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Kochanowski B, Kageki-Bonnert K, Pinkerton EA, Dougherty DD, Chou T. A Review of Transcranial Magnetic Stimulation and Transcranial Direct Current Stimulation Combined with Medication and Psychotherapy for Depression. Harv Rev Psychiatry 2024; 32:77-95. [PMID: 38728568 DOI: 10.1097/hrp.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
LEARNING OBJECTIVES After participating in this CME activity, the psychiatrist should be better able to:• Compare and contrast therapies used in combination with transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) for treating MDD. BACKGROUND Noninvasive neuromodulation, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), has emerged as a major area for treating major depressive disorder (MDD). This review has two primary aims: (1) to review the current literature on combining TMS and tDCS with other therapies, such as psychotherapy and psychopharmacological interventions, and (2) to discuss the efficacy, feasibility, limitations, and future directions of these combined treatments for MDD. METHOD This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched three databases: PubMed, PsycInfo, and Cochrane Library. The last search date was December 5, 2023. RESULTS The initial search revealed 2,519 records. After screening and full-text review, 58 studies (7 TMS plus psychotherapy, 32 TMS plus medication, 7 tDCS plus psychotherapy, 12 tDCS plus medication) were included. CONCLUSIONS The current literature on tDCS and TMS paired with psychotherapy provides initial support for integrating mindfulness interventions with both TMS and tDCS. Adding TMS or tDCS to stable doses of ongoing medications can decrease MDD symptoms; however, benzodiazepines may interfere with TMS and tDCS response, and antipsychotics can interfere with TMS response. Pairing citalopram with TMS and sertraline with tDCS can lead to greater MDD symptom reduction compared to using these medications alone. Future studies need to enroll larger samples, include randomized controlled study designs, create more uniform protocols for combined treatment delivery, and explore mechanisms and predictors of change.
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Affiliation(s)
- Brian Kochanowski
- From Harvard Medical School, Division of Neurotherapeutics, Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA
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Wang Y, Olsson S, Lipp OV, Ney LJ. Renewal in human fear conditioning: A systematic review and meta-analysis. Neurosci Biobehav Rev 2024; 159:105606. [PMID: 38431150 DOI: 10.1016/j.neubiorev.2024.105606] [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: 12/10/2023] [Revised: 02/13/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
Renewal is a 'return of fear' manipulation in human fear conditioning to investigate learning processes underlying anxiety and trauma. Even though renewal paradigms are widely used, no study has compared the strength of different renewal paradigms. We conduct a systematic review (N = 80) and meta-analysis (N = 23) of human fear conditioning studies assessing renewal. Our analysis shows that the classic ABA design is the most effective paradigm, compared to ABC and ABBA designs. We present evidence that conducting extinction in multiple contexts and increasing the similarity between acquisition and extinction contexts reduce renewal. Furthermore, we show that additional cues can be used as safety and 'protection from extinction' cues. The review shows that alcohol weakens the extinction process and that older adults appear less sensitive to context changes and thus show less renewal. The large variability in approaches to study renewal in humans suggests that standardisation of fear conditioning procedures across laboratories would be of great benefit to the field.
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Affiliation(s)
- Yi Wang
- School of Psychology and Counselling, Queensland University of Technology, Australia.
| | - Sarah Olsson
- School of Psychology and Counselling, Queensland University of Technology, Australia
| | - Ottmar V Lipp
- School of Psychology and Counselling, Queensland University of Technology, Australia
| | - Luke J Ney
- School of Psychology and Counselling, Queensland University of Technology, Australia
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Lubin RE, Fitzgerald HE, Rosenfield D, Carpenter JK, Papini S, Dutcher CD, Dowd SM, Hofmann SG, Pollack MH, Smits JAJ, Otto MW. Using pre-treatment de novo threat conditioning outcomes to predict treatment response to DCS augmentation of exposure-based CBT. J Psychiatr Res 2023; 164:357-363. [PMID: 37399757 PMCID: PMC10557473 DOI: 10.1016/j.jpsychires.2023.06.008] [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: 03/16/2023] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Over a decade and a half of research has resulted in inconsistent evidence for the efficacy of d-cycloserine (DCS), a partial glutamatergic N-methyl-D-aspartate agonist, for augmenting exposure-based cognitive behavioral therapy (CBT) for anxiety- and fear-based disorders. These variable findings have motivated the search for moderators of DCS augmentation efficacy. METHODS In this secondary analysis of a previous randomized clinical trial, we evaluated the value of de novo threat conditioning outcomes-degree of threat acquisition, extinction, and extinction retention-for predicting treatment response to exposure-based CBT for social anxiety disorder, applied with and without DCS augmentation in a sample of 59 outpatients. RESULTS We found that average differential skin conductance response (SCR) during extinction and extinction retention significantly moderated the prediction of clinical response to DCS: participants with poorer extinction and extinction retention showed relatively improved treatment response with DCS. No such effects were found for expectancy ratings, consistent with accounts of DCS selectively aiding lower-order but not higher-order extinction learning. CONCLUSIONS These findings provide support for extinction and extinction retention outcomes from threat conditioning as potential pre-treatment biomarkers for DCS augmentation benefits. Independent of DCS augmentation, the current study did not support threat conditioning outcomes as useful for predicting response to exposure-based CBT.
