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Khademi A, Kamyab P, Kouchaki H, Kazemi M, Goharinia M. Age of onset, sociodemographic, and clinical predictors of depression: a population-based study in Rural Southern Iran. BMC Public Health 2025; 25:1825. [PMID: 40382587 PMCID: PMC12085029 DOI: 10.1186/s12889-025-22993-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2025] [Accepted: 04/30/2025] [Indexed: 05/20/2025] Open
Abstract
BACKGROUND Depression is the leading cause of disability worldwide and a growing public health concern. In Iran, the prevalence of depression has shown an increasing trend, with rural populations facing unique challenges in access to mental health care. This study aimed to determine sociodemographic and clinical predictors of depression and explore how these factors influence age at onset in a rural population, providing valuable insights for preventive strategies. METHODS The present cross-sectional investigation utilized baseline data of the Fasa PERSIAN Cohort, comprising 10,133 adults aged 35 and older from a rural region in southern Iran. Depression diagnoses were based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Logistic regression analyses were conducted to identify predictors of depression, while linear regression models examined associations between baseline characteristics and age at depression onset. RESULTS Among participants, 6.7% met the criteria for depression, with a higher prevalence among females (78.7%) and the unemployed (70.9%). Independent predictors included female sex, unemployed status, literacy, diabetes, fatty liver disease, and psychiatric comorbidities, which emerged as the strongest predictor (odds ratio = 6.605, p < 0.001). The average age at depression onset was 39.5 years, with men experiencing onset earlier than women. Earlier onset was also associated with higher education levels, opioid use, psychiatric comorbidities, and higher energy intake, whereas later onset was linked to medical conditions, including hypertension, cardiovascular disease, and stroke. CONCLUSION This study highlights important demographic and clinical factors linked to depression and its age of onset, underscoring the complex interplay between sociodemographic characteristics, lifestyle factors, and comorbidities. These findings can guide targeted mental health interventions and support tailored prevention strategies in similar rural populations.
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Affiliation(s)
- Ali Khademi
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | - Parnia Kamyab
- Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Zand Avenue, Shiraz, 71348-14336, Iran.
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Hosein Kouchaki
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Kazemi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Mohsen Goharinia
- Clinical Research Development Unit, Valiasr Hospital, Fasa University of Medical Sciences, Fasa, 74616-86688, Iran.
- Department of Pharmacology, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran.
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Enderami A, Shariati B, Zarghami M, Aliasgharian A, Ghazaiean M, Darvishi‐Khezri H. Metformin and Cognitive Performance in Patients With Type 2 Diabetes: An Umbrella Review. Neuropsychopharmacol Rep 2025; 45:e12528. [PMID: 39871536 PMCID: PMC11772738 DOI: 10.1002/npr2.12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 01/02/2025] [Accepted: 01/05/2025] [Indexed: 01/29/2025] Open
Abstract
Contradictory results for the association between metformin intake and changes in cognitive function have been reported. We attempted to overview systematic reviews and meta-analyses showing the role of metformin, as mono or combination therapy, in cognitive performance alterations among patients with type 2 diabetes mellitus (T2DM) and to determine the quality of the evidence as well. To find the English-written reviews, a literature search was conducted on PubMed, Web of Science, Scopus, Cochrane Library, Trip, and Google Scholar by May 1, 2023. The literature search unearthed 2672 records, 10 of which were included in the study. Metformin may provide cognitive benefits for patients with type 2 diabetes, as evidence suggests potential improvements in memory and a reduced risk of neurodegenerative diseases. Even though the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) score alterations correspond to raising concerns about cognitive decline, Mini-Mental State Examination (MMSE) and selective reminding test (SRT) score improvements support metformin's role in improving specific cognitive domains. As such, metformin may exert differential impacts on various aspects of cognitive performance in these patients. However, the inconsistency and low quality of current evidence point toward the need for accurate research to elucidate whether metformin's cognitive effects are protective, neutral, or context-dependent based on patient profiles.
