Effect of selective serotonin reuptake inhibitors on platelet activation: can they prevent acute myocardial infarction?

Antidepressant and antiobesity drug-induced serotonin syndrome complicated by multiple organ injury: A case report

RATIONALE

Serotonin syndrome (SS), also referred to as serotonin toxicity, is a potentially life-threatening condition associated with increased serotonergic activity in the central nervous system, but often underdiagnosed due to its variable presentation.

PATIENT CONCERNS

A 46-year-old woman presented to the emergency department with complaints of fever, confused mental status with slurred speech, agitation. The patient also exhibited lower extremities weakness with spontaneous clonus. The physical examination revealed tachycardia and tachypnea. The patient was taking fluoxetine for depression disorder and anti-obesity medications including topiramate and phentermine. Initial laboratory finding demonstrated severe hypoxemia and rhabdomyolysis with renal dysfunction.

DIAGNOSES

Spinal tap and brain magnetic resonance imaging showed no clues that could explain the patient's neuromuscular symptoms. Based on the patient's overall presentation and use of medications, a diagnosis of SS was made. However, the patient's inpatient treatment was complicated by pulmonary thromboembolism (PTE) and stress-induced cardiomyopathy (SCM).

INTERVENTIONS

The patient was intubated and admitted to the intensive care unit for supportive care, including mechanical ventilation and hemodialysis. The patient received an intravenous benzodiazepine and vecuronium for controlling autonomic dysfunction and neuromuscular symptoms. Anticoagulation was also initiated promptly following the diagnosis of PTE.

OUTCOMES

After intensive supportive care, she was discharged 1 month after admission with normalized left ventricular motion and systolic function.

LESSONS

This case highlights that SS should be considered as an etiology of unexplained episodes of altered mental status and neuromuscular abnormalities. Rarely, this condition can be complicated by multiple organ injury, involving conditions such as rhabdomyolysis, renal failure, SCM and PTE. Thus, physicians must be aware of the various and atypical manifestations of serotonin syndrome in order to avoid missing the diagnosis of a potentially fatal condition.

Neuropsychiatric Manifestations of Long COVID-19: A Narrative Review of Clinical Aspects and Therapeutic Approaches

The COVID-19 (C-19) pandemic has highlighted the significance of understanding the long-term effects of this disease on the quality of life of those infected. Long COVID-19 (L-C19) presents as persistent symptoms that continue beyond the main illness period, usually lasting weeks to years. One of the lesser-known but significant aspects of L-C19 is its impact on neuropsychiatric manifestations, which can have a profound effect on an individual's quality of life. Research shows that L-C19 creates neuropsychiatric issues such as mental fog, emotional problems, and brain disease symptoms, along with sleep changes, extreme fatigue, severe head pain, tremors with seizures, and pain in nerves. People with cognitive problems plus fatigue and mood disorders experience great difficulty handling everyday activities, personal hygiene, and social interactions. Neuropsychiatric symptoms make people withdraw from social activity and hurt relationships, thus causing feelings of loneliness. The unpredictable state of L-C19 generates heavy psychological pressure through emotional suffering, including depression and anxiety. Neuropsychiatric changes such as cognitive impairment, fatigue, and mood swings make it hard for people to work or study effectively, which decreases their output at school or work and lowers their job contentment. The purpose of this narrative review is to summarize the clinical data present in the literature regarding the neuropsychiatric manifestations of L-C19, to identify current methods of diagnosis and treatment that lead to correct management of the condition, and to highlight the impact of these manifestations on patients' quality of life.

Prevalence and Determinants of Long-Term Post-COVID Conditions in the United States: 2022 Behavioral Risk Factor Surveillance System

BACKGROUND

A significant proportion of COVID survivors experience lingering and debilitating symptoms following acute COVID-19 infection. According to the national research plan on long COVID, it is a national priority to identify the prevalence of post-COVID conditions and their associated factors.

METHOD

We performed a cross-sectional analysis of the Prevention Behavioral Risk Factor Surveillance System (BRFSS) 2022, the largest continuously gathered health survey dataset worldwide by the Centers for Disease Control. After identifying individuals with a positive history of COVID-19, we grouped COVID-19 survivors based on whether they experienced long-term post-COVID conditions. Using survey-specific R packages, we compared the two groups' socio-demographics, comorbidities, and lifestyle-related factors. A logistic regression model was used to identify factors associated with post-COVID conditions.

RESULTS

The overall estimated prevalence of long-term post-COVID conditions among COVID survivors was 21.7%. Fatigue (5.7%), dyspnea (4.2%), and anosmia/ageusia (3.8%) were the most frequent symptoms. Based on multivariate logistic regression analysis, female sex, body mass index (BMI)≥25, lack of insurance, history of pulmonary disease, depression, and arthritis, being a former smoker, and sleep duration <7 h/d were associated with higher odds of post-COVID conditions. On the other hand, age >64 y/o, Black race, and annual household income ≥$100k were associated with lower odds of post-COVID conditions.

CONCLUSION

Our findings indicate a notable prevalence of post-COVID conditions, particularly among middle-aged women and individuals with comorbidities or adverse lifestyles. This high-risk demographic may require long-term follow-up and support. Further investigations are essential to facilitate the development of specified healthcare and therapeutic strategies for those suffering from post-COVID conditions.

Sertraline in depressed patients with or at risk for coronary heart disese: a systemic review

BACKGROUND AND AIMS

Depression is a prevalent comorbidity among patients with coronary heart disease (CHD). While recent studies have hinted at a possible association between CHD and antidepressant medications like sertraline, the existing evidence remains inconclusive. To investigate this potential link, we conducted a comprehensive systematic review.

METHODS

We systematically searched PubMed, Google Scholar, and Scopus for relevant articles published up to March 2023. After a thorough screening of titles and abstracts, 12 studies were included in our review.