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Affiliation(s)
- Rebecca E Lubin
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, 2nd Fl, Boston, MA, 02215, USA.
| | - Hayley E Fitzgerald
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, 2nd Fl, Boston, MA, 02215, USA
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, 6116 North Central Expressway, Dallas, TX, 75206, USA
| | - Joseph K Carpenter
- National Center for Posttraumatic Stress Disorder, Women's Health Sciences Division, 150 S Huntington Ave, Boston, MA, 02130, USA; VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA, 02130, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, 72 E Concord St, Boston, MA, 02118, USA
| | - Santiago Papini
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Christina D Dutcher
- Institute of Mental Health Research and Department of Psychology, The University of Texas at Austin, 108 E Dean Keeton St, Austin, TX, 78712, USA
| | - Sheila M Dowd
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, 1645 West Jackson Blvd Suite 400, Chicago, IL, 60612, USA
| | - Stefan G Hofmann
- Department of Clinical Psychology, Philipps University Marburg, Schulstrasse 12, 35037, Marburg/Lahn, Germany
| | - Mark H Pollack
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, 1645 West Jackson Blvd Suite 400, Chicago, IL, 60612, USA; Sage Therapeutics, 215 First St, Cambridge, MA, 02142, USA
| | - Jasper A J Smits
- Institute of Mental Health Research and Department of Psychology, The University of Texas at Austin, 108 E Dean Keeton St, Austin, TX, 78712, USA
| | - Michael W Otto
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, 2nd Fl, Boston, MA, 02215, USA
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Correll CU, Solmi M, Cortese S, Fava M, Højlund M, Kraemer HC, McIntyre RS, Pine DS, Schneider LS, Kane JM. The future of psychopharmacology: a critical appraisal of ongoing phase 2/3 trials, and of some current trends aiming to de-risk trial programmes of novel agents. World Psychiatry 2023; 22:48-74. [PMID: 36640403 PMCID: PMC9840514 DOI: 10.1002/wps.21056] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 01/15/2023] Open
Abstract
Despite considerable progress in pharmacotherapy over the past seven decades, many mental disorders remain insufficiently treated. This situation is in part due to the limited knowledge of the pathophysiology of these disorders and the lack of biological markers to stratify and individualize patient selection, but also to a still restricted number of mechanisms of action being targeted in monotherapy or combination/augmentation treatment, as well as to a variety of challenges threatening the successful development and testing of new drugs. In this paper, we first provide an overview of the most promising drugs with innovative mechanisms of action that are undergoing phase 2 or 3 testing for schizophrenia, bipolar disorder, major depressive disorder, anxiety and trauma-related disorders, substance use disorders, and dementia. Promising repurposing of established medications for new psychiatric indications, as well as variations in the modulation of dopamine, noradrenaline and serotonin receptor functioning, are also considered. We then critically discuss the clinical trial parameters that need to be considered in depth when developing and testing new pharmacological agents for the treatment of mental disorders. Hurdles and perils threatening success of new drug development and testing include inadequacy and imprecision of inclusion/exclusion criteria and ratings, sub-optimally suited clinical trial participants, multiple factors contributing to a large/increasing placebo effect, and problems with statistical analyses. This information should be considered in order to de-risk trial programmes of novel agents or known agents for novel psychiatric indications, increasing their chances of success.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Marco Solmi
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York, NY, USA
| | - Maurizio Fava
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikkel Højlund
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
- Mental Health Services in the Region of Southern Denmark, Department of Psychiatry Aabenraa, Aabenraa, Denmark
| | - Helena C Kraemer
- Department of Psychiatry and Behavioral Sciences, Stanford University, Cupertino, CA, USA
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Daniel S Pine
- Section on Developmental Affective Neuroscience, National Institute of Mental Health, Bethesda, MD, USA
| | - Lon S Schneider
- Department of Psychiatry and Behavioral Sciences, and Department of Neurology, Keck School of Medicine, and L. Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - John M Kane
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
