Electroretinographic effects induced in humans by psychopharmacologic agents

Exploring the ElectroRetinoGraphy as a biomarker for predicting and monitoring therapeutic response to antidepressants in major depressive disorder: study protocol for the MESANTIDEP trial

Background

Major depressive disorder (MDD) is a frequent and highly debilitating condition for which current antidepressant treatments show limited effectiveness. In addition, their implementation requires one or more trial-and-error processes, which involves months of untreated illness. Achieving faster efficacy by identifying the most adapted treatment for each patient as the first line treatment could significantly reduce MDD-related morbidity and mortality while enhancing patients' quality of life. To achieve this goal, there is a need to identify markers for predicting and monitoring therapeutic response to antidepressants.

Methods

The MESANTIDEP study is designed to identify electroretinographic (ERG) biomarkers that can predict the therapeutic response at 12 weeks to the two main classes of antidepressants prescribed as first-line treatments for MDD: Selective Serotonin Reuptake Inhibitors (SSRIs) and alpha-2 adrenergic receptor antagonists (α2-antagonists). Secondly, the study aims to explore the relationship between ERG measurements and therapeutic response at 6 and 12 weeks in MDD patients treated with SSRIs or α2-antagonists. To this end, patients diagnosed with MDD and needing to start an antidepressant from the SSRI or α2-antagonist classes will be enrolled. At the inclusion visit, prior to starting their antidepressant treatment, patients will undergo various assessments, including clinical and sleep questionnaires, as well as ERG tests. Patients will initiate their antidepressant treatment the day after the inclusion visit. Subsequent evaluations, identical to those at baseline, will be conducted 6 and 12 weeks afterwards to monitor therapeutic response to antidepressants.

Discussion

The MESANTIDEP study will contribute to identify ERG markers predicting and monitoring the therapeutic response to antidepressants. If such markers are highlighted, it is intended to help clinicians in the treatment management of MDD patients. ERG measurements being easy to perform and accessible to all, they could be integrated into a multimodal treatment approach in routine clinical practice. It would enable more rapid therapeutic intervention tailored to each patient could reduce the functional impact of the disease, improve patients' quality of life, and decrease MDD-associated morbidity and mortality.

Clinical Trial Registration

Clinicaltrials.gov, identifier NCT06532604.

Effects of medications on the human electroretinogram: A comprehensive review

The electroretinogram (ERG) is a well-established method to investigate retinal function and can often provide critical diagnostic information for underlying retinal disorders. ERG responses rely on the neuronal activity of retinal cells which, like neurons elsewhere, are subject to perturbation by a wide spectrum of neuromodulating substances. These agents have the potential to confound electrophysiologic recordings used to evaluate visual function. We provide a comprehensive literature review of studies that have examined the impact of pharmacologic agents on human electrophysiologic testing of retinal function. This review is focused primarily on full-field ERG data, but also includes a limited number of studies examining effects of medications on pattern ERG and visual evoked potential recordings. The studies reviewed are categorized by medication class and evidence level according to the strength of the supporting data; for example, some included studies have a lower evidence level because they included a small number of subjects or did not use international electrophysiology testing standards. We identified numerous widely-used medications and some recreational substances that have been shown to alter ERG responses, underscoring the need to take a complete medical and medication history for each patient undergoing ERG testing.

The electroretinography to identify biomarkers of idiopathic hypersomnia and narcolepsy type 1

Hypersomnia spectrum disorders are underdiagnosed and poorly treated due to their heterogeneity and absence of biomarkers. The electroretinography has been proposed as a proxy of central dysfunction and has proved to be valuable to differentiate certain psychiatric disorders. Hypersomnolence is a shared core feature in central hypersomnia and psychiatric disorders. We therefore aimed to identify biomarkers by studying the electroretinography profile in patients with narcolepsy type 1, idiopathic hypersomnia and in controls. Cone, rod and retinal ganglion cells electrical activity were recorded with flash-electroretinography in non-dilated eye of 31 patients with idiopathic hypersomnia (women 84%, 26.6 ± 5.9 years), 19 patients with narcolepsy type 1 (women 63%, 36.6 ± 12.7 years) and 43 controls (women 58%, 30.6 ± 9.3 years). Reduced cone a-wave amplitude (p = 0.039) and prolonged cone (p = 0.022) and rod b-wave (p = 0.009) latencies were observed in patients with narcolepsy type 1 as compared with controls, while prolonged photopic negative response-wave latency (retinal ganglion cells activity) was observed in patients with idiopathic hypersomnia as compared with controls (p = 0.033). The rod and cone b-wave latency clearly distinguished narcolepsy type 1 from idiopathic hypersomnia and controls (area under the curve > 0.70), and the photopic negative response-wave latency distinguished idiopathic hypersomnia and narcolepsy type 1 from controls with an area under the curve > 0.68. This first original study shows electroretinography anomalies observed in patients with hypersomnia. Narcolepsy type 1 is associated with impaired cone and rod responses, whereas idiopathic hypersomnia is associated with impaired retinal ganglion cells response, suggesting different phototransduction alterations in both hypersomnias. Although these results need to be confirmed with a larger sample size, the electroretinography may be a promising tool for clinicians to differentiate hypersomnia subtypes.