RESULTS

The included studies, spanning from 1999 to 2021, comprised 11 randomized controlled trials (RCTs) and one pilot study. A total of 2767 participants with major depressive disorder and a history of cardiovascular disease or at risk for such events were included. The majority of these studies demonstrated improvements in mood status among patients treated with serotonin-targeting antidepressants and a reduced risk of cardiovascular events, as measured by various outcomes. While some cardiac adverse effects were observed with serotonin treatment, these did not reach statistical significance.

CONCLUSION

Our findings provide evidence supporting the beneficial effects of serotonin-targeting antidepressants for both depressive symptoms and the prevention of coronary adverse outcomes. These results highlight the potential value of serotonin-based treatments for depression in high-risk populations.

The Importance of Genetic Background and Neurotransmission in the Pathogenesis of the Co-Occurrence of Sleep Bruxism and Sleep-Disordered Breathing-Review of a New Perspective

Sleep bruxism (SB) and sleep-disordered breathing (SDB) are two prevalent conditions that significantly impact overall health. Studies suggest that up to 49.7% of individuals with SDB also exhibit symptoms of SB. This review aims to provide a comprehensive analysis of the role of genetic background and neurotransmission in the pathogenesis of the co-occurrence of SB and SDB. It seeks to synthesize current knowledge, highlight gaps in the existing literature, and propose a new perspective that integrates genetic and neurobiological factors. This review shows that both SB and SDB may be influenced by a combination of genetic, neurochemical, and environmental factors that contribute to their shared pathophysiology. The key neurotransmitters-dopamine, serotonin, and GABA-may play a significant role in their co-occurrence by regulating motor activity, sleep architecture, and respiratory control. Understanding genetic and neurochemical mechanisms may allow for more precise diagnostic tools and more personalized treatment approaches regarding SB and SDB. Clinically, there is a need for interdisciplinary collaboration between sleep specialists, dentists, neurologists, and geneticists. There is also a need to conduct large-scale genetic studies, coupled with neuroimaging and neurophysiological research, uncovering additional insights into the shared mechanisms of SB and SDB.

Subsets of Nanometer Vesicles in the Fly Release Differential Fractions of Vesicular Serotonin Content during Exocytosis

Serotonin, a monoamine neurotransmitter, is important in both the central nervous system (CNS) and the peripheral nervous system. Malfunction of serotonin signaling leads to various disorders. We studied serotonin signaling from serotonergic neurons inside the ventral nerve cord of Drosophila melanogaster. Serotonergic neurons and stimulated release were visualized and achieved with mCherry and channelrhodopsin-2 (an optogenetically transfected ion channel), respectively, and two electrochemical techniques quantified serotonin release and vesicular content. Mean vesicular serotonin content released during exocytosis from these neurons was 84 %, considerably higher than reported in previous studies regarding octopamine (4.5 %) and glutamate release (31 %). Serotonin content within all vesicles is uniformly changed when serotonin concentration is inhibited or enhanced. However, serotonin release exhibits two Gaussian distributions: higher frequency of small release events, and similar or slightly higher frequency of large events, resulting in differential release fractions ranging from partial (13-18 %) to full (100 %) release after treatment with agents to either enhance or diminish release. This is the first example of consistent full exocytotic release events we have observed in any system. We suggest one pool of vesicles can release significantly diverse fractions of transmitter load during exocytosis, a potentially novel pathway to regulate exocytosis and neuronal signaling.

Major depression is not associated with higher myocardial infarction rates: insights from a large database

Background: Depression has been suggested to increase the risk of cardiovascular disease, but many studies assessed depression after heart disease onset. This study evaluated the association between depression and myocardial infarction (MI) using a large inpatient database.Methods: We analyzed patients from the National Inpatient Sample hospitals from 2005 to 2020, selecting those aged >30 with ICD-9 and ICD-10 codes for segment elevation (ST) elevation myocardial infarction (STEMI), non-ST elevation myocardial elevation (NSTEMI) and major depression.Results: Our data included 4413,113 STEMI patients (224,430 with depression) and 10,421,346 NSTEMI patients (437,058 with depression). No significant association was found between depression and MI. For STEMI, the 2005 odds ratio was 0.12 (95% CI: 0.10-0.15, p < 0.001) and the 2020 odds ratio was 0.71 (95% CI: 0.69-0.73, p < 0.001). Similar patterns were observed for NSTEMI.Conclusion: Depression may not independently be a significant risk factor for MI.

Negative Prognostic Associations of Selective Serotonin Reuptake Inhibitors Use in Hospitalized COVID-19 Patients and Potential Contribution of Cardiovascular Comorbidities

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a causative agent of coronavirus disease 2019 (COVID-19), a very contagious systemic disease dominantly affecting the respiratory tract. Recent findings oppose earlier suggestions that selective serotonin reuptake inhibitors (SSRIs) might be protective during acute SARS-CoV-2 infection, prompting the current study.

METHODS

The institutional registry of a tertiary referral center was retrospectively evaluated for SSRI use and associated clinical outcomes among hospitalized COVID-19 patients with mostly severe and critical disease.

RESULTS

Among 1,558 patients, there were 78 (5%) exposed to SSRI during hospitalization. SSRI users in comparison to non-users did not significantly differ in their demographic characteristics, comorbidity profile or the severity of COVID-19 symptoms and associated inflammatory response at admission. In multivariate analyses adjusted for clinically meaningful variables, SSRI use was significantly associated with higher risks of death, mechanical ventilation, intensive care unit treatment, and bacteremia, whereas no significant relationship with risks of venous, arterial thrombosis, and major bleeding was present. Patients with less severe initial COVID-19 presentation, lower inflammatory burden, higher platelet count, lower cumulative comorbidity burden, presence of hyperlipidemia, atrial fibrillation, chronic heart failure and nonexposed to acetylsalicylic-acid had higher mortality associated with SSRI use.

CONCLUSIONS

Findings of the current study validate findings of higher mortality but also report higher tendency for respiratory deterioration, intensive care unit treatment, and bacteremia associated with SSRI use among hospitalized COVID-19 patients. These findings also suggest the potential contribution of cardiovascular comorbidities to detrimental clinical course of SSRI exposed patients.