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Affiliation(s)
- Athena Enderami
- Department of Psychiatry, School of MedicineMazandaran University of Medical SciencesSariIran
| | - Behnam Shariati
- Mental Health Research CenterIran University of Medical SciencesTehranIran
| | - Mehran Zarghami
- Department of Psychiatry, School of Medicine and Psychiatry and Behavioral Sciences Research CenterAddiction Institute, Mazandaran University of Medical SciencesSariIran
| | - Aily Aliasgharian
- Thalassemia Research Center (TRC)Hemoglobinopathy Institute, Mazandaran University of Medical SciencesSariIran
| | - Mobin Ghazaiean
- Gut and Liver Research CenterNon‐communicable Disease Institute, Mazandaran University of Medical SciencesSariIran
| | - Hadi Darvishi‐Khezri
- Thalassemia Research Center (TRC)Hemoglobinopathy Institute, Mazandaran University of Medical SciencesSariIran
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Yoshida S, Aizawa E, Ishihara N, Hattori K, Segawa K, Kunugi H. High Rates of Abnormal Glucose Metabolism Detected by 75 g Oral Glucose Tolerance Test in Major Psychiatric Patients with Normal HbA1c and Fasting Glucose Levels. Nutrients 2025; 17:613. [PMID: 40004942 PMCID: PMC11858036 DOI: 10.3390/nu17040613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Revised: 02/06/2025] [Accepted: 02/06/2025] [Indexed: 02/27/2025] Open
Abstract
Objectives: Comorbid diabetes is an important factor in the treatment of major psychiatric disorders. However, a substantial proportion of diabetic patients remain undetected by routine diabetic indices such as blood glucose and HbA1c. This study tried to estimate rates of such unidentified diabetic or prediabetic patients by using a 75 g oral glucose tolerance test (OGTT). Methods: Participants in the test were 25 patients with major depressive disorder (MDD), 28 patients with bipolar disorder (BP), 26 patients with schizophrenia, and 28 psychiatrically normal controls. They were all Japanese, and showed non-diabetic levels of blood glucose (<126 mg/dL) and HbA1c (<6.0%). Results: Relatively high rates of psychiatric patients showed diabetes mellites (DM)-type abnormality (32% of MDD, 21.4% of BP and 42.3% of schizophrenia v. 10.7% of controls). The difference in the rates between schizophrenia and control groups was statistically significant (p = 0.008). When abnormal glucose metabolism was defined as a prediabetic state (either normal high glycemia, impaired fast glycemia or impaired glucose tolerance) or DM type in OGTT, it was more frequently seen in the psychiatric patients than in controls (64% of MDD, 46.4% of BP and 46.2% of schizophrenia v. 35.7% of controls). Individuals with DM type showed higher HbA1c values compared with those with normal (p < 0.001) and prediabetic (p = 0.021) states. Conclusions: The results suggest that relatively high proportions of patients with a major psychiatric disorder remain undetected by routine indices for abnormal glucose metabolism, indicating the importance of OGTT even if the patients showed non-diabetic levels in blood glucose or HbA1c.
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Affiliation(s)
- Sumiko Yoshida
- Department of Psychiatric Rehabilitation, National Center of Neurology and Psychiatry Hospital, Tokyo 187-8551, Japan
- Mood Disorder Center for Advanced Therapy, National Center of Neurology and Psychiatry Hospital, Tokyo 187-8551, Japan;
- Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan;
| | - Emiko Aizawa
- Department of Mental Disorder Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan;
- Faculty of Human Sciences, Sendai Shirayuri Women’s University, Sendai 981-3107, Japan
| | - Naoko Ishihara
- Mood Disorder Center for Advanced Therapy, National Center of Neurology and Psychiatry Hospital, Tokyo 187-8551, Japan;
- Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan;
| | - Kotaro Hattori
- Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan;
- Department of Mental Disorder Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan;
| | - Kazuhiko Segawa
- Department of General Medicine, National Center of Neurology and Psychiatry Hospital, Tokyo 187-8551, Japan;
| | - Hiroshi Kunugi
- Mood Disorder Center for Advanced Therapy, National Center of Neurology and Psychiatry Hospital, Tokyo 187-8551, Japan;
- Department of Mental Disorder Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan;
- Department of Psychiatry, Teikyo University School of Medicine, Tokyo 173-8605, Japan
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Fanelli G, Raschi E, Hafez G, Matura S, Schiweck C, Poluzzi E, Lunghi C. The interface of depression and diabetes: treatment considerations. Transl Psychiatry 2025; 15:22. [PMID: 39856085 PMCID: PMC11760355 DOI: 10.1038/s41398-025-03234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 12/11/2024] [Accepted: 01/10/2025] [Indexed: 01/27/2025] Open
Abstract
This state-of-the-art review explores the relationship between depression and diabetes, highlighting the two-way influences that make treatment challenging and worsen the outcomes of both conditions. Depression and diabetes often co-occur and share genetic, lifestyle, and psychosocial risk factors. Lifestyle elements such as diet, physical activity, and sleep patterns play a role on the development and management of both conditions, highlighting the need for integrated treatment strategies. The evidence suggests that traditional management strategies focusing on either condition in isolation fall short of addressing the intertwined nature of diabetes and depression. Instead, integrated care models encompassing psychological support and medical management are recommended to improve treatment efficacy and patient adherence. Such models require collaboration across multiple healthcare disciplines, including endocrinology, psychiatry, and primary care, to offer a holistic approach to patient care. This review also identifies significant patient-related barriers to effective management, such as stigma, psychological resistance, and health literacy, which need to be addressed through patient-centered education and support systems. Future directions for research include longitudinal studies in diverse populations to further elucidate causal relationships and the exploration of novel therapeutic targets, as well as the effectiveness of healthcare models aimed at preventing the onset of one condition in individuals diagnosed with the other.
