Side effects of antidepressants during long-term use in a naturalistic setting

Long-term antidepressant use in general practice: a qualitative study of GPs' views on discontinuation

Background

There is considerable concern about increasing antidepressant use, with Australians among the highest users in the world. Evidence suggests this is driven by patients on long-term use, rather than new prescriptions. Most antidepressant prescriptions are generated in general practice, and it is likely that attempts to discontinue are either not occurring or are proving unsuccessful.

Aim

To explore GPs’ insights about long-term antidepressant prescribing and discontinuation.

Design and setting

A qualitative interview study with Australian GPs.

Method

Semi-structured interviews explored GPs’ discontinuation experiences, decision-making, perceived risks and benefits, and support for patients. Data were analysed using reflexive thematic analysis.

Results

Three overarching themes were identified from interviews with 22 GPs. The first, ‘not a simple deprescribing decision’, spoke to the complex decision-making GPs undertake in determining whether a patient is ready to discontinue. The second, ‘a journey taken together’, captured a set of steps GPs take together with their patients to initiate and set-up adequate support before, during, and after discontinuation. The third, ‘supporting change in GPs’ prescribing practices’, described what GPs would like to see change to better support them and their patients to discontinue antidepressants.

Conclusion

GPs see discontinuation of long-term antidepressant use as more than a simple deprescribing decision. It begins with considering a patient’s social and relational context, and is a journey involving careful preparation, tailored care, and regular review. These insights suggest interventions to redress long-term use will need to take these considerations into account and be placed in a wider discussion about the use of antidepressants.

Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults

BACKGROUND

Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants.

OBJECTIVES

To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults.

SEARCH METHODS

We searched all databases for randomised controlled trials (RCTs) until January 2020.

SELECTION CRITERIA

We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety.

AUTHORS' CONCLUSIONS

Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression.   There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.

Validation of Smartphone Based Heart Rate Tracking for Remote Treatment of Panic Attacks

Panic attacks are an impairing mental health problem that affects 11% of adults every year [1]. Those who suffer from panic attacks often do not seek psychological treatment, citing the inability to receive care during their attacks as a contributing factor. A digital medicine solution which provides an accessible, real-time mobile health (mHealth) biofeedback intervention for panic attacks may address this problem. Critical to this approach are methods for capturing physiological arousal during an attack. Herein, we validate an algorithm for capturing physiological arousal using smartphone video of the fingertip. Results demonstrate that the algorithm is able to estimate heart rates that are highly correlated with ECG-derived values (r > 0.99), effectively reject low-quality data often captured outside of controlled laboratory environments (AUC > 0.90), and resolve the physiological arousal experienced during a panic attack. Moreover, patient reported measures indicate that this measurement modality is feasible during panic attacks, and the act of taking the measurement may stop the attack. These results point toward the need for future development and clinical evaluation of this mHealth intervention for preventing panic attacks.

A surrogate measure for patient reported symptom remission in administrative data

BACKGROUND

In real-world pragmatic administrative databases, patient reported remission is often missing.

OBJECTIVE

We evaluate if, in administrative data, five features of antidepressant use patterns can replace patient-reported symptom remission.

METHOD

We re-examined data from Sequence Treatment Alternatives to Relieve Depression (STAR*D) study. Remission was measured using 50% reduction in Hamilton index. Pattern of antidepressant use was examined through five variables: (a) number of prior ineffective antidepressants, (b) duration of taking current antidepressant, (c) receiving therapeutic dose of the medication, and (d) switching to another medication, or (e) augmenting with another antidepressant. The likelihood ratio (LR) associated with each of these predictors was assessed in 90% of data (3329 cases) and evaluated in 10% of data (350 cases) set-aside for evaluation. The accuracy of predictions was calculated using Area under the Receiver Operating Curve (AROC).

RESULTS

Patients who took antidepressants for 14 weeks (LR = 2.007) were more likely to have symptom remission. Prior use of 3 antidepressants reduced the odds of remission (LR = 0.771). Patients who received antidepressants below therapeutic dose were 5 times less likely to experience remission (LR = 0.204). Antidepressant that were augment or switched, almost never led to remission (LR = 0.008, LR = 0.002 respectively). Patterns of antidepressant use accurately (AROC = 0.93) predicted symptom remission.

CONCLUSION

Within the first 100 days, antidepressants use patterns could serve as a surrogate measure for patient-reported remission of symptoms.

The Efficacy, Safety, and Tolerability of Probiotics on Depression: Clinical Results From an Open-Label Pilot Study

Background: A growing body of research has shown that consumption of probiotics can improve symptoms associated with mood and anxiety disorders through activity of the gut-brain axis. However, the effects of probiotics have yet to be tested in a clinical sample of treatment-naïve patients diagnosed with Major Depressive Disorder (MDD). The aim of this 8-week, open-label pilot study is to examine changes in depressive symptoms before and after the introduction of a probiotic supplement in 10 treatment-naïve MDD patients and to provide data on the feasibility of conducting a larger double-blind, randomized, placebo-controlled trial in the same patient population. Here we report on the clinical outcome measures of the study. Methods: Participants recruited from the community in Kingston, Ontario, Canada consumed a probiotic supplement containing Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 (CEREBIOME®) at a dose of 3 × 109 CFU once per day for 8 weeks. Clinical symptoms of depression were measured using a validated battery of clinical scales and self-report questionnaires (CAN-BIND protocol). Data was collected at baseline, week 4, and week 8. Results: Significant improvements in affective clinical symptoms were observed at week 4 and were sustained at week 8. Significant improvements in subjective sleep quality were observed by week 8. No side effects or adverse effects associated with the probiotic supplement were observed. Conclusions: The findings from this study support the existing evidence in this emerging field for probiotics having a role in alleviating symptoms of depression in treatment-naïve, moderately depressed patients and indicate that the probiotic supplement is safe and well-tolerated in this population. However, further comprehensive studies are required to draw conclusions.

The Role of Hypothalamic Inflammation in Diet-Induced Obesity and Its Association with Cognitive and Mood Disorders

Obesity is often associated with cognitive and mood disorders. Recent evidence suggests that obesity may cause hypothalamic inflammation. Our aim was to investigate the hypothesis that there is a causal link between obesity-induced hypothalamic inflammation and cognitive and mood disorders. Inflammation may influence hypothalamic inter-connections with regions important for cognition and mood, while it may cause dysregulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis and influence monoaminergic systems. Exercise, healthy diet, and glucagon-like peptide receptor agonists, which can reduce hypothalamic inflammation in obese models, could improve the deleterious effects on cognition and mood.

Occurrence of Side Effects in Treatment-Resistant Depression: Role of Clinical, Socio-Demographic and Environmental Characteristics

Introduction: Treatment-resistant depression (TRD) is a disabling psychiatric condition characterized by the failure of two antidepressants (ADs). Since the occurrence of side effects (SEs) appears to be one of the main determinants of early discontinuation of pharmacological treatments contributing to a pseudo-resistance, the purpose of this study was to determine the parameters associated with the occurrence of SEs under ADs in a cohort of patients with TRD. Methods: An observational, cross-sectional, multicentre study was carried out using data from the French network of Expert Centers for TRD. For the 108 patients enrolled in the study, the statistical analyses focused on the overall occurrence and on the profile of the SEs (9 categories, 32 items). Results: SEs were influenced by age and sex and were positively associated with the intensity of anxious, depressive and suicidal symptoms, a history of childhood trauma (sexual abuse, emotional abuse and neglect), and negatively associated with self-esteem, and assessment of overall functioning. Conclusion: Using variables accessible in common practice, these results fall within the dynamic of a more tailored approach to medicine that could allow, through integrated pharmacological management, the continuation of antidepressant treatments, and therefore limit the risk of therapeutic failure.

