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Drysdale AT, Poleshuck E, Ramsey MH, Monk C. New treatments: Opportunities and challenges. Semin Perinatol 2024; 48:151941. [PMID: 39068046 DOI: 10.1016/j.semperi.2024.151941] [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] [Indexed: 07/30/2024]
Abstract
Across the spectrum of perinatal mental illness, there exist a variety of effective treatments. However, the available treatments are not always matched to the presentation, resources, constraints, or values of each patient. Furthermore, provider, local, and systemic factors complicate access to current treatment options. New and emerging approaches offer the potential of more effective treatment for specific perinatal psychiatric disorders. From neuroactive steroid medications to accelerated psychotherapy interventions, recent innovations have demonstrated enhanced efficacy on a faster timeline. Optimally, these developments will also lower barriers to care but this is not necessarily true. We review novel and upcoming interventions across perinatal mental illness and place them in the context of existing treatments and common challenges.
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Affiliation(s)
- Andrew T Drysdale
- Department of Psychiatry, Columbia University Medical Center, New York, NY, United States; New York State Psychiatric Institute, New York, NY, United States.
| | - Ellen Poleshuck
- Department of Psychiatry, University of Rochester Medical Center, United States; Department of Obstetrics and Gynecology, University of Rochester Medical Center, United States
| | - MaKenzie H Ramsey
- New York State Psychiatric Institute, New York, NY, United States; Department of Human Development, Teachers College, Columbia University, New York, NY, United States
| | - Catherine Monk
- Department of Psychiatry, Columbia University Medical Center, New York, NY, United States; New York State Psychiatric Institute, New York, NY, United States; Department of Obstetrics & Gynecology, Columbia University Medical Center, New York, NY, United States
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2
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Leistikow N, Smith MH. The role of sleep protection in preventing and treating postpartum depression. Semin Perinatol 2024; 48:151947. [PMID: 39048415 DOI: 10.1016/j.semperi.2024.151947] [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] [Indexed: 07/27/2024]
Abstract
Postpartum sleep disruption is a risk factor for postpartum depression (PPD) as well as a potential treatment target. In the first 6 months after delivery, when the risk of PPD is greatest, fragmented maternal sleep is most often related to necessary infant night feedings. Clinicians' conversations about planning for and navigating postpartum sleep should include questions about patient expectations, cultural traditions, and available support. For women at high risk of PPD, or with moderate to severe PPD or other symptoms of mental illness, protecting one 4-5 hour period of consolidated nighttime sleep may be necessary and effective. This can be achieved by having another adult step in for 1-2 infant night feedings or by employing other strategies. OBs can encourage high-risk patients to develop a postpartum plan for sleep protection by initiating this conversation during pregnancy.
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Affiliation(s)
- Nicole Leistikow
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Milena H Smith
- Department of Psychiatry & Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Scheggi S, Concas L, Corsi S, Carta M, Melis M, Frau R. Expanding the therapeutic potential of neuro(active)steroids: a promising strategy for hyperdopaminergic behavioral phenotypes. Neurosci Biobehav Rev 2024; 164:105842. [PMID: 39103066 DOI: 10.1016/j.neubiorev.2024.105842] [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: 05/23/2024] [Revised: 07/10/2024] [Accepted: 08/01/2024] [Indexed: 08/07/2024]
Abstract
Imbalances in dopamine activity significantly contribute to the pathophysiology of several neuropsychiatric disorders, including addiction, ADHD, schizophrenia, impulse control disorders, and Parkinson's Disease. Neuro(active)steroids, comprising endogenous steroids that finely modulate neuronal activity, are considered crucial regulators of brain function and behavior, with implications in various physiological processes and pathological conditions. Specifically, subclasses of Neuro(active)steroids belonging to the 5α reductase pathway are prominently involved in brain disorders characterized by dopaminergic signaling imbalances. This review highlights the neuromodulatory effects of Neuro(active)steroids on the dopamine system and related aberrant behavioral phenotypes. We critically appraise the role of pregnenolone, progesterone, and allopregnanolone on dopamine signaling. Additionally, we discuss the impact of pharmacological interventions targeting 5α reductase activity in neuropsychiatric conditions characterized by excessive activation of the dopaminergic system, ranging from psychotic (endo)phenotypes and motor complications to decision-making problems and addiction.
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Affiliation(s)
- Simona Scheggi
- Dept. of Molecular and Developmental Medicine, University of Siena, Italy
| | - Luca Concas
- Dept. Of Biomedical Sciences, University of Cagliari, Italy
| | - Sara Corsi
- Dept. of Developmental and Regenerative Neurobiology, Lund University, Sweden
| | - Manolo Carta
- Dept. Of Biomedical Sciences, University of Cagliari, Italy
| | - Miriam Melis
- Dept. Of Biomedical Sciences, University of Cagliari, Italy
| | - Roberto Frau
- Dept. Of Biomedical Sciences, University of Cagliari, Italy; Guy Everett Laboratory, University of Cagliari, Cagliari, Italy.
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Sharma P, Khera K. A novel tool for risk assessment, screening, diagnosis, assessment, and therapy in postpartum depression. Int J Gynaecol Obstet 2024; 166:617-625. [PMID: 38343269 DOI: 10.1002/ijgo.15421] [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: 10/05/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 07/18/2024]
Abstract
Postpartum depression (PPD), as a common condition occurring in women in the postnatal period, is underdiagnosed, seldom identified, and infrequently treated. Undiagnosed PPD can have negative consequences for overall quality-of-life outcomes in the mother, psychological growth of the infant, and bonding between the infant and its mother. However, early diagnosis and prompt treatment of PPD can lead to an improvement in postpartum maternal health and a healthier relationship between the mother and her infant. Additionally, early identification of risk factors in the prenatal and antenatal period can enable preventive treatment and ensure that the expectant or pregnant woman remains free of disease after giving birth. Therefore, we propose a protocol for the risk assessment, screening, diagnosis, assessment, and therapy of postnatal depression (RASDAT). The RASDAT protocol recommends assessment of risk factors for PPD in the perinatal period as well as early diagnosis and treatment in the early-to-mid postpartum period. It also recognizes, for the first time, insomnia and anxiety as important predictors, comorbidities, and poor prognostic factors in postpartum depression. Further studies are necessary to determine the feasibility and applicability of this novel tool, including costs of availing health facilities, burden on the health system, and knowledge, attitudes, and practices among physicians and clinical pharmacists regarding PPD and its resolution.