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Affiliation(s)
- Giuseppe Fanelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Silke Matura
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Carmen Schiweck
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elisabetta Poluzzi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlotta Lunghi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
- Population Health and Optimal Health Practices Research Group, CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada.
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Xie X, Li W, Xiong Z, Xu J, Liao T, Sun L, Xu H, Zhang M, Zhou J, Xiong W, Fu Z, Li Z, Han Q, Cui D, Anthony DC. Metformin reprograms tryptophan metabolism via gut microbiome-derived bile acid metabolites to ameliorate depression-Like behaviors in mice. Brain Behav Immun 2025; 123:442-455. [PMID: 39303815 DOI: 10.1016/j.bbi.2024.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 09/08/2024] [Accepted: 09/13/2024] [Indexed: 09/22/2024] Open
Abstract
As an adjunct therapy, metformin enhances the efficacy of conventional antidepressant medications. However, its mode of action remains unclear. Here, metformin was found to ameliorate depression-like behaviors in mice exposed to chronic restraint stress (CRS) by normalizing the dysbiotic gut microbiome. Fecal transplants from metformin-treated mice ameliorated depressive behaviors in stressed mice. Microbiome profiling revealed that Akkermansia muciniphila (A. muciniphila), in particular, was markedly increased in the gut by metformin and that oral administration of this species alone was sufficient to reverse CRS-induced depressive behaviors and normalize aberrant stress-induced 5-hydroxytryptamine (5-HT) metabolism in the brain and gut. Untargeted metabolomic profiling further identified the bile acid metabolites taurocholate and deoxycholic acid as direct A. muciniphila-derived molecules that are, individually, sufficient to rescue the CRS-induced impaired 5-HT metabolism and depression-like behaviors. Thus, we report metformin reprograms 5-HT metabolism via microbiome-brain interactions to mitigate depressive syndromes, providing novel insights into gut microbiota-derived bile acids as potential therapeutic candidates for depressive mood disorders from bench to bedside.
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Affiliation(s)
- Xiaoxian Xie
- Shanghai Mental Health Center, Shanghai Jiao Tong University, School of Medicine, Shanghai 201109, PR China; Department of Pharmacology, University of Oxford, Mansfield Road, OX1 3QT Oxford, UK; College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, PR China
| | - Wenwen Li
- Affiliated Mental Health Center and Hangzhou Seventh People's Hospital, School of Brain Science and Brain Medicine, Zhejiang University School of Medicine, Hangzhou 310058, PR China
| | - Ze Xiong
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, PR China
| | - Junyu Xu
- NHC and CAMS Key Laboratory of Medical Neurobiology, Ministry of Education Frontier Science Center for Brain Research and Brain Machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, PR China
| | - Tailin Liao
- NHC and CAMS Key Laboratory of Medical Neurobiology, Ministry of Education Frontier Science Center for Brain Research and Brain Machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, PR China
| | - Lei Sun
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, PR China
| | - Haoshen Xu
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, PR China
| | - Mengya Zhang
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, PR China
| | - Jiafeng Zhou
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, PR China
| | - Wenzheng Xiong
- Department of Pharmacology, University of Oxford, Mansfield Road, OX1 3QT Oxford, UK
| | - Zhengwei Fu
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou 310032, PR China
| | - Zezhi Li
- The Affiliated Brain Hospital, Guangzhou Medical University, Guangzhou 510370, PR China; Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, PR China.
| | - Qi Han
- Center for Brain Science Shanghai Children s Medical Center, Department of Anatomy and Physiology, Shanghai Frontiers Science Center of Cellular Homeostasis and Human Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, PR China; Shanghai Center for Brain Science and Brain-inspired Technology, Shanghai 200031, PR China.