Cost-effectiveness of vortioxetine compared with levomilnacipran and vilazodone in patients with major depressive disorder switching from an initial antidepressant

Introduction: Many patients with major depressive disorder (MDD) do not achieve remission with their first antidepressant (AD), resulting in a high burden due to treatment failure. Vortioxetine is a valid treatment option for patients with MDD only partially responding to their first AD. Characterization of vortioxetine's potential benefits versus other approved treatments is important. Areas covered: The cost-effectiveness of vortioxetine, including cognitive outcomes, was modeled in comparison with levomilnacipran and vilazodone for patients switched to these medications after inadequate responses to a first AD. Expert opinion: Vortioxetine was associated with incremental quality-adjusted life-year (QALY) gains versus levomilnacipran (0.008) or vilazodone (0.009). Vortioxetine was dominant versus levomilnacipran and cost-effective versus vilazodone (incremental cost-effectiveness ratio [ICER],33,829 USD/QALY). In sensitivity analyses using residual cognitive dysfunction rates (vortioxetine, 49%; levomilnacipran, 58%, and vilazodone, 64%), incremental QALY gains for vortioxetine versus levomilnacipran (0.0085) or vilazodone (0.0109) were found. Vortioxetine remained dominant versus levomilnacipran and cost-effective versus vilazodone (ICER, 27,633 USD/QALY). ICER reduction was found with cognition outcomes inclusion. This model provides additional support for considering vortioxetine for patients requiring a switch of MDD treatments, although its conclusions are limited by the data available for inclusion. Additional research and real-world trials are needed to confirm the findings.

Mums on the Move: A pilot randomised controlled trial of a home-based physical activity intervention for mothers at risk of postnatal depression

BACKGROUND

Postnatal women are commonly physically inactive, and, when coupled with depressive symptoms, barriers to physical activity can be heightened. This study aimed to 1) examine the feasibility and acceptability of a multi-component home-based physical activity intervention delivered to mothers at risk of postnatal depression, and 2) examine changes in health behaviours (physical activity, sedentary behaviour, sleep, diet) and indicators of mental health.

METHODS

Sixty-two mothers (3 - 9 months postpartum) who at baseline were insufficiently active and experiencing heightened depressive symptoms were recruited into a 12-week randomised controlled trial in 2018. Participants were randomised into either a) Intervention group (receiving a theoretically underpinned multi-component program including free exercise equipment at home, access to smartphone web-app, and an online forum); or b) Control group (usual routine). Primary outcomes were program feasibility and acceptability. Secondary outcomes included self-reported and accelerometer-assessed physical activity and sedentary behavior, sleep, diet, determinants of physical activity, and mental health (depressive and anxiety symptoms), measured at baseline and follow-up (12-weeks), with self-reported physical activity, sedentary behaviour and depressive symptoms also measured at weeks 4 and 8. Qualitative data was analysed following inductive content analysis, and quantitative data using linear mixed models.

RESULTS

Exercise equipment use in the home was shown to be a feasible strategy to re-engage postnatal women in physical activity. Other components of the program (e.g. web-app, online forum) had low compliance. The program had high acceptability, predominately due to its accessibility, flexibility and ability to overcome key barriers to physical activity. The program resulted in improvements in short-term self-reported physical activity (increased 162min/week at 4 weeks, 95% CI: 37.7, 286.2), behavioural skills (B=0.4, 95% CI: 0.0, 0.8) and perceived barriers to physical activity. However, accelerometer measured physical activity decreased in the intervention group, compared to control group at week 12 (B=-1.3, 95% CI:-2.5, -0.1). There were no changes in other outcomes.

CONCLUSIONS

A home-based physical activity program involving free exercise equipment is acceptable and feasible amongst women experiencing heightened postnatal depressive symptoms. Such programs may be effective in increasing engagement in physical activity, yet additional strategies may be needed to enhance maintenance of physical activity and improvements in mental health.

The Effects of Probiotics on Symptoms of Depression: Protocol for a Double-Blind Randomized Placebo-Controlled Trial

BACKGROUND

A growing body of evidence has linked mental health outcomes to the gut microbiome. This has led to the investigation of the GI tract as a target for novel treatments and interventions for depression, including probiotic supplementation. Our recent pilot study provided the first evidence of probiotics improving symptoms of depression in treatment-naive depressed patients. To further support and expand upon this evidence, data from the pilot study were used to plan a 16-week, double-blind, randomized, placebo-controlled trial to assess the effects of probiotics on depression. Here, we report the protocol for this trial.

METHODS

Participants diagnosed with depression will orally consume a probiotic supplement containing Lactobacillus helveticus and Bifidobacterium longum or placebo once daily. Participants will undergo assessments measuring clinical outcomes using a battery of validated clinical scales and questionnaires. Sleep architecture and quality will be measured using polysomnography. Neuroimaging data will be collected using magnetic resonance imaging to examine functional and structural neurophysiological changes. Molecular data will be collected from blood, stool, and urine samples to examine cytokine levels and explore potential genes and proteins that may predict outcomes in depression.

RESULTS

We expect results to replicate and expand on our pilot data demonstrating that probiotics may be effective in alleviating symptoms of depression, and to find biomarkers that will predict these outcomes.

CONCLUSIONS

The findings from this study will add to the growing body of research in this emerging field, which eventually may provide evidence for probiotics having a role in alleviating symptoms of depression.

The 'patient voice': patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition

BACKGROUND

Stopping antidepressants commonly causes withdrawal symptoms, which can be severe and long-lasting. National Institute for Health and Care Excellence (NICE) guidance has been recently updated to reflect this; however, for many years withdrawal (discontinuation) symptoms were characterised as 'usually mild and self-limiting over a week'. Consequently, withdrawal symptoms might have been misdiagnosed as relapse of an underlying condition, or new onset of another medical illness, but this has never been studied.

METHOD

This paper outlines the themes emerging from 158 respondents to an open invitation to describe the experience of prescribed psychotropic medication withdrawal for petitions sent to British parliaments. The accounts include polypharmacy (mostly antidepressants and benzodiazepines) but we focus on antidepressants because of the relative lack of awareness about their withdrawal effects compared with benzodiazepines. Mixed method analysis was used, including a 'lean thinking' approach to evaluate common failure points.

RESULTS

The themes identified include: a lack of information given to patients about the risk of antidepressant withdrawal; doctors failing to recognise the symptoms of withdrawal; doctors being poorly informed about the best method of tapering prescribed medications; patients being diagnosed with relapse of the underlying condition or medical illnesses other than withdrawal; patients seeking advice outside of mainstream healthcare, including from online forums; and significant effects on functioning for those experiencing withdrawal.

DISCUSSION

Several points for improvement emerge: the need for updating of guidelines to help prescribers recognise antidepressant withdrawal symptoms and to improve informed consent processes; greater availability of non-pharmacological options for managing distress; greater availability of best practice for tapering medications such as antidepressants; and the vital importance of patient feedback. Although the patients captured in this analysis might represent medication withdrawal experiences that are more severe than average, they highlight the current inadequacy of health care systems to recognise and manage prescribed drug withdrawal, and patient feedback in general.

Evaluating the effect of Coriandrum sativum syrup on being migraine-free using mixture models

Background:Coriandrum sativum (coriander) is prescribed as a treatment for headache in traditional Persian medicine. Several investigations have been carried out to find the medicinal properties of this plant. However, no study has evaluated the effectiveness of this plant on becoming migraine-free.

Methods: Sixty-eight migraineurs were randomly allocated to two equal groups of intervention and control . Each received 500 mg of sodium valproate in addition to 15 mL of coriander or placebo syrup three times a day. We followed subjects and recorded their migraine duration in the 1^st, 2^nd, 3^rd, and 4^th weeks. We applied an appropriate statistical model so as to consider special features of the data, which led to more accurate results using SAS 9.4

Results: Our findings showed that the probability of being migraine-free was not only considerably higher in final weeks of the study (p<0.001) in all patients of the intervention group than placebo group, but it was also significantly higher in patients less than 30 years of age compared to patients older than 30 years old. Migraine duration in migraineurs using coriander syrup reduced considerably during the study (p<0.001).