The real-world effectiveness of fluvoxamine therapy in mild to moderate COVID-19 patients; A historical cohort study (Fluvoxa Trial)

BACKGROUND

Fluvoxamine (FVX) has been proposed as a potential treatment for severe COVID-19 by the σ-1 receptor agonist, which can reduce cytokine production. However, the efficacy of FVX remains controversial.

METHODS

A historical retrospective cohort study was conducted in mild to moderate COVID-19 patients, 2:1 ratio of standard of care (SOC) and FVX treatments to assess the effectiveness of FVX in preventing deterioration by the fifth day of treatment.

RESULTS

Of 752 eligible patients, 234 received FVX while 518 received SOC, and there was no significant difference in the effectiveness of FVX and SOC in preventing clinical deterioration. On the fifth day after treatment, 86.1 % of patients in the FVX-treated group did not experience clinical deterioration compared to 78.7 % in the SOC group. Notably, the FVX group had higher rates of pneumonia development and hospitalization, requiring more oxygen supplementation while showing less reduction in viral shedding than the SOC group. However, no difference in mechanical ventilation use, ICU admission, and survival was observed.

CONCLUSION

Fluvoxamine treatment is failed to demonstrate effectiveness in preventing deterioration in mild to moderate COVID-19 and may lead to a higher incidence of pneumonia, hospitalization, and oxygen supplementation, necessitating careful consideration before prescribing the drug for COVID-19.

Efficacy of combination therapy of fluvoxamine and favipiravir vs favipiravir monotherapy to prevent severe COVID-19 among mild to moderate COVID-19 patients: Open-label randomized controlled trial (EFFaCo study)

OBJECTIVES

Fluvoxamine (FVX) is an antidepressant proposed to its immunomodulatory effects in preventing deterioration in mild and moderate COVID-19.

METHODS

An open-label, 1:1 randomized controlled trial was assigned either combination therapy 50 mg twice daily of FVX for 10 days and favipiravir (FPV) or FPV alone to assess the efficacy in preventing disease progression in mild to moderate COVID-19 on the 5th day.

RESULTS

In total, 134 patients with mild COVID-19 received FPV and 132 received FVX/FPV, 31 patients with moderate COVID-19 received FPV/dexamethasone (FPV/Dex), and 30 received FVX/FPV/Dex. The intention-to-treat (ITT) analysis showed no difference of no clinical deterioration on the 5th day in both mild COVID-19 (100% in FPV vs 97% in FVX/FPV) and moderate COVID-19 (83.9% in FPV/Dex vs 86.7% in FVX/FPV/Dex). However, there was a low rate of oxygen supplemental, hospitalization, or intensive care in both groups and zero death in all groups. No significant difference in oxygen supplemental, hospitalization, radiological, virological, or biochemical outcomes, and the immunomodulatory effect was observed between the group.

CONCLUSION

The combined fluvoxamine treatment did not add benefit in preventing deterioration in patients with mild to moderate COVID-19 without the immunomodulatory effect observed, although it demonstrated low hospitalization rates, oxygen supplemental, intensive care needed, and zero mortality.

TRIAL REGISTRATION

Thai clinical trials registry (TCTR) no. 20210615002.

An exploratory study on the association between serotonin and sleep breathing disorders

This exploratory observational study aimed to evaluate whether the blood levels of serotonin and enzymes involved in serotonin synthesis are associated with sleep breathing parameters. A total of 105 patients were included in this study, who were subjected to single-night polysomnography with simultaneous audio-video recordings. Peripheral blood samples were collected to estimate the serum levels of serotonin, tryptophan hydroxylase 1 (TPH1), and aromatic l-amino acid decarboxylase (AADC). Results showed a negative correlation between blood serotonin levels, and oxygen desaturation index (ODI) (p = 0.027), central apnea (p = 0.044) and obstructive apnea (OA) (p = 0.032) scores. Blood TPH1 levels were negatively correlated with average (p = 0.003) and minimal saturation (p = 0.035) and positively correlated with apnea-hypopnea index (p = 0.010), OA (p = 0.049), and hypopnea index (p = 0.007) scores. A tendency to sleep-disordered breathing seemed to co-occur with lower blood serotonin and higher TPH1 levels.Clinical Trial Registration : www.ClinicalTrials.gov , identifier NCT04214561.

Selective serotonin reuptake inhibitors: New hope in the fight against COVID-19

The emerging COVID-19 pandemic led to a dramatic increase in global mortality and morbidity rates. As in most infections, fatal complications of coronavirus affliction are triggered by an untrammeled host inflammatory response. Cytokine storms created by high levels of interleukin and other cytokines elucidate the pathology of severe COVID-19. In this respect, repurposing drugs that are already available and might exhibit anti-inflammatory effects have received significant attention. With the in vitro and clinical investigation of several studies on the effect of antidepressants on COVID-19 prognosis, previous data suggest that selective serotonin reuptake inhibitors (SSRIs) might be the new hope for the early treatment of severely afflicted patients. SSRIs' low cost and availability make them potentially eligible for COVID-19 repurposing. This review summarizes current achievements and literature about the connection between SSRIs administration and COVID-19 prognosis.

Antidepressant psychopharmacology: is inflammation a future target?

Raised inflammatory setpoints have been associated with major depression and its detrimental consequences on brain function, as they lead to increased production of cytokines, changes in gene expression and activated brain microglia. Three main lines of evidence support immune-inflammatory mechanisms as targets for the treatment of depression. First, higher inflammation hampers response to antidepressants, and effective antidepressant treatment decreases inflammation. Second, conventional antidepressants share immune-modulatory and anti-inflammatory properties, which could affect inflammation during the depression. Third, anti-inflammatory and immune-modulatory treatments proved superior to placebo in randomized controlled antidepressant trials. New targets and new pharmacologic treatment for immune-mediated inflammatory diseases have been identified and tested in several medical settings and interest is warranted for testing them as antidepressants.