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Affiliation(s)
- Prachi Sharma
- Department of Pharmacology, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, India
| | - Kanav Khera
- Department of Pharmacology, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, India
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Riebel M, Brunner LM, Nothdurfter C, Wein S, Schwarzbach J, Liere P, Schumacher M, Rupprecht R. Neurosteroids and translocator protein 18 kDa (TSPO) ligands as novel treatment options in depression. Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01843-7. [PMID: 38976049 DOI: 10.1007/s00406-024-01843-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/06/2024] [Indexed: 07/09/2024]
Abstract
Recently, the gamma-aminobutyric acid (GABA) system has come into focus for the treatment of anxiety, postpartum depression, and major depressive disorder. Endogenous 3α-reduced steroids such as allopregnanolone are potent positive allosteric modulators of GABAA receptors and have been known for decades. Current industry developments and first approvals by the U.S. food and drug administration (FDA) for the treatment of postpartum depression with exogenous analogues of these steroids represent a major step forward in the field. 3α-reduced steroids target both synaptic and extrasynaptic GABAA receptors, unlike benzodiazepines, which bind to synaptic receptors. The first FDA-approved 3α-reduced steroid for postpartum depression is brexanolone, an intravenous formulation of allopregnanolone. It has been shown to provide rapid relief of depressive symptoms. An orally available 3α-reduced steroid is zuranolone, which also received FDA approval in 2023 for the treatment of postpartum depression. Although a number of studies have been conducted, the efficacy data were not sufficient to achieve approval of zuranolone in major depressive disorder by the FDA in 2023. The most prominent side effects of these 3α-reduced steroids are somnolence, dizziness and headache. In addition to the issue of efficacy, it should be noted that current data limit the use of these compounds to two weeks. An alternative to exogenous 3α-reduced steroids may be the use of substances that induce endogenous neurosteroidogenesis, such as the translocator protein 18 kDa (TSPO) ligand etifoxine. TSPO has been extensively studied for its role in steroidogenesis, in addition to other functions such as anti-inflammatory and neuroregenerative properties. Currently, etifoxine is the only clinically available TSPO ligand in France for the treatment of anxiety disorders. Studies are underway to evaluate its antidepressant potential. Hopefully, neurosteroid research will lead to the development of fast-acting antidepressants.
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Affiliation(s)
- Marco Riebel
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany.
| | - Lisa-Marie Brunner
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Caroline Nothdurfter
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Simon Wein
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Jens Schwarzbach
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
| | - Philippe Liere
- U1195 Inserm and University Paris-Saclay, Le Kremlin-Bicêtre, Paris, 94276, France
| | - Michael Schumacher
- U1195 Inserm and University Paris-Saclay, Le Kremlin-Bicêtre, Paris, 94276, France
| | - Rainer Rupprecht
- Department of Psychiatry and Psychotherapy, University Regensburg, Universitätsstrasse 84, 93053, Regensburg, Germany
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Singhal M, Modi N, Bansal L, Abraham J, Mehta I, Ravi A. The Emerging Role of Neurosteroids: Novel Drugs Brexanalone, Sepranolone, Zuranolone, and Ganaxolone in Mood and Neurological Disorders. Cureus 2024; 16:e65866. [PMID: 39219949 PMCID: PMC11364262 DOI: 10.7759/cureus.65866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
This review investigates the potential of neurosteroids, including brexanolone, zuranolone, sepranolone, and ganaxalone, as therapeutic agents for a range of mood and neurological disorders. Notably, these disorders encompass postpartum depression, post-traumatic stress disorder (PTSD), major depressive disorder (MDD), epilepsy, and Alzheimer's disease. Brexanolone and zuranolone have emerged as frontrunners in the treatment of postpartum depression, offering rapid relief from debilitating symptoms. Their mechanism of action involves modulation of the gamma-aminobutyric acid (GABA) system, which plays a pivotal role in mood regulation. Clinical trials have demonstrated their efficacy, heralding a potential breakthrough in addressing this often-overlooked condition. In the context of PTSD and MDD, neurosteroids have demonstrated significant promise. Their positive allosteric modulation of GABA-A receptors translates into improved mood stabilization and reduced symptoms. This novel approach represents a departure from conventional treatments and could offer newfound hope for individuals grappling with these disorders. Beyond mood disorders, neurosteroids, especially ganaxalone, exhibit potential in the realm of epilepsy management. Ganaxalone's capacity to control seizures is attributed to its GABAergic activity, which helps restore the delicate balance of neurotransmission in epileptic brains. Moreover, neurosteroids have revealed neuroprotective properties in Alzheimer's disease models. By influencing the GABAergic system, they mitigate excitotoxicity, a hallmark of Alzheimer's pathology. This neuroprotection opens a novel avenue for slowing neurodegeneration, although further research and clinical validation are essential. In conclusion, this review underscores the substantial therapeutic promise of neurosteroids in mood and neurological disorders. Their modulation of the GABA system emerges as a central mechanism of action, emphasizing the importance of GABAergic signaling in these conditions. The path forward entails continued investigation and clinical trials to fully unlock the potential of neurosteroids, offering hope for enhanced treatments in these challenging clinical domains.
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Affiliation(s)
- Malay Singhal
- Neurology, Mahatma Gandhi Memorial Medical College, Indore, IND
| | - Nishi Modi
- Psychiatry and Behavioral Sciences, Government Medical College Surat, Surat, IND
| | - Lajpat Bansal
- Psychiatry and Behavioral Sciences, Maharaja Agrasen Institute of Medical Research and Education, Hissar, IND
| | - Jeby Abraham
- General Medicine, Yenepoya Medical College, Mangalore, IND
| | - Ishani Mehta
- Neurology, Maharaja Agrasen Institute of Medical Research and Education, Hissar, IND
| | - Arun Ravi
- Psychiatry and Behavioral Sciences, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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Johnston GAR, Beart PM. Milestone review: GABA, from chemistry, conformations, ionotropic receptors, modulators, epilepsy, flavonoids, and stress to neuro-nutraceuticals. J Neurochem 2024; 168:1179-1192. [PMID: 38383146 DOI: 10.1111/jnc.16087] [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: 12/09/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
Arising out of a PhD project more than 50 years ago to synthesise analogues of the neurotransmitter GABA, a series of new chemical entities were found to have selective actions on ionotropic GABA receptors. Several of these neurochemicals are now commercially available. A new subtype of these receptors was discovered that could be a target for the treatment of myopia, the facilitation of learning and memory, and the improvement of post-stroke motor recovery. The development of these new chemical entities over many years demonstrates the importance of neurochemicals with which to investigate selective aspects of GABA receptors and illustrates the significance of collaboration between chemists and biologists in neurochemistry. Vital were the improvements in synthetic organic chemistry and the use of functional human receptors expressed in oocytes. Current interest in ionotropic GABA receptors includes the clinical development of subtype-specific agents and the role of gain-of-function receptor variants in epilepsy. Dietary flavonoids were found to cross the blood-brain barrier to influence brain function. Natural and synthetic flavonoids had a range of effects on GABA receptors, ranging from positive, silent, and negative allosteric modulators, to even second-order modulation of first-order modulators. Flavonoids have been called "a new family of benzodiazepines." Like benzodiazepines, flavonoids reduce stress. Stress produces changes in GABA receptors in the brain that may be because of changes in endogenous modulators, such as neurosteroids and corticosteroids. GABA also occurs naturally in the diet leading to studies of the effects of oral GABA on brain function. This finding has resulted in studies of GABA and related neurochemicals as neuro-nutraceuticals. GABA systems in the gut microbiome are essential to such studies. The actions of oral GABA and of GABA-enriched beverages and foodstuffs are now an area of considerable scientific and commercial interest. GABA is a deceptively simple chemical that can take up many shapes, which may underlie its complex functions. The need for new chemical entities with selective actions for further studies highlights the need for continuing collaboration between chemists and biologists.