Signature of Altered Retinal Microstructures and Electrophysiology in Schizophrenia Spectrum Disorders Is Associated With Disease Severity and Polygenic Risk

BACKGROUND

Optical coherence tomography and electroretinography studies have revealed structural and functional retinal alterations in individuals with schizophrenia spectrum disorders (SSDs). However, it remains unclear which specific retinal layers are affected; how the retina, brain, and clinical symptomatology are connected; and how alterations of the visual system are related to genetic disease risk.

METHODS

Optical coherence tomography, electroretinography, and brain magnetic resonance imaging were applied to comprehensively investigate the visual system in a cohort of 103 patients with SSDs and 130 healthy control individuals. The sparse partial least squares algorithm was used to identify multivariate associations between clinical disease phenotype and biological alterations of the visual system. The association of the revealed patterns with individual polygenic disease risk for schizophrenia was explored in a post hoc analysis. In addition, covariate-adjusted case-control comparisons were performed for each individual optical coherence tomography and electroretinography parameter.

RESULTS

The sparse partial least squares analysis yielded a phenotype-eye-brain signature of SSDs in which greater disease severity, longer duration of illness, and impaired cognition were associated with electrophysiological alterations and microstructural thinning of most retinal layers. Higher individual loading onto this disease-relevant signature of the visual system was significantly associated with elevated polygenic risk for schizophrenia. In case-control comparisons, patients with SSDs had lower macular thickness, thinner retinal nerve fiber and inner plexiform layers, less negative a-wave amplitude, and lower b-wave amplitude.

CONCLUSIONS

This study demonstrates multimodal microstructural and electrophysiological retinal alterations in individuals with SSDs that are associated with disease severity and individual polygenic burden.

ElectroRetinoGraphy toward an exploration of the therapeutic potential of antidepressants in patients with major depressive disorder: A scoping review of the literature

Major Depressive Disorder (MDD) is characterized by at least one major depressive episode. It requires medical attention typically involving the prescription of antidepressants. Remission in MDD patients is often difficult to achieve because of the limited effectiveness of these drugs. Nowadays, numerous patients undergo various antidepressant treatments, with subjective changes in their personal experiences being regularly monitored. Therefore, it is essential to find clinical and objective tools that offer a more tailored approach to antidepressant selection. The neurochemistry of the retina being similar to the brain, one promising approach would be to use ElectroRetinoGraphy (ERG) measurements on MDD patients requiring antidepressant treatment. Thus, the aim of this scoping review is to highlight effects of different classes of antidepressants on retinal function evaluated by full-field ERG (ffERG), Pattern ERG (PERG) and multifocal ERG (mfERG) waveforms in MDD patients. These ERG measurements could serve as pivotal indicators in defining patient profiles, facilitating a more objective and personalized approach to therapeutic interventions, thereby advancing precision psychiatry.

Complete evaluation of retinal function in Major Depressive Disorder: From central slowdown to hyperactive periphery

BACKGROUND

Developing easy-to-access biomarkers is crucial in Major Depressive Disorder. The retina has already been suggested as relevant. However, there is a need for a global and local assessment of whole retinal function using a reproducible, standardized protocol allowing for comparison across studies. Our aim is to assess whole retinal function in patients with actual unipolar Major Depressive Episode (MDE) using pattern, flash and multifocal electroretinogram (ERG) according to the International Society for Clinical Electrophysiology of Vision standardized protocols.

METHODS

We assessed retinal function in 14 males and females with MDE, diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, and in age- and sex-matched healthy controls.