Rapid response to selective serotonin reuptake inhibitors in post-COVID depression

The spreading of the Severe Acute Respiratory Syndrome Coronavirus (COVID-19) pandemic could be associated with psychiatric implications. After COVID-19, depression was reported in 40% of patients at one-, three-, and six-months follow-up. Emerging literature suggests anti-inflammatory and antiviral properties of antidepressants in the treatment of SARS-CoV-2. We aim to investigate the efficacy of Selective Serotonin Reuptake Inhibitor (SSRI) in treating post-COVID depression. We included 60 patients affected by a major depressive episode and treated with SSRI in the six months following recovery from COVID. The severity of depression was rated at baseline and after four weeks on the Hamilton Depression Rating Scale (HDRS). Response to treatment was considered when the patients achieved a 50% HDRS reduction. To investigate changes of depressive symptomatology over time, repeated measures ANOVAs according to clinical variables were performed. We found that 55 (92%) patients showed a clinical response to antidepressant. Patients showed a significant decrease over time of HDRS score (baseline HDRS = 23.37 ± 3.94, post-treatment HDRS = 6.71±4.41, F = 618.90, p < 0.001), irrespectively of sex, previous psychiatric history, previous history of mood disorder, and SSRI type. This is the first study to explore the SSRI efficacy in post-COVID depression, suggesting rapid antidepressant effects in most patients. SSRIs treatment could contribute to the rapid antidepressant response by directly targeting the neuroinflammation triggered by SARS-CoV-2. We suggest screening psychopathology of COVID-19 survivors to diagnose emergent depression and pharmacologically treat it to reduce the disease burden and related years of life lived with disability.

Effect of early treatment with fluvoxamine on risk of emergency care and hospitalisation among patients with COVID-19: the TOGETHER randomised, platform clinical trial

BACKGROUND

Recent evidence indicates a potential therapeutic role of fluvoxamine for COVID-19. In the TOGETHER trial for acutely symptomatic patients with COVID-19, we aimed to assess the efficacy of fluvoxamine versus placebo in preventing hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to a tertiary hospital due to COVID-19.

METHODS

This placebo-controlled, randomised, adaptive platform trial done among high-risk symptomatic Brazilian adults confirmed positive for SARS-CoV-2 included eligible patients from 11 clinical sites in Brazil with a known risk factor for progression to severe disease. Patients were randomly assigned (1:1) to either fluvoxamine (100 mg twice daily for 10 days) or placebo (or other treatment groups not reported here). The trial team, site staff, and patients were masked to treatment allocation. Our primary outcome was a composite endpoint of hospitalisation defined as either retention in a COVID-19 emergency setting or transfer to tertiary hospital due to COVID-19 up to 28 days post-random assignment on the basis of intention to treat. Modified intention to treat explored patients receiving at least 24 h of treatment before a primary outcome event and per-protocol analysis explored patients with a high level adherence (>80%). We used a Bayesian analytic framework to establish the effects along with probability of success of intervention compared with placebo. The trial is registered at ClinicalTrials.gov (NCT04727424) and is ongoing.

FINDINGS

The study team screened 9803 potential participants for this trial. The trial was initiated on June 2, 2020, with the current protocol reporting randomisation to fluvoxamine from Jan 20 to Aug 5, 2021, when the trial arms were stopped for superiority. 741 patients were allocated to fluvoxamine and 756 to placebo. The average age of participants was 50 years (range 18-102 years); 58% were female. The proportion of patients observed in a COVID-19 emergency setting for more than 6 h or transferred to a teritary hospital due to COVID-19 was lower for the fluvoxamine group compared with placebo (79 [11%] of 741 vs 119 [16%] of 756); relative risk [RR] 0·68; 95% Bayesian credible interval [95% BCI]: 0·52-0·88), with a probability of superiority of 99·8% surpassing the prespecified superiority threshold of 97·6% (risk difference 5·0%). Of the composite primary outcome events, 87% were hospitalisations. Findings for the primary outcome were similar for the modified intention-to-treat analysis (RR 0·69, 95% BCI 0·53-0·90) and larger in the per-protocol analysis (RR 0·34, 95% BCI, 0·21-0·54). There were 17 deaths in the fluvoxamine group and 25 deaths in the placebo group in the primary intention-to-treat analysis (odds ratio [OR] 0·68, 95% CI: 0·36-1·27). There was one death in the fluvoxamine group and 12 in the placebo group for the per-protocol population (OR 0·09; 95% CI 0·01-0·47). We found no significant differences in number of treatment emergent adverse events among patients in the fluvoxamine and placebo groups.

INTERPRETATION

Treatment with fluvoxamine (100 mg twice daily for 10 days) among high-risk outpatients with early diagnosed COVID-19 reduced the need for hospitalisation defined as retention in a COVID-19 emergency setting or transfer to a tertiary hospital.

FUNDING

FastGrants and The Rainwater Charitable Foundation.

TRANSLATION

For the Portuguese translation of the abstract see Supplementary Materials section.

Candidate Psychotropics against SARS - CoV - 2: A Narrative Review

Since few therapeutic options are clinically accessible for coronavirus disease 2019 (COVID-19), effective, safe, and globally available pharmaceuticals need to be urgently developed to prevent severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) and alleviate the severity of COVID-19. In this regard, the present paper is intended to provide an extensive review of the clinical and preclinical evidence on the psychotropics' anti-SARS-CoV-2 effects, giving an insight into their potential applications for patients with a proven or high likelihood of COVID-19 pneumonia. The results showed that psychotropic drugs such as melatonin, lithium carbonate, valproate, olanzapine, quetiapine, clozapine, fluoxetine, escitalopram, fluvoxamine, and cannabidiol could help lower the mortality due to SARS-CoV-2 infection. According to these medications' direct immunomodulatory actions against the destructive cytokine storm, as well as other direct/indirect mechanisms (e. g., the endolysosomal pathway modulation, interactions with specific receptors, and membrane fusion), it was perceived that such drugs could effectively weaken the worsened immune response and avoid adult respiratory distress syndrome and acute lung injury. According to the author's analysis of the currently available evidence, there is significant support for psychotropics as complementary interventions during SARS-CoV-2 infection. However, further studies need to be carried out to assess the effects of the above psychotropic drugs in vitro and clinical settings.