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Affiliation(s)
- Graham A R Johnston
- Faculty of Medicine and Health, Pharmacology, Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Philip M Beart
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Björväng RD, Walldén Y, Fransson E, Comasco E, Sundström-Poromaa I, Skalkidou A. Mid-pregnancy allopregnanolone levels and trajectories of perinatal depressive symptoms. Psychoneuroendocrinology 2024; 164:107009. [PMID: 38442504 DOI: 10.1016/j.psyneuen.2024.107009] [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: 12/20/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/07/2024]
Abstract
Perinatal depression is a major cause of disability for individuals giving birth worldwide, with detrimental effects on short- and long-term parental and child outcomes. There is emerging evidence that the neuroactive steroid hormone allopregnanolone is implicated in the pathophysiology and course of perinatal mood symptoms. However, no study thus far has examined allopregnanolone levels whilst making use of longitudinal data on depressive symptom trajectories throughout the perinatal period. The present study investigated levels of allopregnanolone at gestational week 17 of 252 participants in relation to perinatal depressive symptom trajectories, with a secondary aim of exploring the role of history of depression as an effect modifier. Four perinatal depressive symptom trajectories were investigated: controls (no depressive symptoms throughout perinatal period) (N=161), antepartum (depressive symptoms prenatally with postpartum remission) (N=31), postpartum-onset (no depressive symptoms during pregnancy, development of depressive symptoms postpartum) (N=23), and persistent (depressive symptoms throughout the perinatal period) (N=37). Results show that for every one nmol/l increase in allopregnanolone, there was 7% higher odds for persistent depressive symptoms (OR 1.07, 95% CI 1.01-1.14) compared to controls. No association was seen for antepartum and postpartum-onset depressive symptoms. History of depression did not modify the association between allopregnanolone and perinatal depressive symptom trajectories. These results show the role of allopregnanolone for persistent depressive symptoms and strengthen the hypothesis of differences in pathophysiology among the trajectories.
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Affiliation(s)
- Richelle D Björväng
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Huddinge 14158, Sweden.
| | - Ylva Walldén
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden
| | - Emma Fransson
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden; Department of Microbiology, Tumor and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Erika Comasco
- Department of Women's and Children's Health, Science for Life Laboratory, Uppsala University, Uppsala 751 85, Sweden
| | | | - Alkistis Skalkidou
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden
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Baune BT, Fromme SE, Kiebs M, Hurlemann R. [Clinical management of treatment-resistant depression]. DER NERVENARZT 2024; 95:416-422. [PMID: 38568318 DOI: 10.1007/s00115-024-01647-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 05/04/2024]
Abstract
Treatment-resistant depression (TRD) is a complex disorder. Although no standardized definition has been established to date, there are promising and well-established treatment options for the condition. Looking at the current pharmacological and neuromodulatory strategies, there is an urgent need for fast-acting and well-tolerated treatment options. The search for new mechanisms of action goes beyond the monoamine hypothesis. For example, esketamine is already an established treatment method that is fast-acting and well tolerated, while psychedelics or esmethadone are currently still undergoing clinical trials. Compounds that can be used off-label, such as dextromethorphan or anti-inflammatory strategies are also presented. Pharmacological approaches that focus on the modulation of the glutamatergic system or belong to the class of psychedelics, appear to be of particular importance for current research and development. These particularly include substances that rapidly exert clinical effects and have a favorable side-effect profile.
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Affiliation(s)
- Bernhard T Baune
- Klinik für Psychische Gesundheit, Universitätsklinikum Münster, Münster, Deutschland
- Department of Psychiatry, University of Melbourne, Melbourne, Australien
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Australien
| | - Sarah E Fromme
- Klinik für Psychische Gesundheit, Universitätsklinikum Münster, Münster, Deutschland
| | - Maximilian Kiebs
- Universitätsklinik für Psychiatrie & Psychotherapie, Fakultät VI Medizin & Gesundheitswissenschaften, Carl von Ossietzky Universität Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Deutschland
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - René Hurlemann
- Universitätsklinik für Psychiatrie & Psychotherapie, Fakultät VI Medizin & Gesundheitswissenschaften, Carl von Ossietzky Universität Oldenburg, Ammerländer Heerstraße 114-118, 26129, Oldenburg, Deutschland.