Conclusion: The finding of this study revealed that coriander has a significant effect both on the probability of being migraine free and the duration of migraine attacks. Its effects were more significant during the final weeks of study.

The investigation of the potential antidepressant-like activity of Xanthium orientale subsp. italicum (Moretti) Greuter in rodents

ETHNOPHARMACOLOGICAL RELEVANCE

Ethnobotanical surveys revealed that Xanthiumorientale subsp. italicum (Moretti) Greuter has been used against central nervous system disorders in Turkish folk medicine. The aim of the present study is to verify the folkloric assertion on this plant. The compounds responsible for the activity were investigated using bioassay-guided fractionation procedures.

MATERIALS AND METHODS

The antidepressant activity of the aqueous, n-hexane, ethyl acetate (EtOAc), methanol (MeOH) extracts; fractions and isolated compounds from active MeOH extract were evaluated by using the in vitro MAO inhibition assay and three different in vivo models namely forced swimming test, tail suspension test, and antagonism of tetrabenazine-induced ptosis, hypothermia, and suppression of locomotor activity. The results were compared with control and reference groups, and active compounds of the plant have been determined. Through the bioassay-guided fractionation procedures, two compounds were isolated from the active fraction and their structures were elucidated by spectroscopic methods.

RESULTS

The MeOH extract of the plant was found to possess antidepressant-like activity. This extract was then subjected to chromatographic techniques. Isolated sesquiterpene lactones were elucidated as xanthatin (1) and xanthinosin (2), which were responsible for the antidepressant-like activity.

CONCLUSIONS

This study discovered the antidepressant potential of X. orientale subsp. italicum. Using bioassay-guided fractionation and isolation techniques, xanthatin (1) and xanthinosin (2) were determined as the main active components of the leaves.

Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial

Background

Anxiety disorders and depression (emotional disorders) are highly prevalent mental disorders. Extensive empirical evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of these disorders. However, there are still some barriers related to their dissemination and implementation, which make it difficult for patients to receive these treatments, especially in public health care settings where resources are limited. Recent advances in improving CBT dissemination encompass different perspectives. One is the transdiagnostic approach, which offers treatment protocols that can be used for a range of emotional disorders. Another approach is the use of the internet to reach a larger number of people who could benefit from CBT.

Objective

This study aimed to analyze the effectiveness and acceptability of a transdiagnostic internet-delivered protocol (EmotionRegulation) with human and automated guidance in patients from public specialized mental health care settings.

Methods

A 2-armed randomized controlled trial (RCT) was conducted to compare the effectiveness of EmotionRegulation with treatment as usual (TAU) in specialized mental health care. In all, 214 participants were randomly assigned to receive either EmotionRegulation (n=106) or TAU (n=108). Measurement assessments were conducted at pre- and postintervention and at a 3-month follow-up.

Results

The results revealed the superiority of EmotionRegulation over TAU on measures of depression (d=0.41), anxiety (d=0.35), and health-related quality of life (d=−0.45) at posttreatment, and these gains were maintained at the 3-month follow-up. Furthermore, the results for expectations and opinions showed that EmotionRegulation was well accepted by participants.

Conclusions

EmotionRegulation was more effective than TAU for the treatment of emotional disorders in the Spanish public mental health system. The implications of this RCT, limitations, and suggestions for future research are discussed.

Trial Registration

ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668

Orphan G Protein Coupled Receptors in Affective Disorders

G protein coupled receptors (GPCRs) are the main mediators of signal transduction in the central nervous system. Therefore, it is not surprising that many GPCRs have long been investigated for their role in the development of anxiety and mood disorders, as well as in the mechanism of action of antidepressant therapies. Importantly, the endogenous ligands for a large group of GPCRs have not yet been identified and are therefore known as orphan GPCRs (oGPCRs). Nonetheless, growing evidence from animal studies, together with genome wide association studies (GWAS) and post-mortem transcriptomic analysis in patients, pointed at many oGPCRs as potential pharmacological targets. Among these discoveries, we summarize in this review how emotional behaviors are modulated by the following oGPCRs: ADGRB2 (BAI2), ADGRG1 (GPR56), GPR3, GPR26, GPR37, GPR50, GPR52, GPR61, GPR62, GPR88, GPR135, GPR158, and GPRC5B.

Gut Microbiota: A Pivotal Hub for Polyphenols as Antidepressants

Polyphenols, present in a broad range of plants, have been thought to be responsible for many beneficial health effects, such as an antidepressant. Despite that polyphenols can be absorbed in the small intestine directly, most of them have low bioavailability and reach the large intestine without any modifications due to their complex structures. The interaction between microbial communities and polyphenols in the intestine is important for the latter to exert antidepressant effects. Gut microbiota can improve the bioavailability of polyphenols; in turn, polyphenols can maintain the intestinal barrier as well as the community of the gut microbiota in normal status. Furthermore, gut microbita catabolize polyphenols to more active, better-absorbed metabolites, further ameliorating depression through the microbial-gut-brain (MGB) axis. Based on this evidence, the review illustrates the potential role of gut microbiota in the processes of polyphenols or their metabolites acting as antidepressants and further envisions the gut microbiota as therapeutic targets for depression.

New insights on the role of the retina in diagnostic and therapeutic strategies in major depressive disorder

Major depressive disorder (MDD) affects people worldwide. MDD treatments include antidepressants, which involve a delayed onset of action, long-term treatment, side effects and, frequently, only partial efficacy. The lack of access to the living brain, and the complex and still poorly elucidated pathophysiology of MDD, hinders treatment development. There is not only a need for new treatment strategies, but also for new approaches to investigating the pathophysiology of MDD. Light therapy is a well-established treatment acting through the retina. Since the retina is part of the central nervous system, it has been suggested as a useful area for investigating mental illness. In this article, we will first set out the evidence that MDD affects the retina's structure and function. We will then review studies evaluating the efficacy of light therapy in unipolar non-seasonal MDD. Finally, we discuss the disruption of melatoninergic pathways in MDD, its assessment through the retina and the treatment of this disruption with light therapy.

Feasibility of behavioral activation group therapy in reducing depressive symptoms and improving quality of life in patients with depression: the BRAVE pilot trial

BACKGROUND

Depression impacts the lives of millions of people worldwide. Behavioral activation (BA), derived from cognitive behavioral therapy, has the potential for improving depressive symptoms in patients with depression. Studies evaluating the effectiveness of BA specifically in the context of group therapy programs in a hospital setting for patients with depression are limited. In this study, we report findings from a pilot trial evaluating group BA for major depressive disorder.

OBJECTIVE

The objectives of this pilot trial are to assess the potential of a full trial of BA group therapy in a large-scale tertiary care setting and to provide preliminary information about possible results regarding mood symptoms and quality of life in adults with depression.

METHODS

Using a parallel single-cohort pragmatic pilot randomized controlled trial design, we evaluated the potential of conducting a large trial of BA effectiveness among adults with depression. Participants were randomized to the intervention (BA in addition to usual care) or control (support group in addition to usual care) groups and were assessed weekly for 18 consecutive weeks. Participants randomized to intervention underwent 28 2-h group BA therapy visits administered by trained therapists and completed assessments to examine treatment outcomes. Feasibility was measured in terms of enrollment rates (min. 20%), completion rates of study (min. 80%), and completion rates of weekly measurement scales (min. 80%). The reporting of this pilot trial is in accordance with the CONSORT extension for randomized pilot and feasibility trials.