Post-COVID-19 Depressive Symptoms: Epidemiology, Pathophysiology, and Pharmacological Treatment

The Coronavirus Disease 2019 (COVID-19) pandemic is still spreading worldwide over 2 years since its outbreak. The psychopathological implications in COVID-19 survivors such as depression, anxiety, and cognitive impairments are now recognized as primary symptoms of the "post-acute COVID-19 syndrome." Depressive psychopathology was reported in around 35% of patients at short, medium, and long-term follow-up after the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. Post-COVID-19 depressive symptoms are known to increase fatigue and affect neurocognitive functioning, sleep, quality of life, and global functioning in COVID-19 survivors. The psychopathological mechanisms underlying post-COVID-19 depressive symptoms are mainly related to the inflammation triggered by the peripheral immune-inflammatory response to the viral infection and to the persistent psychological burden during and after infection. The large number of SARS-CoV-2-infected patients and the high prevalence of post-COVID-19 depressive symptoms may significantly increase the pool of people suffering from depressive disorders. Therefore, it is essential to screen, diagnose, treat, and monitor COVID-19 survivors' psychopathology to counteract the depression disease burden and related years of life lived with disability. This paper reviews the current literature in order to synthesize the available evidence regarding epidemiology, clinical features, neurobiological underpinning, and pharmacological treatment of post-COVID-19 depressive symptoms.

Lower serotonin levels in severe sleep bruxism and its association with sleep, heart rate, and body mass index

BACKGROUND

Sleep bruxism (SB) is a complex behaviour that seems to be associated with the serotoninergic pathway.

OBJECTIVES

This exploratory research aimed to evaluate the levels of serotonin in individuals with sleep bruxism diagnosed by video polysomnography. The study also evaluated whether the levels of serotonin were associated with body mass index, heart rate, and sleep parameters.

METHODS

The study participants were adults hospitalised in the Department and Clinic of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology at the Wroclaw Medical University. They underwent a single-night video polysomnography during which sleep and SB parameters and heart rate were evaluated. Additionally, body mass index and blood serotonin levels were evaluated for each patient.

RESULTS

A total of 105 patients were included in this study (80 women and 25 men). All the patients were Caucasians aged 18-63 years, with a mean age ± (standard deviation) of 33.43± 10.8 years. Seventy-five patients (71.43%) presented sleep bruxism (bruxism episodes index ≥2) and 30 (28.57%) did not. Fifty patients (47.62%) presented severe sleep bruxism (bruxism episodes index >4). The results showed that lower blood serotonin levels were associated with severe sleep bruxism; increased bruxism episodes index, rapid eye movement sleep, and body mass index; and decreased maximal pulse.

CONCLUSION

Severe sleep bruxism and the associated phenomena seem to co-occur with lower blood serotonin levels. The study supports the hypothesis on the relationship between the serotoninergic pathway and sleep bruxism.

S1R agonist modulates rat platelet eicosanoid synthesis and aggregation

Sigma-1 receptor (S1R) is detected in different cell types and can regulate intracellular signaling pathways. S1R plays a role in the pathomechanism of diseases and the regulation of neurotransmitters. Fluvoxamine can bind to S1R and reduce the serotonin uptake of neurons and platelets. We therefore hypothesized that platelets express S1R, which can modify platelet function. The expression of the SIGMAR1 gene in rat platelets was examined with a reverse transcription polymerase chain reaction and a quantitative polymerase chain reaction. The receptor was also visualized by immunostaining and confocal laser scanning microscopy. The effect of S1R agonist PRE-084 on the eicosanoid synthesis of isolated rat platelets and ADP- and AA-induced platelet aggregation was examined. S1R was detected in rat platelets both at gene and protein levels. Pretreatment with PRE-084 of resting platelets induced elevation of eicosanoid synthesis. The rate of elevation in thromboxane B₂ and prostaglandin D₂ synthesis was similar, but the production of prostaglandin E₂ was higher. The concentration-response curve showed a sigmoidal form. The most effective concentration of the agonist was 2 µM. PRE-084 increased the quantity of cyclooxygenase-1 as detected by ELISA. PRE-084 also elevated the ADP- and AA-induced platelet aggregation. S1R of platelets might regulate physiological or pathological functions.

SSRIs: Applications in inflammatory lung disease and implications for COVID-19

Selective serotonin reuptake inhibitors (SSRIs) have anti-inflammatory properties that may have clinical utility in treating severe pulmonary manifestations of COVID-19. SSRIs exert anti-inflammatory effects at three mechanistic levels: (a) inhibition of proinflammatory transcription factor activity, including NF-κB and STAT3; (b) downregulation of lung tissue damage and proinflammatory cell recruitment via inhibition of cytokines, including IL-6, IL-8, TNF-α, and IL-1β; and (c) direct suppression inflammatory cells, including T cells, macrophages, and platelets. These pathways are implicated in the pathogenesis of COVID-19. In this review, we will compare the pathogenesis of lung inflammation in pulmonary diseases including COVID-19, ARDS, and chronic obstructive pulmonary disease (COPD), describe the anti-inflammatory properties of SSRIs, and discuss the applications of SSRIS in treating COVID-19-associated inflammatory lung disease.

Fluvoxamine vs Placebo and Clinical Deterioration in Outpatients With Symptomatic COVID-19: A Randomized Clinical Trial

IMPORTANCE

Coronavirus disease 2019 (COVID-19) may lead to serious illness as a result of an excessive immune response. Fluvoxamine may prevent clinical deterioration by stimulating the σ-1 receptor, which regulates cytokine production.