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Xie H, Xie Z, Luan F, Zeng J, Zhang X, Chen L, Zeng N, Liu R. Potential therapeutic effects of Chinese herbal medicine in postpartum depression: Mechanisms and future directions. JOURNAL OF ETHNOPHARMACOLOGY 2024; 324:117785. [PMID: 38262525 DOI: 10.1016/j.jep.2024.117785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/15/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Postpartum depression (PPD) is a common psychiatric disorder in women after childbirth. Per data from epidemiologic studies, PPD affects about 5%-26.32% of postpartum mothers worldwide. Biological factors underlying this condition are multiple and complex and have received extensive inquiries for the roles they play in PPD. Chinese herbal medicine (CHM), which is widely used as a complementary and alternative therapy for neurological disorders, possesses multi-component, multi-target, multi-access, and low side effect therapeutic characteristics. CHM has already shown efficacy in the treatment of PPD, and a lot more research exploring the mechanisms of its potential therapeutic effects is being conducted. AIM OF THE REVIEW This review provides an in-depth and comprehensive overview of the underlying mechanisms of PPD, as well as samples the progress made in researching the potential role of CHM in treating the disorder. MATERIALS AND METHODS Literature was searched comprehensively in scholarly electronic databases, including PubMed, Web of Science, Scopus, CNKI and WanFang DATA, using the search terms "postpartum depression", "genetic", "hormone", "immune", "neuroinflammation", "inflammation", "neurotransmitter", "neurogenesis", "brain-gut axis", "traditional Chinese medicine", "Chinese herbal medicine", "herb", and an assorted combination of these terms. RESULTS PPD is closely associated with genetics, as well as with the hormones, immune inflammatory, and neurotransmitter systems, neurogenesis, and gut microbes, and these biological factors often interact and work together to cause PPD. For example, inflammatory factors could suppress the production of the neurotransmitter serotonin by inducing the regulation of tryptophan-kynurenine in the direction of neurotoxicity. Many CHM constituents improve anxiety- and depression-like behaviors by interfering with the above-mentioned mechanisms and have shown decent efficacy clinically against PPD. For example, Shen-Qi-Jie-Yu-Fang invigorates the neuroendocrine system by boosting the hormone levels of hypothalamic pituitary adrenal (HPA) and hypothalamic pituitary gonadal (HPG) axes, regulating the imbalance of Treg/T-helper cells (Th) 17 and Th1/Th2, and modulating neurotransmitter system to play antidepressant roles. The Shenguiren Mixture interferes with the extracellular signal-regulated kinase (ERK) pathway to enhance the number, morphology and apoptosis of neurons in the hippocampus of PPD rats. Other herbal extracts and active ingredients of CHM, such as Paeoniflorin, hypericin, timosaponin B-III and more, also manage depression by remedying the neuroendocrine system and reducing neuroinflammation. CONCLUSIONS The pathogenesis of PPD is complex and diverse, with the main pathogenesis not clear. Still, CHM constituents, like Shen-Qi-Jie-Yu-Fang, the Shenguiren Mixture, Paeoniflorin, hypericin and other Chinese Medicinal Formulae, active monomers and Crude extracts, treats PPD through multifaceted interventions. Therefore, developing more CHM components for the treatment of PPD is an essential step forward.
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Affiliation(s)
- Hongxiao Xie
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, PR China.
| | - Zhiqiang Xie
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, PR China.
| | - Fei Luan
- Shaanxi Province Key Laboratory of New Drugs and Chinese Medicine Foundation Research, Pharmacy College, Shaanxi University of Chinese Medicine, Xianyang, 712046, PR China.
| | - Jiuseng Zeng
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, PR China.
| | - Xiumeng Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, PR China.
| | - Li Chen
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, PR China; Department of Pharmacy, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, 610500, PR China.
| | - Nan Zeng
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, PR China.
| | - Rong Liu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, 611137, PR China.
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Dimcea DAM, Petca RC, Dumitrașcu MC, Șandru F, Mehedințu C, Petca A. Postpartum Depression: Etiology, Treatment, and Consequences for Maternal Care. Diagnostics (Basel) 2024; 14:865. [PMID: 38732283 PMCID: PMC11083152 DOI: 10.3390/diagnostics14090865] [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: 01/28/2024] [Revised: 03/18/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Postpartum depression (PPD) is a disabling condition that has recently shown an increase in prevalence, becoming an essential public health problem. This study is a qualitative review summarizing the most frequent risk factors associated with PPD, evaluating molecular aspects of PPD and current approaches to detect and prevent PPD. The most prevalent risk factors were detected in the areas of economic and social factors, obstetrical history, lifestyle, and history of mental illness. Research on the genetic basis for PPD has taken place in recent years to identify the genes responsible for establishing targeted therapeutic methods and understanding its pathogenesis. The most frequently studied candidate gene was the serotonin transporter gene (SERT) associated with PPD. Among biological studies, antidepressants and psychological interventions provided the most evidence of successful intervention. The obstetrician can serve an essential role in screening for and treating PPD. Postpartum women with risk factors should be screened using the Edinburgh Postnatal Depression Scale (EPDS), but, at the moment, there are no prevention programs in Europe. In conclusion, data from this review increase concerns among this vulnerable population and can be used to design a screening tool for high-risk pregnant women and create a prevention program.
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Affiliation(s)
- Daiana Anne-Marie Dimcea
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
| | - Răzvan-Cosmin Petca
- Department of Urology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Urology, “Prof. Dr. Th. Burghele” Clinical Hospital, 050659 Bucharest, Romania
| | - Mihai Cristian Dumitrașcu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
- Department of Obstetrics and Gynecology, University Emergency Hospital, 050098 Bucharest, Romania
| | - Florica Șandru
- Department of Dermatology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Dermatology, Elias University Emergency Hospital, 011461 Bucharest, Romania
| | - Claudia Mehedințu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (D.A.-M.D.); (M.C.D.); (C.M.); (A.P.)
- Department of Obstetrics and Gynecology, Elias University Emergency Hospital, 011461 Bucharest, Romania
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Ali DN, Ali HM, Lopez MR, Kang S, Choi DS. Astrocytic GABAergic Regulation in Alcohol Use and Major Depressive Disorders. Cells 2024; 13:318. [PMID: 38391931 PMCID: PMC10887002 DOI: 10.3390/cells13040318] [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: 11/30/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
Gamma-aminobutyric acid (GABA) is the major inhibitory neurotransmitter in the central nervous system (CNS). Most GABAergic neurons synthesize GABA from glutamate and release it in the synaptic cleft in the CNS. However, astrocytes can also synthesize and release GABA, activating GABA receptors in the neighboring neurons in physiological and pathological conditions. As the primary homeostatic glial cells in the brain, astrocytes play a crucial role in regulating GABA homeostasis and synaptic neurotransmission. Accumulating evidence demonstrates that astrocytic GABA dysregulation is implicated in psychiatric disorders, including alcohol use disorder (AUD) and major depressive disorder (MDD), the most prevalent co-occurring psychiatric disorders. Several current medications and emerging pharmacological agents targeting GABA levels are in clinical trials for treating AUD and MDD. This review offers a concise summary of the role of astrocytic GABA regulation in AUD and MDD. We also provide an overview of the current understanding and areas of debate regarding the mechanisms by which astrocytes regulate GABA in the CNS and their potential significance in the molecular basis of AUD and MDD, paving the way toward future research directions and potential therapeutic target areas within this field.
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Affiliation(s)
- Dina N. Ali
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Hossam M. Ali
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Matthew R. Lopez
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Shinwoo Kang
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
| | - Doo-Sup Choi
- Department of Molecular Pharmacology and Experimental Therapeutics, Rochester, MN 55905, USA; (D.N.A.); (H.M.A.); (M.R.L.); (S.K.)