RESULTS

Comparing the patients with the controls, we observed the following using multifocal ERG: a significant increase in N1 peak time in ring 3 and a decrease in P1 amplitude in ring 2; using pattern ERG: a significant increase in P50 peak time; using flash ERG: a decrease in a- and b-wave peak time and an increase in the b-wave amplitude in dark-adapted 3.0, a decrease in a- and b-wave peak time and an increase in both wave amplitudes in light-adapted 3.0, and a decrease in the b-wave peak time in light-adapted flicker.

LIMITATIONS

Sample size. Contribution of pharmacological treatments to the outcomes cannot be formally excluded.

CONCLUSIONS

Patients with MDE exhibit delayed signaling in the central retina and hyperreactivity to light in the periphery. Central retinal function may be a marker of psychomotor retardation and cognitive impairment in MDE.

Electroretinography in psychiatry: A systematic literature review

This review aims to consolidate the available information on use of electroretinography as a diagnostic tool in psychiatry. The electroretinogram (ERG) has been found to have diagnostic utility in cocaine withdrawal (reduced light-adapted b-wave response), major depressive disorder (reduced contrast gain in pattern ERG), and schizophrenia (reduced a- and b-wave amplitudes). This review examines these findings as well as the applicability of ERG to substance use disorder, Alzheimer's disease, autism spectrum disorder, panic disorder, eating disorders, attention deficit hyperactivity disorder, and medication use. While there have been promising results, current research suffers from a lack of specificity. Further research that quantifies anomalies in ERG present in psychiatric illness is needed.

Integrated assessment of visual perception abnormalities in psychotic disorders and relationship with clinical characteristics

BACKGROUND

The visual system is recognized as an important site of pathology and dysfunction in schizophrenia. In this study, we evaluated different visual perceptual functions in patients with psychotic disorders using a potentially clinically applicable task battery and assessed their relationship with symptom severity in patients, and with schizotypal features in healthy participants.

METHODS

Five different areas of visual functioning were evaluated in patients with schizophrenia and schizoaffective disorder (n = 28) and healthy control subjects (n = 31) using a battery that included visuospatial working memory (VSWM), velocity discrimination (VD), contour integration, visual context processing, and backward masking tasks.

RESULTS

The patient group demonstrated significantly lower performance in VD, contour integration, and VSWM tasks. Performance did not differ between the two groups on the visual context processing task and did not differ across levels of interstimulus intervals in the backward masking task. Performances on VSWM, VD, and contour integration tasks were correlated with negative symptom severity but not with other symptom dimensions in the patient group. VSWM and VD performances were also correlated with negative sychizotypal features in healthy controls.

CONCLUSION

Taken together, these results demonstrate significant abnormalities in multiple visual processing tasks in patients with psychotic disorders, adding to the literature implicating visual abnormalities in these conditions. Furthermore, our results show that visual processing impairments are associated with the negative symptom dimension in patients as well as healthy individuals.

Electroretinographic anomalies in medicated and drug free patients with major depression: Tagging the developmental roots of major psychiatric disorders

The retina is tagged as an approachable part of the brain due to its common embryonic origin and appears as a promising site of investigation for psychiatric disorders. Retinal function is assessed best with the electroretinogram (ERG), which was obtained in a large sample of patients with major depressive disorder and matched controls. ERG cone and rod luminance response functions were recorded in non-dilated eyes in 100 major depressive disorder patients (MDD) and 100 controls, (mean age of 42.8 and 40.9y. o. respectively). Amongst MDD patients, 17 were drug free (mean age 41.2y. o). In medicated patients, at the cone level, a prolonged b-wave was observed (p≤0.01). In drug free patients a prolonged b-wave was discovered only when averaging the implicit time of the 3 highest b-wave amplitudes of the photopic hill. For the medicated patients, the mixed rods/cones a-wave was reduced (p=0.01) whereas a trend (p=0.06) was observed for the pure rod b-wave (reduced) and the mixed rods/cones (reduced and prolonged; p=0.05). In drug free patients, a similar pattern could be observed in terms of effect sizes. Overall, medicated and drug free MDD patients shared some deficits suggesting that some anomalies are present above and beyond the effect of medication. Of interest, the prolonged cone and reduced rod amplitude were reported by our group in schizophrenia patients, suggesting a common neurodevelopmental root of major psychiatric disorders.