RESULTS

We randomized 20 individuals of mean age of 48.8 years (standard deviation = 9.7) with a DSM-5 diagnosis of major depressive disorder to intervention (n = 10) or control (n = 10) groups. Based on our feasibility criteria, our recruitment rate was excellent (20/27; 74%), study completion was found to be a moderate (80% of the total participants in both arms completed the study; BA = 100%, control = 60%), and completeness of measurements on a weekly basis was adequate overall (82%; BA = 86%, control = 79%).

CONCLUSIONS

The study has demonstrated the potential feasibility to perform a larger scale trial upon modifications to the control group to avoid the low rate of study completion (60%) in this group.

TRIAL REGISTRATION

ClinicalTrials NCT02045771, Registered January 22, 2014.

Selective Serotonin Reuptake Inhibitor-Induced Sexual Dysfunction: Current Management Perspectives

Any type of sexual dysfunction is an important problem in half of the patients with depressive disorder. On the other hand, one to a quarter of people without any depressive disorder experience sexual dysfunction. Antidepressant agents can lead to all types of sexual side effects including arousal, libido, orgasm and ejaculation problems. Selective serotonin reuptake inhibitors (SSRIs) are a widely used class of drugs which are prescribed for the treatment of a variety of disorders, including major depressive disorder, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder, generalized anxiety disorder, and impulse control disorders. It has been reported that one in eight people have utilized one of the SSRIs in the past 10 years. Some studies reported up to 80% of SSRI-induced sexual side effects. Management of SSRI-induced sexual dysfunction seems to be complex and hard. In this paper, SSRI-induced sexual dysfunction and new perspectives in the management of this problem were reviewed.

Antidepressant treatment for primary care patients with depressive symptoms: Data from the diamond longitudinal cohort study

BACKGROUND

In light of emerging evidence questioning the safety of antidepressants, it is timely to investigate the appropriateness of antidepressant prescribing. This study estimated the prevalence of possible over- and under-treatment with antidepressants among primary care attendees and investigated the factors associated with potentially inappropriate antidepressant use.

METHODS

In all, 789 adult primary care patients with depressive symptoms were recruited from 30 general practices in Victoria, Australia, in 2005 and followed up every 3 months in 2006 and annually from 2007 to 2011. For this study, we first assessed appropriateness of antidepressant use in 2007 at the 2-year follow-up to enable history of depression to be taken into account, providing 574 (73%) patients with five yearly assessments, resulting in a total of 2870 assessments. We estimated the prevalence of use of antidepressants according to the adapted National Institute for Health and Care Excellence guidelines and used regression analysis to identify factors associated with possible over- and under-treatment.

RESULTS

In 41% (243/586) of assessments where antidepressants were indicated according to adapted National Institute for Health and Care Excellence guidelines, patients reported not taking them. Conversely in a third (557/1711) of assessments where guideline criteria were unlikely to be met, participants reported antidepressant use. Being female and chronic physical illness were associated with antidepressant use where guideline criteria were not met, but no factors were associated with not taking antidepressants where guideline criteria were met.

CONCLUSIONS

Much antidepressant treatment in general practice is for people with minimal or mild symptoms, while people with moderate or severe depressive symptoms may miss out. There is considerable scope for improving depression care through better allocation of antidepressant treatment.

Antidepressant Potential of Lotus corniculatus L. subsp. corniculatus: An Ethnobotany Based Approach

As a Turkish traditional medicinal plant, aerial parts of Lotus corniculatus L. subsp. corniculatus (Fabaceae) are used as a painkiller, antihemoroidal, diuretic and sedative. In this study, the antidepressant potential of the plant has been attempted to clarify. Extracts with water, n-Hexane, ethyl acetate, and methanol were prepared respectively from the aerial parts. Antidepressant activity of the extracts were researched by using three different in vivo test models namely a tail suspension test, antagonism of tetrabenazine-induced hypothermia, ptosis, and suppression of locomotor activity and forced swimming test on male BALB/c mice and in vitro monoamine oxidase (MAO)-A and B inhibition assays. The results were evaluated through comparing with control and reference groups, and then active compounds of the active extract have been determined. Bioassay-guided fractionation of active fraction led to the isolation of three compounds and structures of the compounds were elucidated by spectroscopic methods. The data of this study demonstrate that the MeOH extract of the aerial parts of the plant showed remarkable in vivo antidepressant effect and the isolated compounds medicarpin-3-O-glucoside, gossypetin-3-O-glucoside and naringenin-7-O-glucoside (prunin) from the active sub-fractions could be responsible for the activity. Further mechanistic and toxicity studies are planned to develop new antidepressant-acting drugs.

Causes of drug discontinuation in patients with major depressive disorder in China

BACKGROUND

This research was designed to investigate patient-reported and doctor-reported reasons for the discontinuation of pharmacological treatment in Chinese patients with major depressive disorder (MDD), which was part of the National Survey on Symptomatology of Depression (NSSD) from 2014 to 2015.

METHODS

This cross-sectional study included 649 patients who had discontinued antidepressant medications and 711 patients who had remained on them, selected from a group of 3516 candidates who have had at least one depressive episode. Differences in the two groups' sociodemographic factors, clinical characteristics, medication use, and self-reported reasons for drug discontinuation were compared via Student's t-test or chi-square test. Logistic regression analysis was then used to determine the association of all non-subjective dichotomous and ordinal categorical variables, including the additional 63 items of our physician-evaluated symptomatic assessment, with drug compliance.

RESULTS

Compared to the spontaneous drug discontinuation (SDD) group, the drug adherence (DA) group had significantly lower rates of the following: family history of mental disease (9.0% vs 13.6%), highest level of education achieved being post-graduate or above (1.6% vs 4.7%), smoking (5.8% vs 9.7%), and other health problems (33.9% vs 42.4%) (p's < 0.05). On the other hand, first-episode depression (48.5% vs 21.9%) and taking of mood stabilizer(s) (8.3% vs 5.6%) were higher in the former group than in the latter (p's < 0.05). Logistic Regression Analysis showed that five symptoms, such as depressed mood, were correlated positively with SDD, while another six symptoms, such as psychomotor retardation, were correlated negatively with it. The receiver operating characteristic (ROC) curve of this model yielded an area under the curve (AUC) of 0.701 (95% CI, 0.673-0.729). Notably, there were three main reasons given by patients in the DA group as to why they discontinued their medication(s): (1) concern about long-term side effects (36.1%), (2) no perceived need for taking said medication(s) long-term (34.2%), and (3) believing oneself to have been cured completely (30.0%).

CONCLUSIONS

The aforementioned factors may affect patient compliance and elicit maladaptive thinking even from patients with good educational backgrounds, increasing the risk of drug discontinuation. Compliance of pharmacological treatment might be improved by increasing clarification and elucidation of different symptom clusters to the patient and combating the main reasons for drug discontinuation.

Association Between Side Effects and Blood microRNA Expression Levels and Their Targeted Pathways in Patients With Major Depressive Disorder Treated by a Selective Serotonin Reuptake Inhibitor, Escitalopram: A CAN-BIND-1 Report

INTRODUCTION

Antidepressant drugs are effective therapies for major depressive disorder; however, they are frequently associated with side effects. Although there is some evidence for a relationship between genetic variation and side effects, little is known regarding the role of dynamic molecular factors as moderators of side effects. The aim of this study was to assess microRNA (miRNA) changes associated with side effects during escitalopram treatment and their downstream effects on target gene expression.

METHODS

A total 160 patients with major depressive disorder from the CAN-BIND-1 cohort were included. Side effects were assessed with the Toronto Side Effect Scale after 2 weeks of treatment with escitalopram. We assessed the relationship between side effects and changes in peripheral expression of miRNAs between baseline and week 2. For miRNA whose expression changed, we used target prediction algorithms to identify putative messenger RNA (mRNA) targets and assessed their expression.

