Effects of escitalopram/quetiapine combination therapy versus escitalopram monotherapy on hypothalamic-pituitary-adrenal-axis activity in relation to antidepressant effectiveness

Risk factors for electroconvulsive therapy-induced fever: a retrospective case-control study

Background

Electroconvulsive therapy (ECT)-induced fever can significantly affect patient experience, treatment adherence, and the course of treatment. However, little is known about the prevalence of ECT-induced fever and its associated risk factors in patients with major mental disorders (MMD).

Methods

This retrospective, case-control study included 113 cases and 226 age-matched controls (1:2). The case group comprised patients who exhibited an axillary temperature of ≥37.5°C (99.5°F) at least once within 24 hours post-ECT. Patients diagnosed with MMD underwent ECT between January 1, 2021, and December 31, 2021, at a large psychiatric hospital in China. Demographic and clinical data were extracted from the electronic chart management system (ECMS) for both groups.

Results

The prevalence of ECT-induced fever in patients with MMD was 6.8% [113/1,674, 95% confidence interval (CI): 5.6% to 8.0%], with a session-based prevalence of 1.1% (130/11,570, 95% CI: 0.9% to 1.3%). Multivariate logistic regression analysis identified paliperidone [odds ratios (OR)=2.5, 95% CI: 1.2 to 4.9] as a risk factor, while quetiapine (OR=0.4, 95% CI: 0.3 to 0.8) was found to be protective. No significant association between etomidate and ECT-induced fever was observed in univariate analysis (p>0.05).

Conclusions

This study found a relatively low prevalence of ECT-induced fever. Paliperidone was identified as a risk factor, while quetiapine had a protective effect. Etomidate was not significantly associated with ECT-induced fever in patients with MMD.

The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD): Changes in Preferred Treatment Strategies and Medications over 20 Years and Five Editions

BACKGROUND

The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) is an expert consensus guideline for depressive disorder created in 2002, and since then, four revisions (2006, 2012, 2017, 2021) have been published. In this study, changes in the content of the KMAP-DD survey and recommendations for each period were examined.

METHODS

The development process of the KMAP-DD was composed of two stages. First, opinions from experts with abundant clinical experience were gathered through surveys. Next, a final guideline was prepared through discussion within the working committee regarding the suitability of the results with reference to recent clinical studies or other guidelines.

RESULTS

In mild depressive symptoms, antidepressant (AD) monotherapy was preferred, but when severe depression or when psychotic features were present, a combination of AD and atypical antipsychotics (AD + AAP) was preferred. AD monotherapy was preferred in most clinical subtypes. AD monotherapy was preferred for mild depressive symptoms, and AD + AAP was preferred for severe depression and depression with psychotic features in children, adolescents, and the elderly.

CONCLUSIONS

This study identified the changes in the KMAP-DD treatment strategies and drug preferences in each period over the past 20 years. This work is expected to aid clinicians in establishing effective treatment strategies.

Factors associated with antipsychotic use in non-psychotic depressed patients: results from a clinical multicenter survey

BACKGROUND

The combination of antipsychotics is not well studied among non-psychotic major depressive disorder (MDD). This study aims to explore the antipsychotics use in this population and its associated factors.

METHODS

This cross-sectional and multi-site study was conducted in 11 sites of China. one Thousand five hundred three eligible MDD patients after 8-12 weeks of antidepressant treatment were included consecutively. A structured questionnaire was used to obtain socio-demographic data and medical histories. The Chinese version of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR), the Patient Health Questionnaire-15 (PHQ-15) and the Sheehan Disability Scale (SDS) were used for patient self-rating. Logistic regression model was used to explore the associated factors that could potentially be influential for the use antipsychotic augmentation.

RESULTS

Overall, quetiapine (43.4%) was the most commonly used as an adjunct to antidepressants, followed by olanzapine (38.8%). And antipsychotics were commonly combined with escitalopram (23.1%), venlafaxine (21.7%), sertraline (14.8%). The factors influencing the combination of antipsychotics in non-psychotic depressed patients included service setting (OR = 0.444; p < 0.001; 95%CI = 0.338-0.583), comorbidity of physical illness (OR = 1.704; p < 0.001; 95%CI = 1.274-2.278), PHQ level (OR = 0.680; p < 0.001; 95%CI = 0.548-0.844), SDS level (OR = 1.627; p < 0.001; 95%CI = 1.371-1.930) and antidepressants co-treatment (OR = 2.606; p < 0.001; 95%CI = 1.949-3.485).