Retinal biomarkers provide "insight" into cortical pharmacology and disease

The retina is an easily accessible out-pouching of the central nervous system (CNS) and thus lends itself to being a biomarker of the brain. More specifically, the presence of neuronal, vascular and blood-neural barrier parallels in the eye and brain coupled with fast and inexpensive methods to quantify retinal changes make ocular biomarkers an attractive option. This includes its utility as a biomarker for a number of cerebrovascular diseases as well as a drug pharmacology and safety biomarker for the CNS. It is a rapidly emerging field, with some areas well established, such as stroke risk and multiple sclerosis, whereas others are still in development (Alzheimer's, Parkinson's, psychological disease and cortical diabetic dysfunction). The current applications and future potential of retinal biomarkers, including potential ways to improve their sensitivity and specificity are discussed. This review summarises the existing literature and provides a perspective on the strength of current retinal biomarkers and their future potential.

The brain through the retina: the flash electroretinogram as a tool to investigate psychiatric disorders

Investigating the living brain remains one of the major obstacles in psychiatry research in order to better understand the biological underpinning of brain disorders. Novel approaches are needed to study brain functions indirectly. Since it is part of the central nervous system, retinal functions as measured with the flash electroretinogram (ERG) may reflect the central dysfunctions reported in psychiatric disorders. This review describes the flash ERG anomalies reported in patients with psychiatric disorders such as seasonal affective disorder, schizophrenia, autism spectrum disorder and drug addiction and discusses how changes in retinal functions might be used as biomarkers for psychiatric disorder as well as a potential aid to diagnosis in psychiatry.

Electroretinographic modifications induced by agomelatine: a novel avenue to the understanding of the claimed antidepressant effect of the drug?

BACKGROUND

Agomelatine, the first melatonergic antidepressant, has been postulated to enhance the dopaminergic activity at the central nervous system by 5-hydroxytryptamine receptor type 2C (5-HT2C) antagonism, yet the impact of melatonergic agonism on this pathway is unclear. Previous studies employing simplified, yet reliable, proxy (retinal) measures of the central nervous system dopaminergic activity, namely the standard electroretinogram (ERG) technique, suggested a reduction of the dopaminergic activity of the main ERG parameter, the b-wave, by pure melatonin, notably a hormone devoid of any antidepressant activity. Therefore, the antidepressant effects of the melatonergic antidepressant drug agomelatine should be reflected by a differential b-wave trend at ERG versus the effect exerted by pure melatonin, which was eventually found to be due to a contrasting effect on central dopaminergic transmission between the two drugs.

OBJECTIVE AND METHODS

The aim of the present preliminary ERG study carried out on healthy volunteers (n=23) receiving agomelatine was to explore the impact of this antidepressant drug on b-wave amplitude and latency of cones in daylight conditions using standard ERG.

RESULTS

As postulated, agomelatine induced an enhancement of retinal dopaminergic activity, in contrast to what has been previously documented for melatonin.

CONCLUSION

Given the limits of this explorative study, especially the lack of a control group and that of a luminance response function to measure retinal sensitivity, further studies in clinical samples are recommended to allow more tenable conclusions about the potential role of ERG in discriminating between 5-HT antagonism and melatonergic (MT) agonism in relationship to the claimed antidepressant effect of agomelatine.

Electroretinographic assessment in major depressed patients receiving duloxetine: might differences between responders and non-responders indicate a differential biological background?

INTRODUCTION

Despite intense research efforts, still too little is known about the biological determinants of depression, thus soliciting diverse study approaches. Among others, the electroretinography (ERG) has been proposed even as a putative proxy (retinal) measurement of central dopaminergic activity for Major Depressive Disorder (MDD) both in drug-naïve patients and subjects receiving antidepressant treatments. Nonetheless, current evidences are merely preliminary, essentially considering just older classes of antidepressants, thus requiring confirmation studies even with newer agents as duloxetine.

METHOD

Twenty MDD subjects and 20 matched controls received duloxetine 60 mg/day for 12 weeks, being monitored both by standard ERG recording and by administration of the Hamilton scales for Depression and Anxiety and the Young Mania Rating Scale at baseline and week 12 (end of the study).

RESULTS

ERG mean rod b-wave amplitude significantly reduced from baseline to week 12 in those depressed subjects achieving final response (p=.024), decreasing from the highest rank values to the ones, substantially unmodified, seen among non-responders and controls.

LIMITATIONS

Small sample size and lack of multiple assessments.

CONCLUSIONS

At least some MDD patients responding to duloxetine might exhibit a peculiar ERG pattern, hypothetically indicating a specific biological background. If confirmed by larger-sampled studies, these results might shed further light in the understanding of the biological determinants of different subtypes of depression, ideally showing alternative patterns of response upon different treatment interventions.

A systematic, updated review on the antidepressant agomelatine focusing on its melatonergic modulation

Objective:

To present an updated, comprehensive review on clinical and pre-clinical studies on agomelatine.