RESULTS

Nausea was experienced by 42.5% of patients. We identified 45 miRNAs whose expression changed on initiation of escitalopram treatment, of which 10 displayed a negative association with intensity of nausea (miR15b-5p, miR17-5p, miR20a-5p, miR20b-5p, miR103a-3p, miR103b, miR106a-5p, miR182-5p, miR185-5p, and miR660-5p). Additionally, we found negative associations between 4 microRNAs (miR20a-5p, miR106a-5p, miR185-5p, miR660-5p) and mRNA targets. The expression of the miR185-5p target, CAMK2δ was significantly decreased [log 2 mean = -0.048 (0.233)] between weeks 0 and 2 (P = .01)].

CONCLUSIONS

We identified an overexpression of miR185-5p during escitalopram treatment of major depressive disorder, which was negatively associated with intensity of nausea, and identified a potential mRNA target that may mediate this effect.

Common CYP2D6, CYP2C9, and CYP2C19 Gene Variants, Health Anxiety, and Neuroticism Are Not Associated With Self-Reported Antidepressant Side Effects

Many patients prescribed an antidepressant stop taking it because of side effects. Genetic factors and psychological factors including state or trait anxiety, may explain variation in side effect outcomes. Our aim was to examine the relative contribution of genetic and psychological factors in people with self-reported antidepressant side effects. We undertook a case control study (n = 194) of people who took a selective serotonin reuptake inhibitor (SSRI) or serotonin/noradrenaline reuptake inhibitor (SNRI) in the past 2 years, recruited via social media advertising. Cases had previously not tolerated at least one trial of an SSRI or SNRI, evidenced by stopping the drug or reducing the dose by at least 50% because of a side effect. Control participants had taken an SSRI or SNRI but did not meet case criteria. Variation in the genes CYP2D6, CYP2C19, and CYP2C9 was analyzed by Sanger sequencing on DNA extracted from blood or saliva. Participants completed the Short Health Anxiety Inventory-18, K10, and NEO-FFI-3 personality questionnaire. Participants were 87.1% female. 70.8% had a current K10 score of 22 or more. There was no consistent evidence that cases had higher psychological distress, health anxiety, or neuroticism. There was low correspondence between participants' CYP2D6, CYP2C19, and CYP2C9 phenotypes and their history of antidepressant tolerability. For this cohort of patients a history of not tolerating SSRI or SNRI therapy was not associated with variation in the pharmacogenes we tested, nor was it associated with health anxiety or neuroticism.

Efficacy of a standardised saffron extract (affron®) as an add-on to antidepressant medication for the treatment of persistent depressive symptoms in adults: A randomised, double-blind, placebo-controlled study

BACKGROUND

As a stand-alone intervention, saffron has efficacy for the treatment of mild-to-moderate depression. However, research as an adjunct agent is limited.

AIMS

The effects of saffron as an adjunct to pharmaceutical antidepressants in adults with persistent depression was investigated.

METHODS

In this eight-week, randomised, double-blind, placebo-controlled study, adults with persistent depression, currently taking a pharmaceutical antidepressant were given a placebo or a saffron extract (affron®, 14 mg b.i.d.). Primary outcome measures included the clinician-rated Montgomery-Åsberg Depression Rating Scale (MADRS) and self-rated MADRS (MADRS-S). Secondary outcome measures included the Antidepressant Side-Effect Checklist (ASEC) and Short Form-36 Health Survey (SF-36).

RESULTS

Of the 160 participants enrolled, 139 provided usable data. Based on the MADRS, depressive symptoms decreased more in participants taking saffron compared with a placebo, with reductions of 41 and 21%, respectively (p = 0.001). However, scores on the MADRS-S decreased 27 and 26% in the saffron and placebo conditions, respectively (p = 0.831). Saffron was associated with a greater reduction in adverse effects of antidepressants (p = 0.019), although this was non-significant after covarying for baseline values (p = 0.449). Quality of life improved in both groups with no significant between-group differences (p = 0.638).

CONCLUSION

Adjunctive administration of a standardised saffron extract (affron®) for eight weeks was associated with a greater improvement in depressive symptoms as measured by the clinician-rated MADRS but not the self-report MADRS-S. Given the conflicting results, further research is needed to clarify the clinical benefits of saffron as an adjunctive treatment for adults with persistent depressive symptoms despite antidepressant drug treatment.

Enhancing shared decision making about discontinuation of antidepressant medication: a concept-mapping study in primary and secondary mental health care

BACKGROUND

The apparent rise of antidepressant use seems to be explained to a large extent by an increase in long-term use. Both professionals and patients appear reluctant to discontinue antidepressant medication (ADM). It is not known what factors determine this reluctance.

AIM

This study aimed to identify factors that enable the shared decision-making process about discontinuation of ADM between long-term users and their GPs.

DESIGN AND SETTING

Concept-mapping study of a purposive sample of both patients and professionals from primary and secondary mental health care in the Netherlands.

METHOD

Concept mapping was used to conceptualise and structure the topics relevant to the discontinuation process from the perspective of both patients and professionals. Participants generated topics in brainstorming sessions and subsequently prioritised and sorted them. Multidimensional scaling and hierarchical cluster analyses were used for the cluster topics.

RESULTS

Thirty-seven patients and 27 professionals generated 50 separate topics. Hierarchical cluster analysis revealed six clusters of topics: 'Process of discontinuation', 'Expectations', 'Professional guidance', 'Current use', 'Environment', and 'Side effects'. Patients and professionals came up with largely similar topics. Nevertheless, a difference was found between these groups regarding the perceived importance of professional guidance.

CONCLUSION

This study yielded an informed selection of the topics that seem most important to discuss when considering whether to discontinue ADM. As perspectives of both patients and professionals were combined, the topics may provide patients and GPs with a broader and more balanced scope of factors to consider, and thus facilitate a better shared decision-making process.

Targeting Gap Junctions: New Insights into the Treatment of Major Depressive Disorder

Background:

Major depressive disorder (MDD) is a multifactorial chronic and debilitating mood disease with high lifetime prevalence and associated with excess mortality. Treatments for this disease are not effective in all patients showing the need to find new therapeutic targets.

Objective:

This review aims to update our knowledge on the involvement of astroglial gap junctions and hemichannels in MDD and to show how they have become potential targets for the treatment of this pathology.

Methods:

The method applied in this review includes a systematic compilation of the relevant literature.

Results and Conclusion:

The use of rodent models of depression, gene analysis of hippocampal tissues of MDD patients and post-mortem studies on the brains from MDD patients suggest that astrocytic gap junction dysfunction may be a part of MDD etiologies. Chronic antidepressant treatments of rats, rat cultured cortical astrocytes and human astrocytoma cell lines support the hypothesis that the up-regulation of gap junctional coupling between astrocytes could be an underlying mechanism for the therapeutic effect of antidepressants. However, two recent functional studies suggest that connexin43 hemichannel activity is a part of several antidepressants’ mode of action and that astrocyte gap junctional intercellular communication and hemichannels exert different effects on antidepressant drug response. Even if they emerge as new therapeutic targets for new and more active treatments, further studies are needed to decipher the sophisticated and respective role of astrocytic gap junctions and hemichannels in MDD.

Body mass index (BMI) in major depressive disorder and its effects on depressive symptomatology and antidepressant response

BACKGROUND

Obesity is one of the most prevalent somatic comorbidities of Major Depressive Disorder (MDD). We aimed to investigate the relationship between body mass index (BMI) and MDD, the symptomatology of the disorder as well as the outcome of antidepressant treatment.

METHODS

Early medication change (EMC) trial participants with BMI measurement (n = 811) were categorized according to WHO-criteria in normal or low weight (BMI < 25), overweight (25-< 30), and obese (≥30). Depression severity and BMI was assessed in weekly intervals up to 8 weeks. BMI at baseline and course of BMI during the study were investigated in linear regression models as possible moderators of therapy response. Possible moderators such as plasma concentrations of applied drugs, sex, comorbidities or age were controlled.