CONCLUSIONS

Antipsychotics use is common among non-psychotic MDD patient. Service setting, comorbidity of physical illness, somatic symptoms, social functioning and engagement, and antidepressants co-treatment could be the factors associated with the antipsychotics use in MDD patients.

Cortisol as a Biomarker of Mental Disorder Severity

Cortisol—the most important steroid hormone with a significant effect on body metabolism—strongly affects peripheral tissues and the central nervous system. Fluctuations in cortisol secretion often accompany psychiatric disorders, and normalization of its levels correlates with improvement in the patient’s health. This indicates that cortisol may be useful as a biological marker that can help determine the likelihood of mental illness, its impending onset, and the severity of symptoms, which is especially important in the face of the increasing prevalence of mental disorders, including those associated with social isolation and anxiety during the COVID-19 pandemic. This publication reviews recent reports on cortisol levels in healthy participants and shows the current state of knowledge on changes in the levels of this hormone in people at risk for depression, bipolar disorder, and psychosis. It shows how people with psychiatric disorders react to stressful situations and how the applied therapies affect cortisol secretion. The influence of antidepressants and antipsychotics on cortisol levels in healthy people and those with mental disorders is also described. Finally, it reviews publications on the patterns of cortisol secretion in patients in remission.

Effects of antidepressant drug therapy with or without physical exercise on inflammatory biomarkers in major depressive disorder: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To conduct a systematic review and meta-analysis of the effects of antidepressant drug therapy (with or without physical exercise) on peripheral inflammatory markers in patients with major depressive disorder (MDD).

METHODS

MEDLINE, PyscINFO, Embase, and Google Scholar databases were searched until May 2020. Randomized trials that measured at least one inflammatory biomarker and included adult outpatients with MDD under antidepressant drug therapy (any drug) with or without physical exercise (any modality) were eligible. Results were summarized using the standardized mean difference (SMD) with 95% confidence intervals (95% CI) under a random-effects model. The Cochrane risk of bias tool (2010) was used to evaluate the risk of bias in the included trials.

RESULTS

Sixty-three trials were identified, encompassing data from 3482 patients, and 20 investigated biomarkers. Trials had biases across multiple domains, rising concerns primarily to selection bias/performance bias/detection bias/attrition bias. SMDs between pre- and post-results indicated a significant reduction in the levels of IL-2 (SMD, - 0.25; 95% CI, - 0.41 to - 0.09, P = 0.002), IL-6 (SMD, - 0.19; 95% CI, - 0.35 to - 0.025, P = 0.024), IL-10 (SMD, - 0.32; 95% CI, - 0.57 to - 0.07, P = 0.011), and serum cortisol (SMD, - 0.35; 95% CI, - 0.58 to - 0.12, P = 0.002). Evidence supporting the influence of physical exercise combined with antidepressant drugs on peripheral inflammatory markers in MDD is sparse and heterogeneous.

CONCLUSION

There is some evidence that antidepressant drug therapy is associated with an overall positive reduction in inflammatory markers, but the evidence is heterogeneous. Further research linking how inflammatory biomarkers modulate physiology related to antidepressant response is required.

TRIAL REGISTRATION

CRD42020220735.

Fabrication and Characterization of Fast-Dissolving Films Containing Escitalopram/Quetiapine for the Treatment of Major Depressive Disorder

Major depressive disorder (MMD) is a leading cause of disability worldwide. Approximately one-third of patients with MDD fail to achieve response or remission leading to treatment-resistant depression (TRD). One of the psychopharmacological strategies to overcome TRD is using a combination of an antipsychotic as an augmenting agent with selective serotonin reuptake inhibitors (SSRIs). Among which, an atypical antipsychotic, quetiapine (QUE), and an SSRI, escitalopram (ESC), were formulated as a fixed-dose combination as a fast-dissolving film by coaxial electrospinning. The resultant fiber’s morphology was studied. SEM images showed that the drug-loaded fibers were smooth, un-beaded, and non-porous with a fiber diameter of 0.9 ± 0.1 µm, while the TEM images illustrated the distinctive layers of the core and shell, confirming the successful preparation of these fibers. Differential scanning calorimetry (DSC) and X-ray diffraction (XRD) studies confirmed that both drugs were amorphously distributed within the drug-loaded fibers. The drug-loaded fibers exhibited a disintegration time of 2 s, which accelerated the release of both drugs (50% after 5 min) making it an attractive formulation for oral mucosal delivery. The ex vivo permeability study demonstrated that QUE was permeated through the buccal membrane, but not ESC that might be hindered by the buccal epithelium and the intercellular lipids. Overall, the developed coaxial fibers could be a potential buccal dosage form that could be attributed to higher acceptability and adherence among vulnerable patients, particularly mentally ill patients.