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Kawaminami A, Yamada D, Yanagisawa S, Shirakata M, Iio K, Nagase H, Saitoh A. Selective δ-Opioid Receptor Agonist, KNT-127, Facilitates Contextual Fear Extinction via Infralimbic Cortex and Amygdala in Mice. Front Behav Neurosci 2022; 16:808232. [PMID: 35264937 PMCID: PMC8899726 DOI: 10.3389/fnbeh.2022.808232] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022] Open
Abstract
Facilitation of fear extinction is a desirable action for the drugs to treat fear-related diseases, such as posttraumatic stress disorder (PTSD). We previously reported that a selective agonist of the δ-opioid receptor (DOP), KNT-127, facilitates contextual fear extinction in mice. However, its site of action in the brain and the underlying molecular mechanism remains unknown. Here, we investigated brain regions and cellular signaling pathways that may mediate the action of KNT-127 on fear extinction. Twenty-four hours after the fear conditioning, mice were reexposed to the conditioning chamber for 6 min as extinction training (reexposure 1). KNT-127 was microinjected into either the basolateral nucleus of the amygdala (BLA), hippocampus (HPC), prelimbic (PL), or infralimbic (IL) subregions of the medial prefrontal cortex, 30 min before reexposure 1. Next day, mice were reexposed to the chamber for 6 min as memory testing (reexposure 2). KNT-127 that infused into the BLA and IL, but not HPC or PL, significantly reduced the freezing response in reexposure 2 compared with those of control. The effect of KNT-127 administered into the BLA and IL was antagonized by pretreatment with a selective DOP antagonist. Further, the effect of KNT-127 was abolished by local administration of MEK/ERK inhibitor into the BLA, and PI3K/Akt inhibitor into the IL, respectively. These results suggested that the effect of KNT-127 was mediated by MEK/ERK signaling in the BLA, PI3K/Akt signaling in the IL, and DOPs in both brain regions. Here, we propose that DOPs play a role in fear extinction via distinct signaling pathways in the BLA and IL.
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Affiliation(s)
- Ayako Kawaminami
- Laboratory of Pharmacology, Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
| | - Daisuke Yamada
- Laboratory of Pharmacology, Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
- *Correspondence: Daisuke Yamada,
| | - Shoko Yanagisawa
- Laboratory of Pharmacology, Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
| | - Motoki Shirakata
- Laboratory of Pharmacology, Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
| | - Keita Iio
- International Institute for Integrative Sleep Medicine (WPI-IIIS), University of Tsukuba, Ibaraki, Japan
| | - Hiroshi Nagase
- International Institute for Integrative Sleep Medicine (WPI-IIIS), University of Tsukuba, Ibaraki, Japan
| | - Akiyoshi Saitoh
- Laboratory of Pharmacology, Department of Pharmacy, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
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Hutschemaekers MHM, de Kleine RA, Hendriks GJ, Kampman M, Roelofs K. The enhancing effects of testosterone in exposure treatment for social anxiety disorder: a randomized proof-of-concept trial. Transl Psychiatry 2021; 11:432. [PMID: 34417443 PMCID: PMC8379251 DOI: 10.1038/s41398-021-01556-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/14/2021] [Accepted: 07/29/2021] [Indexed: 02/07/2023] Open
Abstract
Individuals with a social anxiety disorder (SAD) show hypofunctioning of the hypothalamus-pituitary-gonadal (HPG) axis, which is linked to social fear and avoidance behavior. As testosterone administration has been shown to facilitate social-approach behavior in this population, it may enhance the effectiveness of exposure treatment. In this proof-of-concept study, we performed a randomized clinical assay in which 55 women diagnosed with SAD received two exposure therapy sessions. Session 1 was supplemented with either testosterone (0.50 mg) or placebo. Next, transfer effects of testosterone augmentation on within-session subjective fear responses and SAD symptom severity were assessed during a second, unenhanced exposure session (session 2) and at a 1-month follow-up, respectively. The participants having received testosterone showed a more reactive fear pattern, with higher peaks and steeper reductions in fear levels in session 2. Post-hoc exploration of moderating effects of endogenous testosterone levels, revealed that this pattern was specific for women with high basal testosterone, both in the augmented and in the transfer session. In contrast, the participants with low endogenous testosterone showed reduced peak fear levels throughout session 1, again with transfer to the unenhanced session. Testosterone did not significantly affect self-reported anxiety. The effects of testosterone supplementation on fear levels show transfer to non-enhanced exposure, with effects being modulated by endogenous testosterone. These first preliminary results indicate that testosterone may act on important fear mechanisms during exposure, providing the empirical groundwork for further exploration of multi-session testosterone-enhanced exposure treatment for SAD.