RESULTS

388 (48%) patients showed normal weight, 251 (31%) were overweight and 172 (21%) obese. Linear regression analyses revealed an association between BMI and antidepressant therapy outcome: Overweight patients showed the best response to antidepressant treatment. BMI at baseline was significantly correlated with improvement in neurovegetative and cognitive symptoms of depression. Furthermore, weight gain during the study was associated with better therapy response, independent of symptom complex. Other moderators including serum concentrations of drugs were not able to explain the differences between the BMI groups.

LIMITATIONS

Secondary exploratory analysis. No investigation of visceral fat.

CONCLUSION

We showed for the first time that patients with higher initial increase in BMI showed larger decrease in depression severity during study. The underlying mechanisms are unclear and require further investigation.

Effects of cholecalciferol on behavior and production of reactive oxygen species in female mice subjected to corticosterone-induced model of depression

Major depressive disorder (or depression) is one of the most frequent psychiatric illnesses in the population, with chronic stress being one of the main etiological factors. Studies have shown that cholecalciferol supplementation can lead to attenuation of the depressive state; however, the biochemical mechanisms involved in the relationship between cholecalciferol and depression are not very well known. The objective of this study was to investigate the effects of the administration of cholecalciferol on behavioral parameters (tail suspension test (TST), open field test (OFT), splash test (ST)) and redox state (dichlorofluorescein (DCF)) in adult female Swiss mice subjected to a model of depression induced by chronic corticosterone treatment. Corticosterone (20 mg/kg, p.o.) was administered once a day for 21 days. For investigation of the antidepressant-like effect, cholecalciferol (100 IU/kg) or fluoxetine (10 mg/kg, positive control) was administered p.o. within the last 7 days of corticosterone administration. After the treatments, the behavioral tests and biochemical analyses in the hippocampus and prefrontal cortex of the rodent samples were performed. Animals submitted to repeated corticosterone administration showed a depressive-like behavior, evidenced by a significant increase in the immobility time in the TST, which was significantly reduced by the administration of cholecalciferol or fluoxetine. In addition, the groups treated with cholecalciferol and fluoxetine showed a significant decrease in the production of reactive oxygen species (ROS) in the hippocampus. These results show that cholecalciferol, similar to fluoxetine, has a potential antidepressant-like effect, which may be related to the lower ROS production.

Discontinuation of antidepressant medication in primary care supported by monitoring plus mindfulness-based cognitive therapy versus monitoring alone: design and protocol of a cluster randomized controlled trial

Background

Antidepressant use continues to rise, mainly explained by an increase in the proportion of patients receiving long term treatment. Although treatment guidelines recommend discontinuation after sustained remission, discontinuing antidepressants appears to be challenging for both patients and general practitioners (GPs). Mindfulness-Based Cognitive Therapy (MBCT) is an effective intervention that reduces the risk of relapse in recurrent depression and might facilitate discontinuation by teaching patients to cope with withdrawal symptoms and fear of relapse. The current study aims to investigate the effectiveness of the combination of Supported Protocolized Discontinuation (SPD) and MBCT in comparison with SPD alone in successful discontinuation of long-term use of antidepressants in primary care.

Methods

This study involves a cluster-randomized controlled trial conducted in primary care patients with long-term use antidepressants with baseline and 6, 9 and 12 months follow-up assessments. Patients choosing to discontinue their medication will be offered a combination of SPD and MBCT or SPD alone. Our primary outcome will be full discontinuation of antidepressant medication (= 0 mg) within 6 months after baseline assessment. Secondary outcome measures will be the severity of withdrawal symptoms, symptoms of depression and anxiety, psychological well-being, quality of life and medical and societal costs.

Discussion

In theory, stopping antidepressant medication seems straightforward. In practice however, patients and their GPs appear reluctant to initiate and accomplish this process. Both patients and professionals are in need of appropriate tools and information to better support the process of discontinuing antidepressant medication.

Trial registration

ClinicalTrials.gov PRS ID: NCT03361514 retrospectively registered October 2017.

The 5-Year Course of Medication Treatment in Childhood Anxiety Disorders

OBJECTIVE

For pediatric psychiatric disorders, given the marked increase in use of medications without an understanding of the typical treatment course, the primary goal of the current study was to examine the course of pharmacotherapy over 5 years in children with newly diagnosed anxiety disorders.

METHODS

We reviewed provider billing and prescription ordering records of a tertiary medical center from 2008 through 2015 to identify children (aged 7-17 years) newly diagnosed with an anxiety disorder and to determine the psychopharmacologic treatment that they received from 2010 through 2015. The frequency at which patients received prescriptions from 9 classes of psychotropic medications at any point during the study period was determined. We used χ² analyses and independent sample t tests to examine the relationship between receiving a psychotropic prescription and various patient characteristics.

RESULTS

The study cohort included 108 patients (mean [SD] age = 12.8 [3.3] years). In this group, 73.1% received pharmacotherapy on at least 1 occasion over the 5-year period, and 41.7% received medications from more than 1 class. Of those who received a prescription, 50% (27/54) of patients remained on medication for 5 years. This estimate rose to 71% (5/7) within the subset of patients who were medication-naive at the beginning of the observation period and were still in high school during year 5.

CONCLUSIONS

Guidelines implying discontinuation of medication after symptom remission and a limited period of stability do not accurately reflect clinical practice.

Prevention and Treatment for Chemotherapy-Induced Peripheral Neuropathy: Therapies Based on CIPN Mechanisms

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a progressive, enduring, and often irreversible adverse effect of many antineoplastic agents, among which sensory abnormities are common and the most suffering issues. The pathogenesis of CIPN has not been completely understood, and strategies for CIPN prevention and treatment are still open problems for medicine.

OBJECTIVES

The objective of this paper is to review the mechanism-based therapies against sensory abnormities in CIPN.

METHODS

This is a literature review to describe the uncovered mechanisms underlying CIPN and to provide a summary of mechanism-based therapies for CIPN based on the evidence from both animal and clinical studies.

RESULTS

An abundance of compounds has been developed to prevent or treat CIPN by blocking ion channels, targeting inflammatory cytokines and combating oxidative stress. Agents such as glutathione, mangafodipir and duloxetine are expected to be effective for CIPN intervention, while Ca/Mg infusion and venlafaxine, tricyclic antidepressants, and gabapentin display limited efficacy for preventing and alleviating CIPN. And the utilization of erythropoietin, menthol and amifostine needs to be cautious regarding to their side effects.

CONCLUSIONS

Multiple drugs have been used and studied for decades, their effect against CIPN are still controversial according to different antineoplastic agents due to the diverse manifestations among different antineoplastic agents and complex drug-drug interactions. In addition, novel therapies or drugs that have proven to be effective in animals require further investigation, and it will take time to confirm their efficacy and safety.

Personalized prediction of antidepressant v. placebo response: evidence from the EMBARC study

BACKGROUND

Major depressive disorder (MDD) is a highly heterogeneous condition in terms of symptom presentation and, likely, underlying pathophysiology. Accordingly, it is possible that only certain individuals with MDD are well-suited to antidepressants. A potentially fruitful approach to parsing this heterogeneity is to focus on promising endophenotypes of depression, such as neuroticism, anhedonia, and cognitive control deficits.

METHODS

Within an 8-week multisite trial of sertraline v. placebo for depressed adults (n = 216), we examined whether the combination of machine learning with a Personalized Advantage Index (PAI) can generate individualized treatment recommendations on the basis of endophenotype profiles coupled with clinical and demographic characteristics.