Melancholic depression and response to quetiapine: A pooled analysis of four randomized placebo-controlled trials

BACKGROUND

Melancholic depression may preferentially respond to certain treatments. This study examined the efficacy of extended-release quetiapine monotherapy in patients with melancholic and nonmelancholic major depressive disorder.

METHODS

Data from four randomized placebo-controlled trials was pooled. Melancholic features were assessed with baseline depression scale items according to DSM criteria. The outcome measure was response on the Montgomery-Åsberg Depression Rating Scale. Cox regression models predicting response over time with interactions between treatment condition and melancholic status were used to test for treatment effect heterogeneity.

RESULTS

The 6-week response rate difference between quetiapine and placebo was roughly 10% greater in the melancholic subgroup, primarily due to a lower placebo response, although the subgroup-treatment interactions did not reach statistical significance. The main effect of quetiapine was significant in every model.

LIMITATIONS

The main limitations were the retrospective analysis and the post-hoc designation of melancholic depression based on scale items not designed for that purpose. Results should be considered preliminary and exploratory until replicated.

CONCLUSIONS

The lower placebo response rate in the melancholic subgroup is consistent with past research and reinforces the benefit of pharmacotherapy for these patients.

Escitalopram as a modulator of proopiomelanocortin, kisspeptin, Kiss1R and MCHR1 gene expressions in the male rat brain

Neuropeptides are important, multifunctional regulatory factors of the nervous system, being considered as a novel, atypical sites of antidepressants action. It has already been proven that some of them, such as selective serotonin reuptake inhibitors (SSRI), are able to affect peptidergic pathways in various brain regions. Despite these reports, there is so far no reports regarding the effect of treatment with SSRIs on brain proopiomelanocortin (POMC), kisspeptin, Kiss1R and MCHR1 gene expression. In the current study we examined POMC, kisspeptin, Kiss1R and MCHR1 mRNA expression in the selected brain structures (hypothalamus, hippocampus, amygdala, striatum, cerebellum and brainstem) of rats chronically treated with a 10 mg/kg dose of escitalopram using quantitative Real-Time PCR. Long-term treatment with escitalopram led to the upregulation of MCHR1 expression in the rat amygdala. Kisspeptin mRNA level was also increased in the amygdala, but Kiss1R mRNA expressions were elevated in the hippocampus, hypothalamus and cerebellum. POMC mRNA expressions were in turn decreased in the hippocampus, amygdala, cerebellum and brainstem. These results may support the hypothesis that these neuropeptides may be involved in the site-dependent actions of SSRI antidepressants. This is the first report of the effects of escitalopram on POMC, kisspeptin, Kiss1R and MCHR1 in animal brain. Our findings shed a new light on the pharmacology of SSRIs and may contribute to a better understanding of the alternative, neuropeptide-dependent modes of antidepressant action.

In a Model of Neuroinflammation Designed to Mimic Delirium, Quetiapine Reduces Cortisol Secretion and Preserves Reversal Learning in the Attentional Set Shifting Task

Quetiapine, an atypical antipsychotic medication has lacked pre-clinical validation for its purported benefits in the treatment of delirium. This laboratory investigation examined the effects of quetiapine on the attentional set shifting task (ASST), a measure of cognitive flexibility and executive functioning, in a rodent model of lipopolysaccharide (LPS) mediated neuroinflammation. 19 Sprague Dawley female rats were randomly selected to receive intraperitoneal placebo (N = 5), LPS and placebo (N = 7) or LPS and quetiapine (n = 7) and performed the ASST. We measured trials to criterion, errors, non-locomotion episodes and latency to criterion, serum cortisol and tumor necrosis factor alpha (TNF-α) levels. TNF-α levels were not different between groups at 24 h. Cortisol levels in the LPS + Quetiapine group were reduced compared to LPS + Placebo (P < 0.001) and did not differ from the placebo group (P = 0.15). Analysis between LPS + Quetiapine and LPS + Placebo treated rats demonstrated improvement in the compound discrimination reversal (CD Rev1) (P = 0.016) and the intra-dimensional reversal (ID Rev2) (P = 0.007) discriminations on trials to criterion. LPS + Quetiapine treated rats had fewer errors than LPS + Placebo treated animals in the compound discrimination (CD) (P = 0.007), CD Rev1 (P = 0.005), ID Rev2 (P < 0.001) discriminations. There was no difference in non-locomotion frequency or latency to criterion between the three groups in all discriminations (P > 0.0167). We demonstrated preserved reversal learning, no effect on attentional set shifting and normalized cortisol levels in quetiapine-treated rats in this neuroinflammatory model of delirium. This suggests that quetiapine's beneficial effects in delirium may be related to the preservation of reversal learning and potential downstream effects related to reduction in cortisol production. Graphical Abstract.