- Neuroscience Program, Rochester, MN 55905, USA
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
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Zhang M, Xie W, Li J, Zheng J, Zhou Y. Postmarketing safety profile of brexanolone: a pharmacovigilance analysis based on FDA Adverse Event Reporting System (FAERS). Arch Womens Ment Health 2024; 27:35-44. [PMID: 37831172 DOI: 10.1007/s00737-023-01378-1] [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: 06/25/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Brexanolone (Zulresso®) that was approved for the USA in March 2019 is indicated for the treatment of postpartum depression (PPD), but information on adverse drug reactions (ADRs) associated with its use is limited. The main aim of this study was to explore the postmarketing safety profile of brexanolone. METHODS In our case/non-case pharmacovigilance study based on the FDA Adverse Event Reporting System (FAERS), the reporting odds ratio and information component with 95% confidence intervals were estimated as measures of disproportionate reporting. Primary disproportionality analyses were performed by comparing brexanolone with all other drugs or selective serotonin reuptake inhibitors (SSRIs). Sensitivity analyses were performed on a subset of perinatal depression. RESULTS We identified 267 cases using brexanolone. Brexanolone was reported as a primary or secondary suspect drug in most cases (n = 260, 97.38%). Of the total brexanolone cases, positive dechallenge and discontinuation accounted for 12.36% (n = 33) and 26.22% (n = 70), respectively. Serious outcomes were reported in 11.61% (n = 31) patients. Compared to all the other drugs or SSRIs within the same time window, the reporting risks of brexanolone were mainly from psychiatric and nervous systems. Sensitivity analyses indicated that these significant disproportionalities were mostly retained. CONCLUSION Our pharmacovigilance analysis showed a high reporting frequency of psychiatric and nervous system ADRs associated with the use of brexanolone. In additional prospective research, these signals urgently need to be clarified.
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Affiliation(s)
- Meilian Zhang
- Department of Ultrasound, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Wenhuo Xie
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jianbin Li
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Jiaping Zheng
- Department of Rehabilitation Medicine, School of Health, Fujian Medical University, Fuzhou, China.
| | - Yu Zhou
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fujian Medical University, Fuzhou, China.
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Thompson SM. Modulators of GABA A receptor-mediated inhibition in the treatment of neuropsychiatric disorders: past, present, and future. Neuropsychopharmacology 2024; 49:83-95. [PMID: 37709943 PMCID: PMC10700661 DOI: 10.1038/s41386-023-01728-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/14/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
The predominant inhibitory neurotransmitter in the brain, γ-aminobutyric acid (GABA), acts at ionotropic GABAA receptors to counterbalance excitation and regulate neuronal firing. GABAA receptors are heteropentameric channels comprised from subunits derived from 19 different genes. GABAA receptors have one of the richest and well-developed pharmacologies of any therapeutic drug target, including agonists, antagonists, and positive and negative allosteric modulators (PAMs, NAMs). Currently used PAMs include benzodiazepine sedatives and anxiolytics, barbiturates, endogenous and synthetic neurosteroids, and general anesthetics. In this article, I will review evidence that these drugs act at several distinct binding sites and how they can be used to alter the balance between excitation and inhibition. I will also summarize existing literature regarding (1) evidence that changes in GABAergic inhibition play a causative role in major depression, anxiety, postpartum depression, premenstrual dysphoric disorder, and schizophrenia and (2) whether and how GABAergic drugs exert beneficial effects in these conditions, focusing on human studies where possible. Where these classical therapeutics have failed to exert benefits, I will describe recent advances in clinical and preclinical drug development. I will also highlight opportunities to advance a generation of GABAergic therapeutics, such as development of subunit-selective PAMs and NAMs, that are engendering hope for novel tools to treat these devastating conditions.
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Affiliation(s)
- Scott M Thompson
- Center for Novel Therapeutics, Department of Psychiatry, University of Colorado School of Medicine, 12700 E. 19th Ave., Aurora, CO, 80045, USA.
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15
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Yoon S, Kim YK. Endocrinological Treatment Targets for Depressive Disorder. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1456:3-25. [PMID: 39261421 DOI: 10.1007/978-981-97-4402-2_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
Depressive disorder exhibits heterogeneity in clinical presentation, progression, and treatment outcomes. While conventional antidepressants based on the monoamine hypothesis benefit many patients, a significant proportion remains unresponsive or fails to fully recover. An individualized integrative treatment approach, considering diverse pathophysiologies, holds promise for these individuals. The endocrine system, governing physiological regulation and organ homeostasis, plays a pivotal role in central nervous system functions. Dysregulations in endocrine system are major cause of depressive disorder due to other medical conditions. Subtle endocrine abnormalities, such as subclinical hypothyroidism, are associated with depression. Conversely, depressive disorder correlates with endocrine-related biomarkers. Fluctuations in sex hormone levels related to female reproduction, elevate depression risk in susceptible subjects. Consequently, extensive research has explored treatment strategies involving the endocrine system. Treatment guidelines recommend tri-iodothyronine augmentation for resistant depression, while allopregnanolone analogs have gained approval for postpartum depression, with ongoing investigations for broader depressive disorders. This book chapter will introduce the relationship between the endocrine system and depressive disorders, presenting clinical findings on neuroendocrinological treatments for depression.
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Affiliation(s)
- Seoyoung Yoon
- Department of Psychiatry, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Yong-Ku Kim
- Department of Psychiatry, Korea University College of Medicine, Seoul, Republic of Korea.
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Maguire JL, Mennerick S. Neurosteroids: mechanistic considerations and clinical prospects. Neuropsychopharmacology 2024; 49:73-82. [PMID: 37369775 PMCID: PMC10700537 DOI: 10.1038/s41386-023-01626-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/15/2023] [Accepted: 05/17/2023] [Indexed: 06/29/2023]
Abstract
Like other classes of treatments described in this issue's section, neuroactive steroids have been studied for decades but have risen as a new class of rapid-acting, durable antidepressants with a distinct mechanism of action from previous antidepressant treatments and from other compounds covered in this issue. Neuroactive steroids are natural derivatives of progesterone but are proving effective as exogenous treatments. The best understood mechanism is that of positive allosteric modulation of GABAA receptors, where subunit selectivity may promote their profile of action. Mechanistically, there is some reason to think that neuroactive steroids may separate themselves from liabilities of other GABA modulators, although research is ongoing. It is also possible that intracellular targets, including inflammatory pathways, may be relevant to beneficial actions. Strengths and opportunities for further development include exploiting non-GABAergic targets, structural analogs, enzymatic production of natural steroids, precursor loading, and novel formulations. The molecular mechanisms of behavioral effects are not fully understood, but study of brain network states involved in emotional processing demonstrate a robust influence on affective states not evident with at least some other GABAergic drugs including benzodiazepines. Ongoing studies with neuroactive steroids will further elucidate the brain and behavioral effects of these compounds as well as likely underpinnings of disease.