RESULTS

Five pre-treatment variables moderated treatment response. Higher depression severity and neuroticism, older age, less impairment in cognitive control, and being employed were each associated with better outcomes to sertraline than placebo. Across 1000 iterations of a 10-fold cross-validation, the PAI model predicted that 31% of the sample would exhibit a clinically meaningful advantage [post-treatment Hamilton Rating Scale for Depression (HRSD) difference ⩾3] with sertraline relative to placebo. Although there were no overall outcome differences between treatment groups (d = 0.15), those identified as optimally suited to sertraline at pre-treatment had better week 8 HRSD scores if randomized to sertraline (10.7) than placebo (14.7) (d = 0.58).

CONCLUSIONS

A subset of MDD patients optimally suited to sertraline can be identified on the basis of pre-treatment characteristics. This model must be tested prospectively before it can be used to inform treatment selection. However, findings demonstrate the potential to improve individual outcomes through algorithm-guided treatment recommendations.

Pharmaco-epidemiology of antidepressant exposure in a UK cohort record-linkage study

OBJECTIVES

Antidepressants are the most commonly prescribed psychiatric medication but concern has been raised about significant increases in their usage in high income countries. We aimed to quantify antidepressant prevalence, incidence, adherence and predictors of use in the adult population.

METHODS

The study record-linked administrative prescribing and morbidity data to the Generation Scotland cohort ( N = 11,052), between 2009 and 2016. Prevalence and incidence of any antidepressant use was determined. Antidepressant adherence was measured using Proportion of Days Covered and Medication Possession Ratio. Time-to-event analysis for incident antidepressant use within 5 years of Generation Scotland: Scottish Family Health Study (GS:SFHS) recruitment was performed to reveal patient-level predictors of use.

RESULTS

Almost one-third (28.0%, 95%CI 26.9-29.1) of the adults in our sample were prescribed at least one antidepressant in the 5-year period 2012-2016. There was a 36.2% increase in annual prevalence between 2010 and 2016. Incidence was 2.4(2.1-2.7)% per year. The majority of antidepressant episodes (57.6%) were greater than 9 months duration and adherence was generally high (69.0% with Proportion of Days Covered >80%). Predictors of new antidepressant use included history of affective disorder, being female, physical comorbidities, higher neuroticism scores, and lower cognitive function scores.

CONCLUSIONS

Antidepressant prevalence is greater than previously reported but incidence remains relatively stable. We found the majority of antidepressant episodes to be of relatively long duration with good estimated adherence. Our study supports the hypothesis that increased long-term use among existing (and returning) users, along with wider ranges of indications for antidepressants, has significantly increased the prevalence of these medications.

Effects of Xingpi Kaiyu Fang on ATP, Na/K-ATPase, and Respiratory Chain Complexes of Hippocampus and Gastrocnemius Muscle in Depressed Rats

Objective

To clarify the effectiveness and mechanism of the Chinese herbal formula Xingpi Kaiyu Fang (XPKYF) which is composed of American ginseng (Xi-Yang-shen), Radix curcumae (Yu-Jin), Acori tatarinowii rhizoma (Shi-Chang-pu), and Hypericum perforatum (Guan-Ye-lian-qiao) in depressed rats.

Methods

The rat model of depression was established by chronic unpredictable mild stress (CUMS) method for 6 weeks. Rats were randomly divided into six groups: control group, CUMS group, CUMS+XPKYF (3.6g/kg/d, 7.2g/kg/d, 14.4g/kg/d) groups, and CUMS+sertraline (4.5mg/kg/d) group. The sucrose preference test and the forced swimming test were performed to assess the rats' depression behavior. Mitochondrial ultrastructure was observed by transmission electron microscope and adenosine triphosphate (ATP) content, sodium potassium ATPase (Na/K-ATPase) activity, and mitochondrial respiratory chain complexes activities in hippocampus and gastrocnemius muscle were measured at the 14^th and 42^nd day.

Results

Rats subjected to six weeks of CUMS exhibited decreased sucrose preference ratio and prolonged immobility time. CUMS reduced ATP content in hippocampus, decreased Na/K-ATPase activity and respiratory chain complex I, III, and IV activities in hippocampus and gastrocnemius muscle, and damaged mitochondrial ultrastructure of hippocampus and gastrocnemius muscle. XPKYF at 14.4g/kg, the efficacy trend of which was better than the other drug groups, could prevent the stress-induced depressed behavior changes, inhibit the decrease of Na/K-ATPase activity in hippocampus, inhibit the decrease of respiratory chain complex III activities in hippocampus and gastrocnemius muscle, and protect mitochondria from ultrastructural damage.

Conclusions

Energy deficiency and damaged mitochondrial ultrastructure were found in hippocampus and gastrocnemius muscle of depressed rats established by CUMS. XPKYF could partly reverse alterations in ATP, Na/K-ATPase, and respiratory chain complexes of hippocampus and gastrocnemius muscle and protect mitochondria from ultrastructural damage. This provides another experimental evidence for the clinical application of XPKYF in the treatment of depression.

Depression and obesity: evidence of shared biological mechanisms

Depression and obesity are common conditions with major public health implications that tend to co-occur within individuals. The relationship between these conditions is bidirectional: the presence of one increases the risk for developing the other. It has thus become crucial to gain a better understanding of the mechanisms responsible for the intertwined downward physiological spirals associated with both conditions. The present review focuses specifically on shared biological pathways that may mechanistically explain the depression-obesity link, including genetics, alterations in systems involved in homeostatic adjustments (HPA axis, immuno-inflammatory activation, neuroendocrine regulators of energy metabolism including leptin and insulin, and microbiome) and brain circuitries integrating homeostatic and mood regulatory responses. Furthermore, the review addresses interventional opportunities and questions to be answered by future research that will enable a comprehensive characterization and targeting of the biological links between depression and obesity.

Optimized bio-analytical methods development and comparative pharmacokinetic studies of four antidepressants in Egyptian population based on gender difference

The pharmacokinetics (PK) and pharmacodynamics of many oral antidepressants (OADs) vary substantially among different genders and ethnicities. Likewise is their therapeutic effectiveness, time to response and the incidence of adverse drug events. The aim of this study is to compare the PK of four OADs (desvenlafaxine; DSV, venlafaxine; VLX, escitalopram; ESP, and agomelatine; AGT) among Egyptian males and females. In this study, LC-MS/MS methods were developed and validated for determining the four OADs in human plasma. Samples were prepared by liquid-liquid extraction. Chromatographic separation was performed on reversed-phase C₁₈ columns followed by positive-ion electrospray ionization and MS/MS detection. The assays were applied for the assessment of PK parameters in human volunteers (n = 95). The developed methods were linear, accurate, and precise for the determination of DSV, VLX, ESP and AGT with extraction recovery of 90 ± 2.0, 98 ± 1.0, 90 ± 1.3 and 87 ± 4.3%, respectively. OADs levels were successfully measured in subjects' plasma and PK parameters were calculated. A prevalent inter-individual variation in PK of the studied OAD was observed. The PK profile of DSV, VLX or ESP did not vary significantly between male and female subjects (p = 0.07-0.98; confidence level (CL) = 95) while the PK of AGT exhibited a significant gender-based variation in both the C_max and the AUC_∞ (p = 0.047 and 0.0015; CL = 95). Our results highlight the significance of therapeutic drug monitoring of OADs. Further, it indicates the dose adjustment based on gender difference may not be relevant for DSV, VLX and ESP while it may be considered for AGT.

Discovery of new antidepressant agents: In vivo study on Anthemis wiedemanniana Fisch. & Mey

ETHNOPHARMACOLOGICAL RELEVANCE

Many of the currently available antidepressants have serious adverse effects and are also expensive. Traditional medicines are major sources of original drugs, and their role in effective treatment is remarkable. In Turkish folk medicine, decoctions and infusions are prepared from the flowers of Anthemis wiedemanniana Fisch. & Mey. They exert antispasmodic and sedative effects and are also used for treating urinary inflammations. The present study was designed to evaluate the antidepressant activity of A. wiedemanniana, which is used against central nervous system disorders in Turkish folk medicine.