| | - Donghong Cui
- Shanghai Mental Health Center, Shanghai Jiao Tong University, School of Medicine, Shanghai 201109, PR China.
| | - Daniel C Anthony
- Department of Pharmacology, University of Oxford, Mansfield Road, OX1 3QT Oxford, UK
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Zhang J, Sun R, Cai Y, Peng B, Yang X, Gao K. Efficacy and Safety of Antidiabetic Agents for Major Depressive Disorder and Bipolar Depression: A Meta-Analysis of Randomized, Double-Blind, Placebo-Controlled Trials. J Clin Med 2024; 13:1172. [PMID: 38398483 PMCID: PMC10889473 DOI: 10.3390/jcm13041172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND This meta-analysis aimed to determine the efficacy and safety of antidiabetic agents in the treatment of major depressive disorder and bipolar depression. METHODS Randomized controlled trials (RCTs) of antidiabetic agents in major depressive disorder or bipolar depression were searched in three electronic databases and three clinical trial registry websites from their inception up to October 2023. The differences in changes in the depression rating scale scores from baseline to endpoint or pre-defined sessions, response rate, remission rate, rate of side effects and dropout rate between antidiabetic agents and placebo were meta-analyzed. RESULTS Six RCTs involving 399 participants were included in the final meta-analysis, which did not find that antidiabetics outperformed the placebo in reducing depressive symptoms. The standardized mean difference (SMD) in the depression scores from baseline to endpoint was 0.25 (95% CI -0.1, 0.61). However, a subgroup analysis found a significant difference between antidiabetics and placebos in reducing depressive symptoms in Middle Eastern populations, with an SMD of 0.89 (95% CI 0.44, 1.34). CONCLUSIONS The current meta-analysis does not support the efficacy of antidiabetics being superior to the placebo in the treatment of unipolar and bipolar depression. However, a subgroup analysis indicates that patients from the Middle East may benefit from adding an antidiabetic medication to their ongoing medication(s) for their depression. Larger studies with good-quality study designs are warranted.
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Affiliation(s)
- Jian Zhang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
- Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, 10524 Euclid Ave, 12th Floor, Cleveland, OH 44106, USA
| | - Rongyi Sun
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Yang Cai
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Bo Peng
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
| | - Xi Yang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen 518020, China; (J.Z.)
| | - Keming Gao
- Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, 10524 Euclid Ave, 12th Floor, Cleveland, OH 44106, USA
- Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
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Zhang Y, Chan VKY, Chan SSM, Chan EWY, Lee CH, Wong IC, Li X. Effect of metformin on the risk of depression: A systematic review and meta-regression of observational studies. Asian J Psychiatr 2024; 92:103894. [PMID: 38157715 DOI: 10.1016/j.ajp.2023.103894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Yin Zhang
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Vivien Kin-Yi Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Sandra Sau Man Chan
- Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Esther Wai Yin Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region of China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong Special Administrative Region of China
| | - Chi Ho Lee
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region of China
| | - Ian Ck Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region of China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong Special Administrative Region of China; Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom; Aston School of Pharmacy, Aston University, Birmingham, United Kingdom
| | - Xue Li
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region of China; Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region of China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong Special Administrative Region of China.
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Kuate Defo A, Bakula V, Pisaturo A, Labos C, Wing SS, Daskalopoulou SS. Diabetes, antidiabetic medications and risk of dementia: A systematic umbrella review and meta-analysis. Diabetes Obes Metab 2024; 26:441-462. [PMID: 37869901 DOI: 10.1111/dom.15331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/12/2023] [Accepted: 09/29/2023] [Indexed: 10/24/2023]
Abstract
AIMS The objective of this umbrella review and meta-analysis was to evaluate the effect of diabetes on risk of dementia, as well as the mitigating effect of antidiabetic treatments. MATERIALS AND METHODS We conducted a systematic umbrella review on diabetes and its treatment, and a meta-analysis focusing on treatment. We searched MEDLINE/PubMed, Embase, PsycINFO, CINAHL and the Cochrane Library for systematic reviews and meta-analyses assessing the risk of cognitive decline/dementia in individuals with diabetes until 2 July 2023. We conducted random-effects meta-analyses to obtain risk ratios and 95% confidence intervals estimating the association of metformin, thiazolidinediones, pioglitazone, dipeptidyl peptidase-4 inhibitors, α-glucosidase inhibitors, meglitinides, insulin, sulphonylureas, glucagon-like peptide-1 receptor agonists (GLP1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) with risk of dementia from cohort/case-control studies. The subgroups analysed included country and world region. Risk of bias was assessed with the AMSTAR tool and Newcastle-Ottawa Scale. RESULTS We included 100 reviews and 27 cohort/case-control studies (N = 3 046 661). Metformin, thiazolidinediones, pioglitazone, GLP1RAs and SGLT2is were associated with significant reduction in risk of dementia. When studies examining metformin were divided by country, the only significant effect was for the United States. Moreover, the effect of metformin was significant in Western but not Eastern populations. No significant effect was observed for dipeptidyl peptidase-4 inhibitors, α-glucosidase inhibitors, or insulin, while meglitinides and sulphonylureas were associated with increased risk. CONCLUSIONS Metformin, thiazolidinediones, pioglitazone, GLP1RAs and SGLT2is were associated with reduced risk of dementia. More longitudinal studies aimed at determining their relative benefit in different populations should be conducted.