OBJECTIVE

To determine whether fluvoxamine, given during mild COVID-19 illness, prevents clinical deterioration and decreases the severity of disease.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, randomized, fully remote (contactless) clinical trial of fluvoxamine vs placebo. Participants were community-living, nonhospitalized adults with confirmed severe acute respiratory syndrome coronavirus 2 infection, with COVID-19 symptom onset within 7 days and oxygen saturation of 92% or greater. One hundred fifty-two participants were enrolled from the St Louis metropolitan area (Missouri and Illinois) from April 10, 2020, to August 5, 2020. The final date of follow-up was September 19, 2020.

INTERVENTIONS

Participants were randomly assigned to receive 100 mg of fluvoxamine (n = 80) or placebo (n = 72) 3 times daily for 15 days.

MAIN OUTCOMES AND MEASURES

The primary outcome was clinical deterioration within 15 days of randomization defined by meeting both criteria of (1) shortness of breath or hospitalization for shortness of breath or pneumonia and (2) oxygen saturation less than 92% on room air or need for supplemental oxygen to achieve oxygen saturation of 92% or greater.

RESULTS

Of 152 patients who were randomized (mean [SD] age, 46 [13] years; 109 [72%] women), 115 (76%) completed the trial. Clinical deterioration occurred in 0 of 80 patients in the fluvoxamine group and in 6 of 72 patients in the placebo group (absolute difference, 8.7% [95% CI, 1.8%-16.4%] from survival analysis; log-rank P = .009). The fluvoxamine group had 1 serious adverse event and 11 other adverse events, whereas the placebo group had 6 serious adverse events and 12 other adverse events.

CONCLUSIONS AND RELEVANCE

In this preliminary study of adult outpatients with symptomatic COVID-19, patients treated with fluvoxamine, compared with placebo, had a lower likelihood of clinical deterioration over 15 days. However, the study is limited by a small sample size and short follow-up duration, and determination of clinical efficacy would require larger randomized trials with more definitive outcome measures.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04342663.

Is there an association between the use of antidepressants and complications involving dental implants? A systematic review and meta-analysis

The aim of this systematic review was to evaluate published evidence on the association between the use of antidepressants and complications involving dental implants. Two reviewers independently performed electronic searches of the MEDLINE/PubMed, Cochrane Library, and Scopus databases for relevant articles published up to May 30, 2019. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Newcastle-Ottawa Scale was used for the appraisal of the methodological quality of the studies included. A meta-analysis was performed to determine the risk of dental implant failure in individuals taking antidepressants. Five comparative observational studies were selected for this review; these included a total of 2056 participants with 5302 implants. The results suggest a risk ratio of 3.73 (95% confidence interval 1.85-7.52, P=0.0002) for implant failure in antidepressant users submitted to oral rehabilitation when compared to non-users. However, these studies did not present methodological rigour or standardize the drugs used. Thus, there is insufficient evidence for an association between antidepressant use and dental implant complications.

Degree of serotonin reuptake inhibition of antidepressants and ischemic risk: A cohort study

OBJECTIVE

To assess whether use of antidepressants with strong inhibition of serotonin reuptake is associated with a decreased incidence of ischemic stroke and myocardial infarction (MI).

METHODS

We conducted a cohort study using the UK Clinical Practice Research Datalink and considering new users of selective serotonin reuptake inhibitors (SSRIs) or third-generation antidepressants who were ≥18 years of age between 1995 and 2014. Using a nested case-control approach, we matched each case of a first ischemic stroke or MI identified during follow-up with up to 30 controls on age, sex, calendar time, and duration of follow-up. We estimated incidence rate ratios (RRs) and 95% confidence intervals (CIs) of each outcome associated with current use of strong compared with weak inhibitors of serotonin reuptake using conditional logistic regression.

RESULTS

The cohort included 938,388 incident users of SSRIs (n = 868,755) or third-generation antidepressants (n = 69,633). Mean age at cohort entry was 46 years (64% women). During follow-up, 15,860 cases of ischemic stroke and 8,626 cases of MI were identified and matched to 473,712 and 258,022 controls, respectively. Compared with current use of weak inhibitors of serotonin reuptake, current use of strong inhibitors was associated with a decreased rate of ischemic stroke (RR 0.88, 95% CI 0.80-0.97), but the effect size was smaller in some sensitivity analyses. The rate of MI was similar between strong and weak inhibitors (RR 1.00, 95% CI 0.87-1.15).

CONCLUSION

Our large population-based study suggests that antidepressants strongly inhibiting serotonin reuptake may be associated with a small decrease in the rate of ischemic stroke.

Safety and efficacy of reduced dosage ketoprofen with or without tramadol for long-term treatment of osteoarthritis in dogs: a randomized clinical trial

BACKGROUND

This study aimed to evaluate the safety and efficacy of reduced-dosage ketoprofen with or without tramadol in dogs. Five healthy dogs receiving standard-dosage ketoprofen (2 mg/kg SC, then 1 mg/kg PO daily) comprised Group A. Twenty dogs with osteoarthritis were randomized to receive reduced-dosage ketoprofen (0.5 mg/kg SC once; 0.25 mg/kg PO daily) alone (Group B) or in combination with tramadol (5 mg/kg/day PO) (Group C). Treatments were administered for 28 days. Platelet aggregation time (PAT), gastrointestinal (GI) endoscopy and glomerular filtration rate (GFR) were performed up to 60 days after treatment initiation. Pain was scored using a validated clinical metrology instrument up to D120. Data were analyzed with general linear mixed model for repeated measures (α = 0.05).