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Affiliation(s)
- Moniek H. M. Hutschemaekers
- grid.491369.00000 0004 0466 1666Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Pro Persona Institute for Integrated Mental Health Care, Nijmegen, The Netherlands ,grid.5590.90000000122931605Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Rianne A. de Kleine
- grid.5132.50000 0001 2312 1970Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Gert-Jan Hendriks
- grid.491369.00000 0004 0466 1666Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Pro Persona Institute for Integrated Mental Health Care, Nijmegen, The Netherlands ,grid.5590.90000000122931605Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands ,grid.10417.330000 0004 0444 9382Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mirjam Kampman
- grid.491369.00000 0004 0466 1666Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Pro Persona Institute for Integrated Mental Health Care, Nijmegen, The Netherlands ,grid.5590.90000000122931605Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Karin Roelofs
- grid.5590.90000000122931605Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands ,grid.5590.90000000122931605Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroimaging, Radboud University, Nijmegen, The Netherlands
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7
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Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD, Iosifescu DV. Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:222-242. [PMID: 34690588 PMCID: PMC8475923 DOI: 10.1176/appi.focus.19203] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
(Appeared originally in Frontiers in Psychiatry 2020 Dec 23; 11:595584)
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8
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Radiske A, Gonzalez MC, Nôga DA, Rossato JI, Bevilaqua LRM, Cammarota M. GluN2B and GluN2A-containing NMDAR are differentially involved in extinction memory destabilization and restabilization during reconsolidation. Sci Rep 2021; 11:186. [PMID: 33420399 PMCID: PMC7794413 DOI: 10.1038/s41598-020-80674-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/24/2020] [Indexed: 12/01/2022] Open
Abstract
Extinction memory destabilized by recall is restabilized through mTOR-dependent reconsolidation in the hippocampus, but the upstream pathways controlling these processes remain unknown. Hippocampal NMDARs drive local protein synthesis via mTOR signaling and may control active memory maintenance. We found that in adult male Wistar rats, intra dorsal-CA1 administration of the non-subunit selective NMDAR antagonist AP5 or of the GluN2A subunit-containing NMDAR antagonist TCN201 after step down inhibitory avoidance (SDIA) extinction memory recall impaired extinction memory retention and caused SDIA memory recovery. On the contrary, pre-recall administration of AP5 or of the GluN2B subunit-containing NMDAR antagonist RO25-6981 had no effect on extinction memory recall or retention per se but hindered the recovery of the avoidance response induced by post-recall intra-CA1 infusion of the mTOR inhibitor rapamycin. Our results indicate that GluN2B-containing NMDARs are necessary for extinction memory destabilization whereas GluN2A-containing NMDARs are involved in its restabilization, and suggest that pharmacological modulation of the relative activation state of these receptor subtypes around the moment of extinction memory recall may regulate the dominance of extinction memory over the original memory trace.
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Affiliation(s)
- Andressa Radiske
- Memory Research Laboratory, Brain Institute, Federal University of Rio Grande do Norte, Av. Nascimento de Castro 2155, Natal, RN, 59056-450, Brazil
| | - Maria Carolina Gonzalez
- Memory Research Laboratory, Brain Institute, Federal University of Rio Grande do Norte, Av. Nascimento de Castro 2155, Natal, RN, 59056-450, Brazil.,Edmond and Lily Safra International Institute of Neuroscience, Av. Alberto Santos Dumont 1560, Macaiba, RN, 59280-000, Brazil
| | - Diana A Nôga
- Memory Research Laboratory, Brain Institute, Federal University of Rio Grande do Norte, Av. Nascimento de Castro 2155, Natal, RN, 59056-450, Brazil
| | - Janine I Rossato
- Memory Research Laboratory, Brain Institute, Federal University of Rio Grande do Norte, Av. Nascimento de Castro 2155, Natal, RN, 59056-450, Brazil.,Department of Physiology, Federal University of Rio Grande do Norte, Av. Sen. Salgado Filho 3000, Natal, RN, 59064-741, Brazil
| | - Lia R M Bevilaqua
- Memory Research Laboratory, Brain Institute, Federal University of Rio Grande do Norte, Av. Nascimento de Castro 2155, Natal, RN, 59056-450, Brazil
| | - Martín Cammarota
- Memory Research Laboratory, Brain Institute, Federal University of Rio Grande do Norte, Av. Nascimento de Castro 2155, Natal, RN, 59056-450, Brazil.