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Affiliation(s)
- Alvin Kuate Defo
- Vascular Health Unit, Research Institute of the McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Veselko Bakula
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | - Christopher Labos
- Vascular Health Unit, Research Institute of the McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Simon S Wing
- Division of Endocrinology & Metabolism, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Stella S Daskalopoulou
- Vascular Health Unit, Research Institute of the McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Internal Medicine, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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Chen X, Zhao P, Wang W, Guo L, Pan Q. The Antidepressant Effects of GLP-1 Receptor Agonists: A Systematic Review and Meta-Analysis. Am J Geriatr Psychiatry 2024; 32:117-127. [PMID: 37684186 DOI: 10.1016/j.jagp.2023.08.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/05/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023]
Abstract
AIM/HYPOTHESIS Emerging evidence suggests that glucagon-like peptide-1 receptor agonists (GLP-1RAs) may exert positive effects in patients with depression. Our aim was to conduct a systematic review and meta-analysis to examine the antidepressant effects of GLP-1RAs. METHODS Randomized controlled trials and prospective cohort studies investigating the effects of GLP-1RAs versus placebo or other antidiabetic therapies on depressive symptoms were searched for using multiple electronic sources (CENTRAL, PubMed, EMBASE, PsycINFO, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, China Network Knowledge Infrastructure, China Biomedical Database, Wan Fang data, and Chinese Scientific Journals Database) from inception to February 16, 2023. We utilized a random effects model to analyze standardized mean differences for the change in depression rating scales comparing GLP-1RA treated groups with control treated groups. RESULTS The meta-analysis comprising 2,071 participants included 5 randomized controlled trials and 1 prospective cohort study. The meta-analysis indicated that the change from baseline in depression rating scale scores decreased significantly when patients received treatment with GLP-1RAs compared to control treatments (SMD = -0.12, 95% CI [-0.21, -0.03], pSMD <0.01, I2 = 0%, pQ = 0.52). The subgroup analysis showed that the effects of GLP-1RAs on depressive symptoms were consistent in patients with Type 2 diabetes mellitus (SMD = -0.12, 95% CI [-0.21, -0.03], pSMD <0.01, I2 = 2%, pQ = 0.40). CONCLUSIONS Adults treated with GLP-1RAs showed significant reductions in the depression rating scale scores compared to those treated with control substances. Our findings suggest that GLP-1RAs may be a potential treatment for alleviating depressive symptoms in humans.
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Affiliation(s)
- Xinda Chen
- Department of Endocrinology (XC), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Beijing, China
| | - Peiyi Zhao
- Department of Endocrinology (PZ, WW, LG, QP), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China; Graduate School of Peking Union Medical College (PZ), Beijing 100730, China
| | - Weihao Wang
- Department of Endocrinology (PZ, WW, LG, QP), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Lixin Guo
- Department of Endocrinology (PZ, WW, LG, QP), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Pan
- Department of Endocrinology (PZ, WW, LG, QP), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China.