MATERIALS AND METHODS

n-Hexane, ethyl acetate, and methanol (MeOH) extracts were prepared from the flowers of the plant. The antidepressant potentials of these extracts were evaluated in mouse models using the forced swimming test, tail suspension test, and antagonism of tetrabenazine-induced ptosis, hypothermia, and suppression of locomotor activity. The results were compared with those in control and reference groups, and active constituents of the plant were determined. The MeOH extract of A. wiedemanniana was subjected to various chromatographic separation techniques, leading to the isolation and identification of the active component(s).

RESULTS

After confirmation of the antidepressant activity, the MeOH extract was subjected to successive solvent partitioning using solvents of increasing polarity, yielding four subextracts. Each subextract was tested on the same biological activity models. Fraction B was found to have the highest activity and subjected to further chromatographic separation. Isolated germacronolide-type sesquiterpene lactones were elucidated as tatridin A (1) and tanachin (1-epi-tatridin B) (2), which were responsible for the antidepressant activity of the flowers.

CONCLUSIONS

This study explored the antidepressant potential of A. wiedemanniana. Using bioassay-guided fractionation and isolation techniques, tatridin A and tanachin (1-epi-tatridin B) were determined as the main active components of the flowers. Further antidepressant mechanistic studies should be conducted for exploring the activity of these compounds against depression. This study can be an important step in the discovery of newer antidepressants.

Monitoring for antidepressant-associated adverse events in the treatment of patients with major depressive disorder: An international consensus statement

OBJECTIVES

These recommendations were designed to ensure safety for patients with major depressive disorder (MDD) and to aid monitoring and management of adverse effects during treatment with approved antidepressant medications. The recommendations aim to inform prescribers about both the risks associated with these treatments and approaches for mitigating such risks.

METHODS

Expert contributors were sought internationally by contacting representatives of key stakeholder professional societies in the treatment of MDD (ASBDD, CANMAT, WFSBP and ISAD). The manuscript was drafted through iterative editing to ensure consensus.

RESULTS

Adequate risk assessment prior to commencing pharmacotherapy, and safety monitoring during pharmacotherapy are essential to mitigate adverse events, optimise the benefits of treatment, and detect and assess adverse events when they occur. Risk factors for pharmacotherapy vary with individual patient characteristics and medication regimens. Risk factors for each patient need to be carefully assessed prior to initiating pharmacotherapy, and appropriate individualised treatment choices need to be selected. Some antidepressants are associated with specific safety concerns which were addressed.

CONCLUSIONS

Risks of adverse outcomes with antidepressant treatment can be managed through appropriate assessment and monitoring to improve the risk benefit ratio and improve clinical outcomes.

A simple poly(styrene-co-divinylbenzene)-coated glass blood spot method for monitoring of seven antidepressants using capillary liquid chromatography-mass spectrometry

A simple, rapid, selective and sensitive monitoring method for the simultaneous determination of the widely-prescribed antidepressants agomelatine, bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, trazodone in just a human blood drop is here developed and validated. This methodology is based on the use of lab manufactured poly(styrene-co-divinylbenzene)-coated glass (PS-DVB) blood spot for the extraction of the analytes and their subsequent separation and detection by capillary liquid chromatography-mass spectrometry (CLC-MS). Briefly, 10 mm-side squares were punched out from blood spots collected on glass substrate coated by 10 µg of the PS-DVB polymer and eluted with 1.0 mL of 2.0% acetic acid in methanol. The analytes were then separated and detected in less than 20 min by capillary CLC-MS using a Jupiter 4 µm Proteo 90 Å column and water: acetonitrile (20:80 v/v) and ammonium acetate (5 mM, pH 3.0) as mobile phase. Limit of detection (LOD) ranged from 0.018 to 0.038 µg mL^-1, and remarkable precision values for the responses and retention times lower than 5.89% and 1.92% were calculated, respectively. Moreover, accuracy values ranging between 85% and 104% were obtained.

Does Chinese calligraphy therapy reduce neuropsychiatric symptoms: a systematic review and meta-analysis

BACKGROUND

There are currently no systematic reviews or meta-analyses of Chinese calligraphy therapy (CCT) to reduce neuropsychiatric symptoms. The aim of this systematic review and meta-analysis was to explore the efficacy of CCT for people with neuropsychiatric symptoms.

METHODS

We searched Chinese and English databases, including the Cochrane Central Register of Controlled Trials and Wanfang Data for relevant articles published between the earliest year available and December 2016. The search was limited to randomized controlled trials and controlled clinical studies and the associated keywords were "handwriting," "Chinese calligraphy," "Chinese calligraphy therapy," "Calligraphy exercise," and "Calligraphy training." The 21 articles that met these criteria were used in the analysis. The Joanna Briggs Institute critical appraisal checklist was used to assess methodological quality.

RESULTS

CCT significantly reduced psychosis (10 studies, 965 subjects, standardized mean difference [SMD] = - 0.17, 95% confidence intervals [CI] [- 0.30, - 0.40], Z = 2.60, p < 0.01), anxiety symptoms (9 studies, 579 subjects, SMD = - 0.78, 95% CI [- 0.95, - 0.61], Z = 8.98, p < 0.001), and depressive symptoms (7 studies, 456 subjects, SMD = - 0.69, 95% CI [- 0.88, - 0.50], Z = 7.11, p < 0.001). CCT also significantly improved cognitive function (2 studies, 55 subjects, MD = 2.17, 95% CI [- 0.03, 4.38], Z = 1.93, p = 0.05) and neurofeedback (3 studies, 148 subjects, SMD = - 1.09, 95% CI [- 1.44, - 0.73], Z = 6.01, p < 0.001). The therapy also significantly reduced the positive psychopathological expression of schizophrenia symptoms (4 studies, 287 subjects, SMD = - 0.35, 95% CI [- 0.59, - 0.12], Z = 2.96, p = 0.003) and reduced the negative symptoms of schizophrenia (4 studies, 276 subjects, SMD = - 1.39, 95% CI [- 1.65, - 1.12], Z = 10.23, p < 0.001).

CONCLUSIONS

CCT exerts a curative effect on neuropsychiatric symptoms, but the evidence remains insufficient. A large number of RCTs are needed to facilitate additional systematic reviews of evidence for CCT.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Antidepressant prescriptions and mental health nurses: an observational study in Dutch general practice from 2011 to 2015

PURPOSE

The purpose of this study was to investigate developments in antidepressant prescriptions by Dutch general practitioners, alongside the national introduction of mental health nurses. Antidepressant prescriptions are very common in general practice, but are often not in line with recommendations. The recent introduction of mental health nurses may have decreased antidepressant prescriptions, as general practitioners (GPs) have greater potential to offer psychological treatment as a first choice option instead of medication.

MATERIAL AND METHODS

Anonymised data from the medical records of general practices participating in the NIVEL Primary Care Database in 2011-2015 were analysed in an observational study. We used multilevel logistic regression analyses to determine whether total antidepressant prescriptions and antidepressants prescribed within one week of diagnosing anxiety or depression decreased in the period 2011-2015. We analysed whether changes in antidepressant prescriptions were associated with the employment or consultation of mental health nurses.

RESULTS

Antidepressants were prescribed in 30.3% of all anxiety or depression episodes; about half were prescribed within the first week. Antidepressants prescriptions for anxiety or depression increased slightly in the period 2011-2015. The employment of mental health nurses was not associated with a decreased number of prescriptions of antidepressants. Patients who had at least one mental health nurse consultation had fewer immediate prescriptions of antidepressants, but not fewer antidepressants in general.

CONCLUSIONS

Antidepressant prescriptions are still common in general practice. So far, the introduction of mental health nurses has not decreased antidepressant prescriptions, but it may have a postponing effect.