Antidepressant and anxiolytic effects of the proprietary Chinese medicine Shexiang Baoxin pill in mice with chronic unpredictable mild stress

Depression and anxiety often co-occur with cardiac diseases. The Shexiang Baoxin pill (SBP) is a proprietary Chinese medicine initially used to treat cardiac conditions. This study explored whether SBP has antidepressant and anxiolytic effects in addition to hormonal and psychotropic mechanisms. Mice underwent 6 weeks of chronic unpredictable mild stress (CUMS) to induce depression- and anxiety-like behavior. During the 6-week experiment, mice received SBP at intragastric doses of 20.25 mg/kg or 40.5 mg/kg daily. Animals were then tested for depression in sucrose preference, forced-swimming, and tail suspension paradigms, and for anxiety in open field and elevated plus maze tests. Both SBP doses significantly reduced anhedonic behavior in the sucrose preference test; the high SBP dose also increased the number of entries into the central zone of the open field. SBP-treated mice had markedly lower blood levels of corticotrophin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) than stressed mice treated with vehicle. Either low- or high-dose SBP reversed stress-induced reductions of norepinephrine (NE) and dopamine (DA) metabolites and the expression levels of brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), and glial cell-derived neurotrophic factor (GDNF) in related brain regions. These results suggest that SBP could prevent and alleviate prolonged stress-induced anhedonia and anxiety in association with its suppression of the hypothalamic-pituitary-adrenal (HPA) axis hyperactivity, modulation of brain monoamine neurotransmitter metabolism and neurotrophins. SBP may be particularly suitable for the management of depressive and anxiety disorders in patients with cardiac conditions.

Escitalopram affects spexin expression in the rat hypothalamus, hippocampus and striatum

BACKGROUND

Spexin (SPX) is a recently discovered neuropeptide that exhibits a large spectrum of central and peripheral regulatory activity, especially when considered as a potent anorexigenic factor. It has already been proven that antidepressants, including selective serotonin reuptake inhibitors (SSRI), can modulate peptidergic signaling in various brain structures. Despite these findings, there is so far no information regarding the influence of treatment with the SSRI antidepressant escitalopram on brain SPX expression.

METHODS

In this current study we measured SPX mRNA and protein expression in the selected brain structures (hypothalamus, hippocampus and striatum) of rats chronically treated with a 10mg/kg dose of escitalopram using quantitative Real-Time PCR and immunohistochemistry.

RESULTS

Strikingly, long-term (4 week) drug treatment led to the downregulation of SPX expression in the rat hypothalamus. This supports the hypothesis that SPX may be involved in the hypothalamic serotonin-dependent actions of SSRI antidepressants and possibly also in the central mechanism of body mass increase. Conversely, SPX expression increased in the hippocampus and striatum.

CONCLUSIONS

This is the first report of the effects of a neuropsychiatric medication on SPX expression in animal brain. Our findings shed a new light on the pharmacology of antidepressants and may contribute to a better understanding of the alternative mechanisms responsible for antidepressant action.

An Overview of Links Between Obesity and Mental Health

The American Medical Association recently recognized obesity as both an illness and a leading cause of preventable death and chronic disease. This association is not only linked to physical health outcomes, however, as obesity has also been extensively associated with mental illness as well. Both obesity and severe mental illness decrease quality of life and are associated with an increase in disability, morbidity, and mortality, and when they occur together, these adverse health outcomes are magnified. Despite educational campaigns, increased awareness, and improved treatment options, the high prevalence of mental illness and comorbid obesity remains a serious problem. This review examines this overlap, highlighting clinical and biological factors that have been linked to this association in order to improve our understanding and help elucidate potential therapeutic avenues.