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Strekalova T, Svirin E, Gorlova A, Sheveleva E, Burova A, Khairetdinova A, Sitdikova K, Zakharova E, Dudchenko AM, Lyundup A, Morozov S. Resilience and Vulnerability to Stress-Induced Anhedonia: Unveiling Brain Gene Expression and Mitochondrial Dynamics in a Mouse Chronic Stress Depression Model. Biomolecules 2023; 13:1782. [PMID: 38136653 PMCID: PMC10741640 DOI: 10.3390/biom13121782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
The role of altered brain mitochondrial regulation in psychiatric pathologies, including Major Depressive Disorder (MDD), has attracted increasing attention. Aberrant mitochondrial functions were suggested to underlie distinct inter-individual vulnerability to stress-related MDD syndrome. In this context, insulin receptor sensitizers (IRSs) that regulate brain metabolism have become a focus of recent research, as their use in pre-clinical studies can help to elucidate the role of mitochondrial dynamics in this disorder and contribute to the development of new antidepressant treatment. Here, following 2-week chronic mild stress (CMS) using predation, social defeat, and restraint, MDD-related behaviour and brain molecular markers have been investigated along with the hippocampus-dependent performance and emotionality in mice that received the IRS dicholine succinate (DS). In a sucrose test, mice were studied for the key feature of MDD, a decreased sensitivity to reward, called anhedonia. Based on this test, animals were assigned to anhedonic and resilient-to-stress-induced-anhedonia groups, using a previously established criterion of a decrease in sucrose preference below 65%. Such assignment was based on the fact that none of control, non-stressed animals displayed sucrose preference that would be smaller than this value. DS-treated stressed mice displayed ameliorated behaviours in a battery of assays: sucrose preference, coat state, the Y-maze, the marble test, tail suspension, and nest building. CMS-vulnerable mice exhibited overexpression of the inflammatory markers Il-1β, tnf, and Cox-1, as well as 5-htt and 5-ht2a-R, in various brain regions. The alterations in hippocampal gene expression were the closest to clinical findings and were studied further. DS-treated, stressed mice showed normalised hippocampal expression of the plasticity markers Camk4, Camk2, Pka, Adcy1, Creb-ar, Nmda-2r-ar, and Nmda-2r-s. DS-treated and non-treated stressed mice who were resilient or vulnerable to anhedonia were compared for hippocampal mitochondrial pathway regulation using Illumina profiling. Resilient mice revealed overexpression of the mitochondrial complexes NADH dehydrogenase, succinate dehydrogenase, cytochrome bc1, cytochrome c oxidase, F-type and V-type ATPases, and inorganic pyrophosphatase, which were decreased in anhedonic mice. DS partially normalised the expression of both ATPases. We conclude that hippocampal reduction in ATP synthesis is associated with anhedonia and pro-inflammatory brain changes that are ameliorated by DS.
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Affiliation(s)
- Tatyana Strekalova
- Division of Molecular Psychiatry, Center of Mental Health, University of Hospital Würzburg, 97080 Wuerzburg, Germany
| | - Evgeniy Svirin
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Anna Gorlova
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Elizaveta Sheveleva
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Alisa Burova
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Adel Khairetdinova
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Kseniia Sitdikova
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Elena Zakharova
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Alexander M. Dudchenko
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
| | - Aleksey Lyundup
- Endocrinology Research Centre, Dmitry Ulyanov St. 19, Moscow 117036, Russia;
- Research and Education Resource Center, Peoples Friendship University of Russia (RUDN University), 6 Miklukho-Maklaya St, Moscow 117198, Russia
| | - Sergey Morozov
- Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, Moscow 125315, Russia (A.G.); (E.S.); (A.B.); (A.K.); (K.S.); (E.Z.); (A.M.D.); (S.M.)
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11
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Possidente C, Fanelli G, Serretti A, Fabbri C. Clinical insights into the cross-link between mood disorders and type 2 diabetes: A review of longitudinal studies and Mendelian randomisation analyses. Neurosci Biobehav Rev 2023; 152:105298. [PMID: 37391112 DOI: 10.1016/j.neubiorev.2023.105298] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/15/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023]
Abstract
Mood disorders and type 2 diabetes mellitus (T2DM) are prevalent conditions that often co-occur. We reviewed the available evidence from longitudinal and Mendelian randomisation (MR) studies on the relationship between major depressive disorder (MDD), bipolar disorder and T2DM. The clinical implications of this comorbidity on the course of either condition and the impact of antidepressants, mood stabilisers, and antidiabetic drugs were examined. Consistent evidence indicates a bidirectional association between mood disorders and T2DM. T2DM leads to more severe depression, whereas depression is associated with more complications and higher mortality in T2DM. MR studies demonstrated a causal effect of MDD on T2DM in Europeans, while a suggestive causal association in the opposite direction was found in East Asians. Antidepressants, but not lithium, were associated with a higher T2DM risk in the long-term, but confounders cannot be excluded. Some oral antidiabetics, such as pioglitazone and liraglutide, may be effective on depressive and cognitive symptoms. Studies in multi-ethnic populations, with a more careful assessment of confounders and appropriate power, would be important.
