: 24679390 PMCID: PMC4065787 DOI: 10.1016/j.jad.2014.02.017] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 02/05/2014] [Accepted: 02/06/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The N-methyl-d-aspartate receptor antagonist ketamine has rapid antidepressant effects in major depression. Psychotomimetic symptoms, dissociation and hemodynamic changes are known side effects of ketamine, but it is unclear if these side effects relate to its antidepressant efficacy. METHODS Data from 108 treatment-resistant inpatients meeting criteria for major depressive disorder and bipolar disorder who received a single subanesthetic ketamine infusion were analyzed. Pearson correlations were performed to examine potential associations between rapid changes in dissociation and psychotomimesis with the Clinician-Administered Dissociative States Scale (CADSS) and Brief Psychiatric Rating Scale (BPRS), respectively, manic symptoms with Young Mania Rating Scale (YMRS), and vital sign changes, with percent change in the 17-item Hamilton Depression Rating scale (HDRS) at 40 and 230min and Days 1 and 7. RESULTS Pearson correlations showed significant association between increased CADSS score at 40min and percent improvement with ketamine in HDRS at 230min (r=-0.35, p=0.007) and Day 7 (r=-0.41, p=0.01). Changes in YMRS or BPRS Positive Symptom score at 40min were not significantly correlated with percent HDRS improvement at any time point with ketamine. Changes in systolic blood pressure, diastolic blood pressure, and pulse were also not significantly related to HDRS change. LIMITATIONS Secondary data analysis, combined diagnostic groups, potential unblinding. CONCLUSIONS Among the examined mediators of ketamine׳s antidepressant response, only dissociative side effects predicted a more robust and sustained antidepressant. Prospective, mechanistic investigations are critically needed to understand why intra-infusion dissociation correlates with a more robust antidepressant efficacy of ketamine.
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Affiliation(s)
| | | | | | | | | | | | | | - Carlos A. Zarate
- Correspondence to: Experimental Therapeutics & Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health (NIMH), National Institutes of Health (NIH), Building 10, CRC Room 7-534210 Center Drive, Bethesda, MD 20892, USA. Tel.: +1 301 451 0861; fax: +1 301 480 8792. (C.A. Zarate)
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Compton MT, Kelley ME, Ionescu DF. Subtyping first-episode non-affective psychosis using four early-course features: potentially useful prognostic information at initial presentation. Early Interv Psychiatry 2014; 8:50-8. [PMID: 23343467 PMCID: PMC3672389 DOI: 10.1111/eip.12026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 07/31/2012] [Indexed: 11/29/2022]
Abstract
AIM Heterogeneity of symptoms, course and outcomes in primary psychotic disorders complicates prognosis, treatment and diverse aspects of research. This study aimed to identify interpretable subtypes of first-episode non-affective psychosis based on four early-course features (premorbid academic functioning, premorbid social functioning, duration of the prodrome and age at onset of psychosis). METHODS Data from 200 well-characterized patients hospitalized in public-sector inpatient units for first-episode non-affective psychosis were used in latent profile analyses. Derived subtypes were then compared along a number of clinical dimensions using analyses of variance. RESULTS Using four early-course features, three classes were derived. A good premorbid/short prodrome subtype was characterized by a lower severity of positive symptoms, better social/occupational/global functioning, and a shorter duration of untreated psychosis; a poor premorbid/early onset subtype demonstrated greater negative and preoccupation symptoms, as well as greater psychosocial problems; and a long prodrome/late onset subtype was characterized by greater dysphoric symptoms. CONCLUSIONS Findings indicate a need for further research with first-episode samples on the utility of subtyping based on early-course (premorbid, prodromal and onset-related) characteristics. Such efforts could enhance the parsing of heterogeneity, thereby advancing clinical practice and research.
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Affiliation(s)
- Michael T Compton
- Department of Psychiatry and Behavioral Sciences, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Niciu MJ, Ionescu DF, Richards EM, Zarate CA. Glutamate and its receptors in the pathophysiology and treatment of major depressive disorder. J Neural Transm (Vienna) 2013; 121:907-24. [PMID: 24318540 DOI: 10.1007/s00702-013-1130-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 11/25/2013] [Indexed: 12/13/2022]
Abstract
Monoaminergic neurotransmitter (serotonin, norepinephrine and dopamine) mechanisms of disease dominated the research landscape in the pathophysiology and treatment of major depressive disorder (MDD) for more than 50 years and still dominate available treatment options. However, the sum of all brain neurons that use monoamines as their primary neurotransmitter is <20%. In addition, most patients treated with monoaminergic antidepressants are left with significant residual symptoms and psychosocial disability not to mention side effects, e.g., sexual dysfunction. In the past several decades, there has been greater focus on the major excitatory neurotransmitter in the human brain, glutamate, in the pathophysiology and treatment of MDD. Although several preclinical and human magnetic resonance spectroscopy studies had already implicated glutamatergic abnormalities in the human brain, it was rocketed by the discovery that the N-methyl-D-aspartate receptor antagonist ketamine has rapid and potent antidepressant effects in even the most treatment-resistant MDD patients, including those who failed to respond to electroconvulsive therapy and who have active suicidal ideation. In this review, we will first provide a brief introduction to glutamate and its receptors in the mammalian brain. We will then review the clinical evidence for glutamatergic dysfunction in MDD, the discovery and progress-to-date with ketamine as a rapidly acting antidepressant, and other glutamate receptor modulators (including proprietary medications) for treatment-resistant depression. We will finally conclude by offering potential future directions necessary to realize the enormous therapeutic promise of glutamatergic antidepressants.