RESULTS

PAT was not different between groups but was increased with time for all groups. GI lesion scores were higher in Group A than Groups B and C (day 28; P = 0.005) and were increased with time for Group A (P = 0.005). GFR was lower in Group A than Groups B and C (day 28; P < 0.01) and were decreased with time for group A (P < 0.001). Standard-dosage ketoprofen administration resulted in clinically relevant adverse effects. Pain score decreased in both treated groups (B and C) from D0 to D28. Need of rescue analgesia from D29 to D120 was higher in Group B than in Group C (P = 0.039).

CONCLUSIONS

The long-term safety profile of reduced-dosage ketoprofen is similar whether the drug is administered alone or in combination with tramadol to dogs with osteoarthritis. Analgesic efficacy of the combination looks attractive.

Variables affecting the potential efficacy of PRP in providing chronic pain relief

Although chronic pain affects about 1% of the US population, it remains largely resistant to treatment. Despite great variability in pain outcomes, the application of autologous platelet-rich plasma (PRP) has become increasingly popular in attempts to reduce chronic pain. The variability in PRP efficacy raises the question of whether PRP actually has an analgesic capacity, and if so, can that capacity be made consistent and maximized. The best explanation for the variability in PRP analgesic efficacy is the failure during PRP preparation and application to take into account variables that can increase or eliminate its analgesic capabilities. This suggests that if the variables are reduced and controlled, a PRP preparation and application protocol can be developed leading to PRP inducing reliable, complete, and long-term pain relief. The goal of this study was to examine some of the variables that influence platelets and see how they might be controlled to increase the analgesic potential of PRP. Among the variables examined are the physiological status of the patient, methods used to prepare PRP, and methods of PRP application. The goal of modifying these variables is to minimize platelet serotonin content, maximize platelet content of factors that reduce inflammation and pain, while maintaining their bioactivity, maximize platelet capacity to aggregate at injury sites, induce rapid and simultaneous release of their contents, and optimize PRP application protocols. It is concluded that controlling some or many of these variables will lead to PRP that induces reliable, maximum, and long-term relief of chronic pain.

Oral reserpine administration in horses results in low plasma concentrations that alter platelet biology

BACKGROUND

Reserpine is a popular drug in the equine industry for long-term tranquilisation. Clinical observations revealed that blood from horses receiving oral reserpine was hypercoagulable. No studies have documented the pharmacokinetics of orally administered reserpine nor the effects of reserpine on platelets in horses.

OBJECTIVES

To evaluate the pharmacokinetics of oral reserpine in horses and the effects of clinically relevant concentrations of reserpine on platelet functionality in vitro.

STUDY DESIGN

Experimental controlled study.

METHODS

The pharmacokinetics of oral reserpine (2.5 mg/horse, once) were determined in six healthy adult horses. Plasma samples were collected and concentrations of reserpine were determined by UPLC-MS/MS. Using this data, the in vitro effects of reserpine on platelets were examined. Aggregation, adhesion and releasate assays for serotonin and thromboxane B₂ were performed on platelets exposed to varying concentrations of reserpine (0.01-10 ng/mL), aspirin (negative control) and saline (unexposed control).

RESULTS

Oral reserpine administration demonstrated low plasma concentrations with a C_max of 0.2 ± 0.06 ng/mL and a prolonged half-life of 23.6 ± 6.24 h. Simulations over a dose range of 2-8 μg/kg predicted C_max at steady state between 0.06-0.9 ng/mL. Platelets exposed to these reserpine concentrations in vitro displayed increased aggregation and adhesion compared to unexposed or aspirin-exposed platelets as well as compared to higher concentrations of reserpine. These functional changes correlated with lower concentrations of serotonin and higher concentrations of thromboxane B₂ in the platelet suspension supernatant.

MAIN LIMITATIONS

This study used a small number of horses and only in vitro platelet experiments.

CONCLUSIONS

Oral reserpine demonstrates low plasma concentrations and a prolonged half-life in horses. At these concentrations, reserpine causes significant changes in platelet function, most likely due to serotonin release and re-uptake which primes platelets for activation and thromboxane B₂ release. These findings suggest that clinicians should harvest blood for biological processing prior to the onset of reserpine administration.

Immunomodulatory Action of Substituted 1,3,4-Thiadiazines on the Course of Myocardial Infarction

This review focuses on the biological action of the compounds from the group of substituted 1,3,4-thiadiazines on stress response and myocardial infarction. The aim of this review is to propose the possible mechanisms of action of 1,3,4-thiadiazines and offer prospectives in the development of new derivatives as therapeutic agents. It is known, that compounds that have biological effects similar to those used as antidepressants can down-regulate the secretion of proinflammatory cytokines, up-regulate the release of anti-inflammatory ones and affect cell recruitment, which allows them to be considered immunomodulators as well. The results of pharmacological evaluation, in silico studies, and in vivo experiments of several compounds from the group of substituted 1,3,4-thiadiazines with antidepressant properties are presented. It is proposed that the cardioprotective effects of substituted 1,3,4-thiadiazines might be explained by the peculiarities of their multi-target action: the ability of the compounds to interact with various types of receptors and transporters of dopaminergic, serotonergic and acetylcholinergic systems and to block the kinase signal pathway PI3K-AKT. The described effects of substituted 1,3,4-thiadiazines suggest that it is necessary to search for a new agents for limiting the peripheral inflammatory/ischemic damage through the entral mechanisms of stress reaction and modifying pro-inflammatory cytokine signaling pathways in the brain.

Early citalopram treatment increases mortality due to left ventricular rupture in mice after myocardial infarction

AIMS

Both anxiety and depression are common and independent outcome predictors in patients after myocardial infarction (MI). However, it is unclear whether and how anti-depressants influence remodeling after MI. Thus, we studied cardiac remodeling in mice after experimental MI under treatment with citalopram, a selective serotonin reuptake inhibitor widely used as antidepressant.