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Affiliation(s)
- Chiara Possidente
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giuseppe Fanelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Department of Human Genetics, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Alessandro Serretti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
| | - Chiara Fabbri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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12
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Kunugi H. Depression and lifestyle: Focusing on nutrition, exercise, and their possible relevance to molecular mechanisms. Psychiatry Clin Neurosci 2023; 77:420-433. [PMID: 36992617 PMCID: PMC11488618 DOI: 10.1111/pcn.13551] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/03/2023] [Accepted: 03/25/2023] [Indexed: 03/31/2023]
Abstract
Accumulating evidence has suggested the important role of lifestyle factors in depressive disorder. This paper aimed to introduce and outline recent research on epidemiological and intervention studies on lifestyle-related factors in depressive disorder with a special focus on diet. Evidence on exercise, sleep. and related behaviors is also described. Here, findings from meta-analytic studies are emphasized and related studies by the author's research group are introduced. Dietary factors that increase the risk of the illness include energy overload, skipping breakfast, unhealthy diet styles such as Western diet, inflammation-prone diet, and high consumption of ultraprocessed food (UPF). Nutritional imbalances such as inadequate intake of protein, fish (Ω3 polyunsaturated fatty acids), vitamins (folate and vitamin D), and minerals (iron and zinc) increases the risk of depression. Poor oral hygiene, food allergy, addiction to alcohol, and smoking constitute risk factors. Sedentary lifestyle and increased screen time (e.g. video games and the internet) confer the risk of depression. Insomnia and disturbed sleep-wake rhythm are also involved in the pathogenesis of depression. There is accumulating evidence at the meta-analysis level for interventions to modify these lifestyle habits in the protection and treatment of depressive disorder. Main biological mechanisms of the link between lifestyle factors and depression include monoamine imbalance, inflammation, altered stress response, oxidative stress, and dysfunction of brain-derived neurotrophic factor, although other players such as insulin, leptin, and orexin also play a role. To increase resilience to modern stress and ameliorate depression through modification of lifestyle habits, a list of 30 recommendable interventions is presented.
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Affiliation(s)
- Hiroshi Kunugi
- Department of PsychiatryTeikyo University School of MedicineTokyoJapan
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13
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Nolasco-Rosales GA, Villar-Juárez GE, Pérez-Osorio DA, Cruz-Castillo JD, Molina-Guzmán G, González-Castro TB, Tovilla-Zárate CA, Rodríguez-Sánchez E, Genis-Mendoza AD, Hernández-Palacios F, Juárez-Rojop IE. Assessment of cognitive impairment and depressive signs in patients with type 2 diabetes treated with metformin from Southeast Mexico: A cross-sectional study. J Psychiatr Res 2023; 162:65-70. [PMID: 37088045 DOI: 10.1016/j.jpsychires.2023.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/21/2023] [Accepted: 04/05/2023] [Indexed: 04/25/2023]
Abstract
Multiple factors associate diabetes with cognitive impairment and depression. Antidiabetic drugs have reported antidepressant and pro-cognitive effects in diabetic and non-diabetic subjects. Antidepressant and pro-cognitive effects of metformin are reported in various studies; however, these effects are not consistent among researches. We designed a cross-sectional study. We recruited patients with T2D diagnosis from the Diabetes Clinic of the Regional Hospital of High Specialty "Dr. Gustavo A. Rovirosa Pérez" from January 2019 to May 2022. We included 431 subjects with T2D, 374 patients with metformin treatment and 57 subjects without metformin. These patients were on intensive therapies and had not a previous diagnosis of cognitive impairment or depression. We applied Mini-Mental State Examination (MMSE) to evaluate cognitive impairment, and Hamilton Depression Rating Scale (HAM-D) to assess depressive signs. Our sample had a mean age of 53.77 ± 13.43 years. Metformin users were 374 individuals, and 57 subjects didn't use metformin. MMSE found cognitive impairment in 8.3% (n = 31) of metformin users, and 14.8% (n = 8) of patients without metformin. HAM-D scale showed that 39.5% (n = 147) of patients with metformin had depression signs, subjects without metformin and depressive signs were 44.6% (n = 25). We found no differences between groups for cognitive impairment and depression grades. We did not find associations between metformin treatment, cognitive impairment measures and depression sign measures. However, chronic metformin treatment, insulin use, glycemic control and age could influence our results.