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Smits JAJ, Pollack MH, Rosenfield D, Otto MW, Dowd S, Carpenter J, Dutcher CD, Lewis EM, Witcraft SM, Papini S, Curtiss J, Andrews L, Kind S, Conroy K, Hofmann SG. Dose Timing of D-Cycloserine to Augment Exposure Therapy for Social Anxiety Disorder: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e206777. [PMID: 32496566 PMCID: PMC7273198 DOI: 10.1001/jamanetworkopen.2020.6777] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Findings suggest that the efficacy of D-cycloserine (DCS) for enhancing exposure therapy may be strongest when administered after sessions marked by low fear at the conclusion of exposure practice. These findings have prompted investigation of DCS dosing tailored to results of exposure sessions. OBJECTIVE To compare tailored postsession DCS administration with presession DCS administration, postsession DCS administration, and placebo augmentation of exposure therapy for social anxiety disorder. DESIGN, SETTING, AND PARTICIPANTS This double-blind randomized clinical trial involved adults with social anxiety disorder enrolled at 3 US university centers. Symptom severity was assessed at baseline, weekly during treatment, and at 1-week and 3-month follow-up. Data analysis was performed from September 2019 to March 2020. INTERVENTIONS Participants completed a 5-session treatment and received pills commensurate with their condition assignment at sessions 2 through 5, which emphasized exposure practice. MAIN OUTCOMES AND MEASURES Symptom severity was evaluated by the Liebowitz Social Anxiety Scale and Social Phobic Disorders-Severity Form as administered by independent evaluators. RESULTS A total of 152 participants were enrolled (mean [SD] age, 29.24 [10.16] years; 84 men [55.26%]). Compared with placebo, presession and postsession conditions showed greater symptom improvement (b = -0.25; 95% CI, -0.37 to -0.13; P < .001; d = 1.07; and b = -0.20; 95% CI, -0.32 to -0.07; P = .002; d = 0.85) and lower symptom severity (b = -0.51; 95% CI, -0.81 to -0.21; P < .001; d = 0.76; and b = -0.49; 95% CI, -0.80 to -0.18; P = .002; d = 0.72) at 3-month follow-up. No differences were found between presession and postsession conditions. The tailored condition showed no advantage over placebo. Compared with the tailored condition, presession and postsession conditions evidenced greater decreases (b = -0.22; 95% CI, -0.34 to -0.10; P < .001; d = 0.94; and b = -0.17, 95% CI, -0.29 to -0.04; P = .008; d = 0.72) and lower symptom severity (b = -0.44, 95% CI, -0.73 to -0.14; P = .004; d = 0.64; and b = -0.41, 95% CI, -0.72 to -0.11; P = .008; d = 0.61) at 3-month follow-up. CONCLUSIONS AND RELEVANCE Administration of DCS enhanced exposure therapy for social anxiety disorder when given before or after the exposure session. However, the study failed to achieve the aim to develop a tailored clinical application. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02066792.