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Affiliation(s)
- Jamie L Maguire
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Ave, Boston, MA, 02111, USA
| | - Steven Mennerick
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.
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Epperson CN. Hormones as Psychotropic Interventions in Females. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:63-66. [PMID: 38694158 PMCID: PMC11058925 DOI: 10.1176/appi.focus.20230031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Affiliation(s)
- C Neill Epperson
- Department of Psychiatry, Helen and Arthur E. Johnson Depression Center, Aurora, Colorado; Center for Women's Behavioral Health and Wellness, Aurora, Colorado; and Department of Psychiatry and Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Gopalan P, Spada ML, Shenai N, Kratzer I, Nichols N, Kucherer S, Chou S, Hovis E, Beck S, Glance J. An Overview for the General Psychiatrist Evaluating Patients With Obstetric and Neonatal Complications and Perinatal Loss. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:35-43. [PMID: 38694157 PMCID: PMC11058915 DOI: 10.1176/appi.focus.20230021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
When neonatal and obstetrical complications occur, the identification and management of mood and anxiety disorders become complex with an ever-expanding array of psychiatric needs that include the management of grief- and trauma-related disorders. With high rates of maternal morbidity and mortality in the United States and laws in many states restricting reproductive health access, psychiatrists must be proficient in managing psychiatric sequelae in this context. High-risk groups for peripartum mood and anxiety disorders, posttraumatic stress disorder, and complicated grief include those with neonatal intensive care unit (NICU) stays and those who have experienced infertility and recurrent pregnancy loss. Groups who have been historically marginalized by the medical system (e.g., Black, Indigenous, people of color) and those from LGBTQ+ communities are at similarly high risk, and more interventions are needed to support these groups. Strategies emphasizing trauma-informed care, psychotherapeutic approaches, and using patient-centered language are recommended.
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Affiliation(s)
- Priya Gopalan
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Meredith L Spada
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Neeta Shenai
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Isabella Kratzer
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Nona Nichols
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Shelly Kucherer
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Shinnyi Chou
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Elizabeth Hovis
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Stacy Beck
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
| | - Jody Glance
- Department of Psychiatry, University of Pittsburgh Medical Center Western Psychiatric Hospital (Gopalan, Spada, Kratzer, Kucherer, Chou, Glance); Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio (Nichols); Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh (Beck); Department of Psychiatry, University of Wisconsin-Madison (Shenai); Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee (Hovis)
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Reproductive Psychiatry: Postpartum Depression is Only the Tip of the Iceberg. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:77-78. [PMID: 38694164 PMCID: PMC11058928 DOI: 10.1176/appi.focus.23021027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
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Marecki R, Kałuska J, Kolanek A, Hakało D, Waszkiewicz N. Zuranolone - synthetic neurosteroid in treatment of mental disorders: narrative review. Front Psychiatry 2023; 14:1298359. [PMID: 38116383 PMCID: PMC10729607 DOI: 10.3389/fpsyt.2023.1298359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023] Open
Abstract
With each passing year, the number of people suffering from mental disorders grows at a disturbing speed. Neuroactive steroids are a new promising group of drugs with the potential for use in many diseases like postpartum depression, postnatal psychosis, major depression, insomnia, bipolar disorder, and Parkinson's tremor, due to their ability to modulate the activity of GABAA receptor. Neurosteroids are progesterone metabolites that are synthesized from cholesterol or steroid hormones in various brain regions. They regulate neuronal development, regeneration, and neurotransmission. They are implicated in mood disorders, anxiety disorders, schizophrenia, PTSD, and impulsive aggression. Neurosteroids have been studied for their potential to prevent or treat neurodegenerative diseases such as Alzheimer's disease and HIV-associated dementia. They can promote neurogenesis, neuronal survival, myelination, and memory function. They can also affect the growth and sensitivity of hormone-dependent brain tumors such as gliomas. Zuranolone, a newly registered neurosteroid drug has shown huge flexibility in both clinical and ambulatory treatment thanks to its pharmacokinetic traits, especially the possibility for oral administration, unlike its predecessor Brexanolone. Zuranolone is a synthetic positive allosteric modulator of the GABAA receptor that can be taken orally. The review aims to summarize the current knowledge on zuranolone as a novel neurosteroid drug for various mental disorders, especially for postpartum mental disorders for which this drug was meant originally. It covers studies indexed in the PubMed, Scopus, and Web of Science databases published since 2017. Keywords used in the search, as well as inclusion and exclusion criteria, are given in the aims and methodology section. The review explains the evidence for the role of neurosteroids, especially allopregnanolone, in the pathophysiology and treatment of postpartum depression. It discusses the mechanisms of neurosteroid action, the changes in neurosteroid levels during pregnancy and postpartum, and the clinical trials of brexanolone and zuranolone, two synthetic analogs of allopregnanolone, for postpartum depression. It provides an overview of the biosynthesis and metabolism of neurosteroids in the central and peripheral nervous system. Furthermore, it explains the different sources and pathways of neurosteroid production and the factors that influence their synthesis and regulation, such as stress, hormones, drugs, and genetic variations. The review also explores the potential relevance of neurosteroids for other psychiatric disorders, such as major depression, bipolar disorder, post-traumatic stress disorder (PTSD), schizophrenia, and premenstrual dysphoric disorder. Finally, it highlights the associations between neurosteroid levels and symptom severity and the effects of neurosteroid modulation on mood, cognition, and neuroplasticity.
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Carlini SV, Osborne LM, Deligiannidis KM. Current pharmacotherapy approaches and novel GABAergic antidepressant development in postpartum depression. DIALOGUES IN CLINICAL NEUROSCIENCE 2023; 25:92-100. [PMID: 37796239 PMCID: PMC10557560 DOI: 10.1080/19585969.2023.2262464] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
Postpartum depression has deleterious effects on childbearing persons globally. Existing treatments have been largely extrapolated from those for other forms of depression and have included pharmacotherapy, psychotherapy, and neuromodulation. Hormonal treatments with oestrogen and progestogens, thought to be a rational approach to treatment in response to an emerging literature on the pathophysiology of postpartum depression, have only limited evidence for efficacy to date. Novel antidepressant development with allopregnanolone analogues, in contrast, has proven a promising avenue for the development of rationally designed and efficacious treatments. This state-of-the-art review presents the evidence for the current standard-of-care pharmacotherapy, hormonal treatment, and emerging allopregnanolone analogues for the treatment of postpartum depression along with a discussion of the current understanding of its neuroactive steroid-driven pathophysiology.