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Affiliation(s)
- Mark J Niciu
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, Department of Health and Human Services, National Institute of Mental Health, National Institutes of Health, 10 Center Drive, Building 10/CRC, Room 7-5545, Bethesda, MD, 20892, USA,
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Niciu MJ, Luckenbaugh DA, Ionescu DF, Mathews DC, Richards EM, Zarate CA. Subanesthetic dose ketamine does not induce an affective switch in three independent samples of treatment-resistant major depression. Biol Psychiatry 2013; 74:e23-4. [PMID: 23726512 PMCID: PMC3805682 DOI: 10.1016/j.biopsych.2013.01.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 01/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Mark J. Niciu
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, Bethesda, Maryland
| | - David A. Luckenbaugh
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, Bethesda, Maryland
| | - Dawn F. Ionescu
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, Bethesda, Maryland
| | - Daniel C. Mathews
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, Bethesda, Maryland
| | - Erica M. Richards
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, Bethesda, Maryland
| | - Carlos A. Zarate
- National Institutes of Health/National Institute of Mental Health, Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, Bethesda, Maryland,Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC,Corresponding author:
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Grillon C, Franco-Chaves JA, Mateus CF, Ionescu DF, Zarate CA. Major depression is not associated with blunting of aversive responses; evidence for enhanced anxious anticipation. PLoS One 2013; 8:e70969. [PMID: 23951057 PMCID: PMC3738594 DOI: 10.1371/journal.pone.0070969] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 06/26/2013] [Indexed: 12/19/2022] Open
Abstract
According to the emotion-context insensitivity (ECI) hypothesis, major depressive disorder (MDD) is associated with a diminished ability to react emotionally to positive stimuli and with blunting of defensive responses to threat. That defensive responses are blunted in MDD seems inconsistent with the conceptualization and diagnostic nosology of MDD. The present study tested the ECI hypothesis in MDD using a threat of shock paradigm. Twenty-eight patients with MDD (35.5±10.4 years) were compared with 28 controls (35.1±7.4 years). Participants were exposed to three conditions: no shock, predictable shock, and unpredictable shock. Startle magnitude was used to assess defensive responses. Inconsistent with the ECI hypothesis, startle potentiation to predictable and unpredictable shock was not reduced in the MDD group. Rather, MDD patients showed elevated startle throughout testing as well as increased contextual anxiety during the placement of the shock electrodes and in the predictable condition. A regression analysis indicated that illness duration and Beck depression inventory scores explained 37% (p<.005) of the variance in patients' startle reactivity. MDD is not associated with emotional blunting but rather enhanced defensive reactivity during anticipation of harm. These results do not support a strong version of the ECI hypothesis. Understanding the nature of stimuli or situations that lead to blunted or enhanced defensive reactivity will provide better insight into dysfunctional emotional experience in MDD.
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Affiliation(s)
- Christian Grillon
- Section on Neurobiology of Fear and Anxiety, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, United States of America.
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Ionescu DF, Niciu MJ, Mathews DC, Richards EM, Zarate CA. Neurobiology of anxious depression: a review. Depress Anxiety 2013; 30:374-85. [PMID: 23495126 PMCID: PMC3698573 DOI: 10.1002/da.22095] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/15/2013] [Accepted: 02/19/2013] [Indexed: 11/07/2022] Open
Abstract
Anxious depression is a common, distinct clinical subtype of major depressive disorder (MDD). This review summarizes current neurobiological knowledge regarding anxious depression. Peer-reviewed articles, published January 1970 through September 2012, were identified via PUBMED, EMBASE, and Cochrane Library, using the following key words: anxious depression electroencephalography (EEG), anxious depression functional magnetic resonance imaging (fMRI), anxious depression genetics, anxious depression neurobiology, and anxious melancholia neurobiology. Despite a general dearth of neurobiological research, the results suggest that anxious depression-when defined either syndromally or dimensionally-has distinct neurobiological findings that separate it from nonanxious depression. Structural neuroimaging, EEG, genetics, and neuropsychiatric studies revealed differences in subjects with anxious depression compared to other groups. Endocrine differences between individuals with anxious depression and those with nonanxious depression have also been noted, as evidenced by abnormal responses elicited by exogenous stimulation of the system. Despite these findings, heterogeneity in the definition of anxious depression complicates the results. Because exploring the neurobiology of this depressive subtype is important for improving diagnosis, prognosis, and treatment, enrichment strategies to decrease heterogeneity within the field should be employed for future research.
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Affiliation(s)
- Dawn F Ionescu
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD 20892, USA.
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