Method:

A MEDLINE, Psycinfo and Web of Science search (1966-May 2009) was performed using the following keywords: agomelatine, melatonin, S20098, efficacy, safety, adverse effect, pharmacokinetic, pharmacodynamic, major depressive disorder, bipolar disorder, Seasonal Affective Disorder (SAD), Alzheimer, ADHD, Generalized Anxiety Disorder (GAD), Panic Disorder (PD), Obsessive-Compulsive Disorder (OCD), anxiety disorders and mood disorder.

Study collection and data extraction:

All articles in English identified by the data sources were evaluated. Randomized, controlled clinical trials involving humans were prioritized in the review. The physiological bases of melatonergic transmission were also examined to deepen the clinical comprehension of agomelatine’ melatonergic modulation.

Data synthesis:

Agomelatine, a melatonergic analogue drug acting as MT₁/MT₂ agonist and 5-HT_2C antagonist, has been reported to be an effective antidepressant therapy.

Conclusions:

Although a bias in properly assessing the “sleep core” of depression may still exist with current screening instruments, therefore making difficult to compare agomelatine’ efficacy to other antidepressant ones, comparative studies showed agomelatine to be an intriguing option for depression and, potentially, for other therapeutic targets as well.

Pathogenesis of degenerative retinopathies induced by thioridazine and other antipsychotics: a dopamine hypothesis

Thioridazine and other antipsychotics (neuroleptics, dopaminergic antagonists) can cause degenerative retinopathies with histological, electrophysiological and symptomatological features similar to those of primary retinitis pigmentosa. It was formerly suggested that these retinopathies are due to drug absorption by melanin of the eye which damages the choriocapillaris first and subsequently the photoreceptors and the retinal pigment epithelium. An alternative explanation of the still unclear mechanisms involved in the pathogenesis of thioridazine and other phenothiazines retinopathies has underlined the role of the drug effects on the activity of some retinal enzymatic systems which can lead to retinal dystrophy. More recent data on the complex role of dopamine (DA) and of its receptor subtypes in the retina has provided evidence that the D2 family of DA receptors, in particular the D4 receptor, is involved in the control of the synthesis of melatonin, a factor that has been shown to regulate several aspects of retinal physiology and to increase photoreceptor susceptibility to be damaged by light. Based on this knowledge, as well as on clinical data and on pharmacological considerations concerning the differences recently shown to exist among the various antipsychotics as regards their affinity for the DA receptor subtypes, we hypothesize that neuroleptic induced blockade of retinal D2/D4 receptors is among the initial events of these drug-induced degenerative retinopathies. Clinicians should be aware of the retinotoxic effects not only of thioridazine and some others phenothiazines, but also of those possibly caused by other typical and atypical antipsychotics. By evaluating the retinal status and function before and during the treatment of psychiatric patients, it should be possible to choose more accurately the safest drugs, particularly when treating predisposed subjects.

The effects of dopamine blockade on the human flash electroretinogram

Single-cell electrophysiologic studies have shown that dopamine modulates retinal activity, but its role in human retinal processing is unclear. We investigated the effects of short-term oral administration of dopaminergic receptor blocking agents on the flash electroretinogram in humans. Both chlorpromazine (25 and 50 mg) and fluphenazine (1 and 2 mg) significantly reduced electroretinogram b-wave amplitudes and also selectively reduced the amplitude of the first oscillatory potential. Implicit times were not altered. Metoclopramide (10 and 20 mg) had no effect on any electroretinographic variable. Our study indicates that dopamine receptor blocking agents with both D-1 and D-2 receptor affinities reduce the amplitude of the electroretinogram in humans.

Selective effects of retinal dopamine depletion on partial ischemia-induced electroretinographic hyperresponses in rabbits

The interaction of retinal dopamine depletion and partial ischemia on the a- and b-wave amplitudes and implicit times of the electroretinogram was examined in adult pigmented rabbits. Seven days after 6-hydroxydopamine treatment, which resulted in a depletion of the amine, partial retinal ischemia was induced by raising the intraocular pressure. As expected, moderate elevation of intraocular pressure produced increases in both a- and b-wave amplitudes. Amplitude hyperresponses were significantly reduced in dopamine-depleted retinas. These reductions were more prominent with relatively lower intensities. However, response delays were not shortened but lengthened by 6-hydroxydopamine pretreatment. Together, these results point to a selective role of dopamine in partial retinal ischemia induced by moderate elevation of intraocular pressure in rabbits.