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Affiliation(s)
- Jasper A J Smits
- Institute for Mental Health Research, Department of Psychology, The University of Texas at Austin, Austin
| | - Mark H Pollack
- Department of Psychiatry, Rush University Medical Center, Chicago, Illinois
- Now with Myriad Genetics, Salt Lake City, Utah
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, Texas
| | - Michael W Otto
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Sheila Dowd
- Department of Psychiatry, Rush University Medical Center, Chicago, Illinois
| | - Joseph Carpenter
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Christina D Dutcher
- Institute for Mental Health Research, Department of Psychology, The University of Texas at Austin, Austin
| | - Elizabeth M Lewis
- Department of Psychiatry, Rush University Medical Center, Chicago, Illinois
- Department of Psychology, Louisiana State University, Baton Rouge
| | - Sara M Witcraft
- Institute for Mental Health Research, Department of Psychology, The University of Texas at Austin, Austin
- Department of Psychology, University of Mississippi, Oxford
| | - Santiago Papini
- Institute for Mental Health Research, Department of Psychology, The University of Texas at Austin, Austin
| | - Joshua Curtiss
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Leigh Andrews
- Department of Psychology, Southern Methodist University, Dallas, Texas
- Department of Psychological and Brain Sciences, University of Delaware, Newark
| | - Shelley Kind
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
- Department of Psychology, Suffolk University, Boston, Massachusetts
| | - Kristina Conroy
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
- Department of Psychology, Florida International University, Coral Gables
| | - Stefan G Hofmann
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
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10
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Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD, Iosifescu DV. Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Front Psychiatry 2020; 11:595584. [PMID: 33424664 PMCID: PMC7786299 DOI: 10.3389/fpsyt.2020.595584] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/13/2020] [Indexed: 12/20/2022] Open
Abstract
Anxiety disorders are the most prevalent psychiatric disorders and a leading cause of disability. While there continues to be expansive research in posttraumatic stress disorder (PTSD), depression and schizophrenia, there is a relative dearth of novel medications under investigation for anxiety disorders. This review's first aim is to summarize current pharmacological treatments (both approved and off-label) for panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and specific phobias (SP), including selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), azapirones (e.g., buspirone), mixed antidepressants (e.g., mirtazapine), antipsychotics, antihistamines (e.g., hydroxyzine), alpha- and beta-adrenergic medications (e.g., propranolol, clonidine), and GABAergic medications (benzodiazepines, pregabalin, and gabapentin). Posttraumatic stress disorder and obsessive-compulsive disorder are excluded from this review. Second, we will review novel pharmacotherapeutic agents under investigation for the treatment of anxiety disorders in adults. The pathways and neurotransmitters reviewed include serotonergic agents, glutamate modulators, GABAergic medications, neuropeptides, neurosteroids, alpha- and beta-adrenergic agents, cannabinoids, and natural remedies. The outcome of the review reveals a lack of randomized double-blind placebo- controlled trials for anxiety disorders and few studies comparing novel treatments to existing anxiolytic agents. Although there are some recent randomized controlled trials for novel agents including neuropeptides, glutamatergic agents (such as ketamine and d-cycloserine), and cannabinoids (including cannabidiol) primarily in GAD or SAD, these trials have largely been negative, with only some promise for kava and PH94B (an inhaled neurosteroid). Overall, the progression of current and future psychopharmacology research in anxiety disorders suggests that there needs to be further expansion in research of these novel pathways and larger-scale studies of promising agents with positive results from smaller trials.
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Affiliation(s)
- Amir Garakani
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Silver Hill Hospital, New Canaan, CT, United States.,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - James W Murrough
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rafael C Freire
- Department of Psychiatry and Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Robyn P Thom
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Kaitlyn Larkin
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Frank D Buono
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Dan V Iosifescu
- Clinical Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, United States.,Department of Psychiatry, New York University School of Medicine, New York, NY, United States
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11
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Nasir M, Trujillo D, Levine J, Dwyer JB, Rupp ZW, Bloch MH. Glutamate Systems in DSM-5 Anxiety Disorders: Their Role and a Review of Glutamate and GABA Psychopharmacology. Front Psychiatry 2020; 11:548505. [PMID: 33329087 PMCID: PMC7710541 DOI: 10.3389/fpsyt.2020.548505] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022] Open
Abstract
Serotonin reuptake inhibitors and benzodiazepines are evidence-based pharmacological treatments for Anxiety Disorders targeting serotonin and GABAergic systems, respectively. Although clearly effective, these medications fail to improve anxiety symptoms in a significant proportion of patients. New insights into the glutamate system have directed attention toward drugs that modulate glutamate as potential alternative treatments for anxiety disorders. Here we summarize the current understanding of the potential role of glutamate neurotransmission in anxiety disorders and highlight specific glutamate receptors that are potential targets for novel anxiety disorder treatments. We also review clinical trials of medications targeting the glutamate system in DSM-5 anxiety disorders. Understanding the role of the glutamate system in the pathophysiology of anxiety disorder may aid in developing novel pharmacological agents that are effective in treating anxiety disorders.
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Affiliation(s)
- Madeeha Nasir
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States
| | - Daniel Trujillo
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States
| | - Jessica Levine
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States
| | - Jennifer B Dwyer
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States.,Yale Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, United States
| | - Zachary W Rupp
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States.,Frank H. Netter School of Medicine, Quinnipiac University, North Haven, CT, United States
| | - Michael H Bloch
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, United States.,Yale Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
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