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Affiliation(s)
- Sara V Carlini
- Department of Psychiatry, Maimonides Medical Center, Brooklyn, NY, USA
- Downstate Health Sciences University, The State University of New York, Brooklyn, NY, USA
| | - Lauren M Osborne
- Departments of Obstetrics & Gynecology and of Psychiatry, Weill Cornell Medicine, New York, NY, USA
| | - Kristina M Deligiannidis
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Zou J, Yang L, Yang G, Gao J. The efficacy and safety of some new GABAkines for treatment of depression: A systematic review and meta-analysis from randomized controlled trials. Psychiatry Res 2023; 328:115450. [PMID: 37683318 DOI: 10.1016/j.psychres.2023.115450] [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: 06/13/2023] [Revised: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023]
Abstract
Positive allosteric modulators of γ-aminobutyric acid-A (GABAA) receptors, or GABAkines, play important roles in the treatment of depression, epilepsy, insomnia, and other disorders. Recently, some new GABAkines (zuranolone and brexanolone) have been administrated to patients with major depressive disorder (MDD) or postpartum depression (PPD) in randomized controlled trials (RCTs). This study aims to systematically review and examine the efficacy and safety of zuranolone or brexanolone for treatment of depression. A systematic literature retrieval was conducted through August 20, 2023. RCTs evaluating the efficacy and safety of zuranolone or brexanolone for treatment of depression were included. Eight studies (nine reports) were identified in the study. The percentages of patients with PPD achieving Hamilton Depression Rating Scale (HAM-D) response and remission were significantly higher after brexanolone or zuranolone administration compared with placebo at different points. The percentages of patients with MDD achieving HAM-D response and remission were significantly increased during the zuranolone treatment period compared with placebo. In addition, zuranolone caused more adverse events in patients with MDD compared with placebo. Our findings support the effects of brexanolone on improving the core symptoms of depression in patients with PPD, and the potential of zuranolone in treating patients with MDD or PPD.
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Affiliation(s)
- Jiao Zou
- Department of Military Cognitive Psychology, School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Ling Yang
- Department of Military Cognitive Psychology, School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Guoyu Yang
- School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Junwei Gao
- Department of Military Cognitive Psychology, School of Psychology, Third Military Medical University (Army Medical University), Chongqing 400038, China.
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23
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Luscher B, Maguire JL, Rudolph U, Sibille E. GABA A receptors as targets for treating affective and cognitive symptoms of depression. Trends Pharmacol Sci 2023; 44:586-600. [PMID: 37543478 PMCID: PMC10511219 DOI: 10.1016/j.tips.2023.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 08/07/2023]
Abstract
In the past 20 years, our understanding of the pathophysiology of depression has evolved from a focus on an imbalance of monoaminergic neurotransmitters to a multifactorial picture including an improved understanding of the role of glutamatergic excitatory and GABAergic inhibitory neurotransmission. FDA-approved treatments targeting the glutamatergic [esketamine for major depressive disorder (MDD)] and GABAergic (brexanolone for peripartum depression) systems have become available. This review focuses on the GABAA receptor (GABAAR) system as a target for novel antidepressants and discusses the mechanisms by which modulation of δ-containing GABAARs with neuroactive steroids (NASs) or of α5-containing GABAARs results in antidepressant or antidepressant-like actions and discusses clinical data on NASs. Moreover, a potential mechanism by which α5-GABAAR-positive allosteric modulators (PAMs) may improve cognitive deficits in depression is presented.
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Affiliation(s)
- Bernhard Luscher
- Department of Biology, Pennsylvania State University, University Park, PA 16802, USA; Department of Biochemistry and Molecular Biology, Pennsylvania State University, University Park, PA 16802, USA; Department of Psychiatry, Pennsylvania State University, University Park, PA 16802, USA; Penn State Neuroscience Institute, Pennsylvania State University, University Park, PA 16802, USA
| | - Jamie L Maguire
- Department of Neuroscience, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Uwe Rudolph
- Department of Comparative Biosciences, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, IL 61802, USA; Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, IL 61802, USA.
| | - Etienne Sibille
- Campbell Family Mental Health Research Institute of the Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
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Reddy DS, Mbilinyi RH, Estes E. Preclinical and clinical pharmacology of brexanolone (allopregnanolone) for postpartum depression: a landmark journey from concept to clinic in neurosteroid replacement therapy. Psychopharmacology (Berl) 2023; 240:1841-1863. [PMID: 37566239 PMCID: PMC10471722 DOI: 10.1007/s00213-023-06427-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/17/2023] [Indexed: 08/12/2023]
Abstract
This article describes the critical role of neurosteroids in postpartum depression (PPD) and outlines the landmark pharmacological journey of brexanolone as a first-in-class neurosteroid antidepressant with significant advantages over traditional antidepressants. PPD is a neuroendocrine disorder that affects about 20% of mothers after childbirth and is characterized by symptoms including persistent sadness, fatigue, dysphoria, as well as disturbances in cognition, emotion, appetite, and sleep. The main pathology behind PPD is the postpartum reduction of neurosteroids, referred to as neurosteroid withdrawal, a concept pioneered by our preclinical studies. We developed neurosteroid replacement therapy (NRT) as a rational approach for treating PPD and other conditions related to neurosteroid deficiency, unveiling the power of neurosteroids as novel anxiolytic-antidepressants. The neurosteroid, brexanolone (BX), is a progesterone-derived allopregnanolone that rapidly relieves anxiety and mood deficits by activating GABA-A receptors, making it a transformational treatment for PPD. In 2019, the FDA approved BX, an intravenous formulation of allopregnanolone, as an NRT to treat PPD. In clinical studies, BX significantly improved PPD symptoms within hours of administration, with tolerable side effects including headache, dizziness, and somnolence. We identified the molecular mechanism of BX in a neuronal PPD-like milieu. The mechanism of BX involves activation of both synaptic and extrasynaptic GABA-A receptors, which promote tonic inhibition and serve as a key target for PPD and related conditions. Neurosteroids offer several advantages over traditional antidepressants, including rapid onset, unique mechanism, and lack of tolerance upon repeated use. Some limitations of BX therapy include lack of aqueous solubility, limited accessibility, hospitalization for treatment, lack of oral product, and serious adverse events at high doses. However, the unmet need for synthetic neurosteroids to address this critical condition supersedes these limitations. Recently, we developed novel hydrophilic neurosteroids with a superior profile and improved drug delivery. Overall, approval of BX is a major milestone in the field of neurotherapeutics, paving the way for the development of novel synthetic neurosteroids to treat depression, epilepsy, and status epilepticus.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA.
- Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, 8447 Riverside Pkwy, Bryan, TX, 77807, USA.
| | - Robert H Mbilinyi
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA
| | - Emily Estes
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, 77807, USA
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Walton NL, Antonoudiou P, Maguire JL. Neurosteroid influence on affective tone. Neurosci Biobehav Rev 2023; 152:105327. [PMID: 37499891 PMCID: PMC10528596 DOI: 10.1016/j.neubiorev.2023.105327] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/07/2023] [Accepted: 07/23/2023] [Indexed: 07/29/2023]
Abstract
Affective disorders such as depression and anxiety are among the most prevalent psychiatric illnesses and causes of disability worldwide. The recent FDA-approval of a novel antidepressant treatment, ZULRESSO® (Brexanolone), a synthetic neurosteroid has fueled interest into the role of neurosteroids in the pathophysiology of depression as well as the mechanisms mediating the antidepressant effects of these compounds. The majority of studies examining the impact of neurosteroids on affective states have relied on the administration of exogenous neurosteroids; however, neurosteroids can also be synthesized endogenously from cholesterol or steroid hormone precursors. Despite the well-established influence of exogenous neurosteroids on affective states, we still lack an understanding of the role of endogenous neurosteroids in modulating affective tone. This review aims to summarize the current literature supporting the influence of neurosteroids on affective states in clinical and preclinical studies, as well as recent evidence suggesting that endogenous neurosteroids may set a baseline affective tone.
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Affiliation(s)
- Najah L Walton
- Program of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA; Department of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Pantelis Antonoudiou
- Program of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA; Department of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Jamie L Maguire
- Program of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA; Department of Neuroscience, Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA.
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Eisenlohr-Moul TA, Barone JC. Optimizing Neuroactive Steroid Treatments for Stress-Related Affective Symptoms: Brief Reflections on Patient Population, Timing, and Access. Biol Psychiatry 2023; 94:191-193. [PMID: 37437990 PMCID: PMC11006370 DOI: 10.1016/j.biopsych.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 07/14/2023]
Affiliation(s)
| | - Jordan C Barone
- Department of Psychiatry, University of Illinois at Chicago, Chicago, Illinois
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Olsavsky AK, Epperson CN. Recalculating the Risk of Prenatal Magnetic Resonance Imaging Research: Previously Unidentified Potential Harms Associated With Urine Pregnancy Testing. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2023; 8:585-587. [PMID: 37286289 PMCID: PMC10655822 DOI: 10.1016/j.bpsc.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Aviva K Olsavsky
- University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado.
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28
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Sivcev S, Kudova E, Zemkova H. Neurosteroids as positive and negative allosteric modulators of ligand-gated ion channels: P2X receptor perspective. Neuropharmacology 2023; 234:109542. [PMID: 37040816 DOI: 10.1016/j.neuropharm.2023.109542] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/06/2023] [Accepted: 04/07/2023] [Indexed: 04/13/2023]
Abstract
Neurosteroids are steroids synthesized de novo in the brain from cholesterol in an independent manner from peripheral steroid sources. The term "neuroactive steroid" includes all steroids independent of their origin, and newly synthesized analogs of neurosteroids that modify neuronal activities. In vivo application of neuroactive steroids induces potent anxiolytic, antidepressant, anticonvulsant, sedative, analgesic and amnesic effects, mainly through interaction with the γ-aminobutyric acid type-A receptor (GABAAR). However, neuroactive steroids also act as positive or negative allosteric regulators on several ligand-gated channels including N-methyl-d-aspartate receptors (NMDARs), nicotinic acetylcholine receptors (nAChRs) and ATP-gated purinergic P2X receptors. Seven different P2X subunits (P2X1-7) can assemble to form homotrimeric or heterotrimeric ion channels permeable for monovalent cations and calcium. Among them, P2X2, P2X4, and P2X7 are the most abundant within the brain and can be regulated by neurosteroids. Transmembrane domains are necessary for neurosteroid binding, however, no generic motif of amino acids can accurately predict the neurosteroid binding site for any of the ligand-gated ion channels including P2X. Here, we will review what is currently known about the modulation of rat and human P2X by neuroactive steroids and the possible structural determinants underlying neurosteroid-induced potentiation and inhibition of the P2X2 and P2X4 receptors.
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Affiliation(s)
- Sonja Sivcev
- Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Science, Charles University, Prague, Czech Republic
| | - Eva Kudova
- Institute of Organic Chemistry and Biochemistry, Czech Academy of Sciences, Prague, Czech Republic
| | - Hana Zemkova
- Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic.
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Vasiliu O. Efficacy, Tolerability, and Safety of Toludesvenlafaxine for the Treatment of Major Depressive Disorder-A Narrative Review. Pharmaceuticals (Basel) 2023; 16:411. [PMID: 36986510 PMCID: PMC10051807 DOI: 10.3390/ph16030411] [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: 01/23/2023] [Revised: 03/05/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
The estimated rate of treatment-resistant major depressive disorder (TRD) remains higher than 30%, even after the discovery of multiple classes of antidepressants in the last 7 decades. Toludesvenlafaxine (ansofaxine, LY03005, or LPM570065) is a first-in-class triple monoaminergic reuptake inhibitor (TRI) that has reached clinical use. The objective of this narrative review was to summarize clinical and preclinical evidence about the efficacy, tolerability, and safety of toludesvenlafaxine. Based on the results of 17 reports retrieved in the literature, the safety and tolerability profiles of toludesvenlafaxine were good in all clinical trials, and the pharmacokinetic parameters were well described in the phase 1 trials. The efficacy of toludesvenlafaxine was demonstrated in one phase 2 and one phase 3 trial, both on primary and secondary outcomes. In conclusion, this review highlights the favorable clinical results of toludesvenlafaxine in only two short-term trials that enrolled patients with major depressive disorder (MDD) (efficacy and tolerability were good for up to eight weeks), indicating the need for more good quality, larger-sample, and longer-term trials. Exploring new antidepressants, such as TRI, can be considered a priority for clinical research due to the high rates of TRD, but also due to the significant percentages of relapse in patients with MDD.
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Affiliation(s)
- Octavian Vasiliu
- Department of Psychiatry, Dr. Carol Davila University Emergency Central Military Hospital, 010825 Bucharest, Romania
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