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Affiliation(s)
| | | | - Daniel Arturo Pérez-Osorio
- Universidad Juarez Autónoma de Tabasco, División Académica de Ciencias de la Salud, Villahermosa, Tabasco, Mexico
| | - Juan Daniel Cruz-Castillo
- Universidad Juarez Autónoma de Tabasco, División Académica de Ciencias de la Salud, Villahermosa, Tabasco, Mexico
| | - Gabriel Molina-Guzmán
- Instituto Mexicano del Seguro Social, Hospital General de Zona 46, Villahermosa, Tabasco, Mexico; Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital General Dr. Daniel Gurría Urgell, Villahermosa, Tabasco, Mexico
| | - Thelma Beatriz González-Castro
- Universidad Juarez Autónoma de Tabasco, División Académica Multidisciplinaria de Jalpa de Méndez, Jalpa de Méndez, Tabasco, Mexico
| | - Carlos Alfonso Tovilla-Zárate
- Universidad Juarez Autónoma de Tabasco, División Académica Multidisciplinaria de Comalcalco, Comalcalco, Tabasco, Mexico
| | - Ester Rodríguez-Sánchez
- Hospital Regional de Alta Especialidad "Gustavo A. Rovirosa Perez", Villahermosa, Tabasco, Mexico
| | - Alma Delia Genis-Mendoza
- Departamento de Genética Psiquiátrica, Instituto Nacional de Medicina Genómica, Ciudad de México, Mexico
| | - Filiberto Hernández-Palacios
- Universidad Juarez Autónoma de Tabasco, División Académica de Ciencias de la Salud, Villahermosa, Tabasco, Mexico
| | - Isela Esther Juárez-Rojop
- Universidad Juarez Autónoma de Tabasco, División Académica de Ciencias de la Salud, Villahermosa, Tabasco, Mexico.
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14
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Dodd S, Sominsky L, Siskind D, Bortolasci CC, Carvalho AF, Maes M, Walker AJ, Walder K, Yung AR, Williams LJ, Myles H, Watson T, Berk M. The role of metformin as a treatment for neuropsychiatric illness. Eur Neuropsychopharmacol 2022; 64:32-43. [PMID: 36191545 DOI: 10.1016/j.euroneuro.2022.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 09/04/2022] [Accepted: 09/07/2022] [Indexed: 12/12/2022]
Abstract
Advances in psychopharmacology have been significantly slower to evolve than in other disciplines of medicine and therefore investigation into novel therapeutic approaches is required. Additionally, concurrent metabolic conditions are prevalent among people with mental disorders. Metformin is a widely used hypoglycaemic agent that is now being studied for use beyond diabetes management. Evidence is emerging that metformin has multiple effects on diverse neurobiological pathways and consequently may be repurposed for treating mental illness. Metformin may have beneficial neuroimmunological, neuroplastic, neuro-oxidative and neuro-nitrosative effects across a range of psychiatric and neurodegenerative illnesses. Mechanisms include glucose lowering effects and effects on AMP-activated protein kinase (AMPK) signalling, however the best evidence for clinical benefit is through the glucose lowering effects, with other mechanisms less supported by the current evidence base. This narrative review aims to draw together the existing evidence for use of metformin as a psychopharmaceutical and present the role of metformin in the context of physical and psychiatric ill health, including metabolic, endocrinological and cancer domains. It not only has therapeutic potential in medical comorbidity but may have potential in core illness domains.
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Affiliation(s)
- Seetal Dodd
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Department of Psychiatry, the University of Melbourne, Parkville, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia.
| | - Luba Sominsky
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Barwon Health Laboratory, University Hospital Geelong, Barwon Health, VIC, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, MIRT, Level 2, 228 Logan Rd, Woolloongabba, Brisbane, Qld 4102, Australia University of Queensland School of Clinical Medicine, Brisbane, Australia Queensland Centre for Mental Health Research, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Chiara C Bortolasci
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Andre F Carvalho
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Michael Maes
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Adam J Walker
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Ken Walder
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Alison R Yung
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia; School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Lana J Williams
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia
| | - Hannah Myles
- Discipline of Psychiatry, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Northern Adelaide Mental Health Service, Salisbury, SA, Australia
| | - Tayler Watson
- Mental Health, Drugs and Alcohol Service, Barwon Health, Geelong VIC, Australia
| | - Michael Berk
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Geelong, Australia; Department of Psychiatry, the University of Melbourne, Parkville, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Parkville, VIC, Australia; Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
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