METHODS AND RESULTS

Treatment with citalopram versus saline was applied via osmotic pump after coronary artery ligation. Two different groups were studied: early treatment during the healing phase (starting immediately after surgery), or late treatment in the remodeling phase (starting 7days after surgery). Late treatment did not change mortality or left ventricular remodeling after MI over the period of 6weeks. However, in the early treatment group mortality was increased in citalopram-treated mice predominantly due to left ventricle rupture without differences in infarct size. Remodeling 4weeks after MI was not altered by the treatment. Neither infiltration of inflammatory cells, as determined by FACS analysis of myocardial tissue, nor mRNA-expression of inflammatory cytokines changed 3days after MI in the early treatment group. However, extracellular matrix functioning was altered: There was a significant increase of MMP13 in citalopram treated animals after MI. Pretreatment with the MMP inhibitor PD 166793 prevented left ventricular ruptures and demonstrated a tendency to improved survival after citalopram treatment.

CONCLUSIONS

Treatment with antidepressant citalopram in the acute but not in the late phase after MI significantly increased mortality in mice by disturbing early healing. Pharmacological MMP inhibition partially reversed the deleterious effects of citalopram.

Pleiotropic effects of statins

Statins or 3-hydroxy-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors not only prevents the synthesis of cholesterol biosynthesis but also inhibits the synthesis of essential isoprenoid intermediates such as farnesyl pyrophosphate, geranylgeranyl pyrophosphate, isopentanyl adenosine, dolichols and polyisoprenoid side chains of ubiquinone, heme A, and nuclear lamins. These isoprenoid intermediates are required for activation of various intracellular/signaling proteins- small guanosine triphosphate bound protein Ras and Ras-like proteins like Rho, Rab, Rac, Ral, or Rap which plays an indispensible role in multiple cellular processes. Reduction of circulating isoprenoids intermediates as a result of HMG CoA reductase inhibition by statins prevents activation of these signalling proteins. Hence, the multiple effects of statins such as antiinflammatory effects, antioxidant effects, antiproliferative and immunomodulatory effects, plaque stability, normalization of sympathetic outflow, and prevention of platelet aggregation are due to reduction of circulating isoprenoids and hence inactivation of signalling proteins. These multiple lipid-independent effects of statins termed as statin pleiotropy would potentially open floodgates for research in multiple treatment domains catching attentions of researchers and clinician across the globe.

Antidepressant use and risk of coronary heart disease: meta-analysis of observational studies

AIMS

Our goal was to evaluate the association between antidepressant use and the risk of coronary heart disease (CHD) among subjects with no history of coronary heart disease.

METHODS

A search of Medline, EMBASE, PsycINFO and the Cochrane Library was performed in January 2013. Two authors independently reviewed and selected eligible observational studies, based on predetermined selection criteria. Pooled relative risks (RRs) with confidence intervals (CIs) were calculated using random-effects or fixed-effects models.

RESULTS

Sixteen observational studies (seven case-control studies and nine cohort studies) were included in the final analysis. There was no association between selective serotonin reuptake inhibitor use and the risk of CHD overall [odds ratio (OR), 0.93; 95% CI, 0.65-1.33] or in subgroup meta-analysis of case-control studies (OR, 0.91; 95% CI, 0.60-1.37) and cohort studies (RR, 0.96; 95% CI, 0.59-1.55). The use of tricyclic antidepressant was associated with an increased risk of CHD overall (OR, 1.51; 95% CI, 1.07-2.12), but it was observed only in case-control studies (OR, 1.56; 95% CI, 1.24-1.96) and low-quality studies (OR, 1.49; 95% CI, 1.20-1.85) in the subgroup meta-analyses.

CONCLUSIONS

This meta-analysis of observational studies in subjects with no history of CHD suggests that neither selective serotonin reuptake inhibitor nor tricyclic antidepressant use is associated with an increased risk of CHD.

Using antidepressants and the risk of stroke recurrence: report from a national representative cohort study

BACKGROUND

Evidence about the association between antidepressants and the risk of stroke recurrence was scanty. This study evaluated the risk of stroke recurrence according to using antidepressants in patients with stroke from a national representative cohort.

METHODS

This cohort study followed 16770 patients aged > =20 years who had an incident stroke from 2000 to 2009 from the National Health Insurance Research Database in Taiwan. Records of each antidepressant prescription were obtained during follow-up. The types of antidepressants were categorized by Anatomical Therapeutic Chemical classification system: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and other antidepressants. The main outcome was a recurrent stroke during the follow-up period. The time-dependent Cox proportional hazards model was used in the analyses.

RESULTS

During 63715 person-years of follow-up, we documented 3769 events for stroke recurrence. Antidepressants use was associated with an increased risk of stroke recurrence (adjusted hazard ratio [HR], 1.42; 95 % confidence interval [C.I.], 1.24-1.62), especially for ischemic stroke (HR, 1.48; 95 % C.I., 1.28-1.70), but not for hemorrhagic stroke (HR, 1.22; 95 % C.I., 0.86-1.73). The increased risk of stoke recurrence was found for TCAs use only (HR, 1.41; 95 % C.I., 1.14-1.74), SSRIs use only (HR, 1.31; 95 % C.I.,1.00-1.73),use of other types of antidepressants only(HR, 1.46; 95 % C.I.,1.15-1.84), or use of multiple types of antidepressants (HR, 1.84; 95 % C.I.,1.04-3.25).

CONCLUSIONS

We demonstrated that use of antidepressants was associated with an increased risk of stroke recurrence, especially in ischemic stroke among Taiwanese. Further studies are warranted to confirm the possible underlying mechanisms of these findings.

Functional constituents of a local serotonergic system, intrinsic to the human coronary artery smooth muscle cells

Human coronary artery smooth muscle cells (HCASMCs) play an important role in the pathogenesis of coronary atherosclerosis and coronary artery diseases (CAD). Serotonin is a mediator known to produce vascular smooth muscle cell mitogenesis and contribute to coronary atherosclerosis. We hypothesize that the HCASMC possesses certain functional constituents of the serotonergic system such as: tryptophan hydroxylase and serotonin transporter. Our aim was to examine the presence of functional tryptophan hydroxylase-1 (TPH1) and serotonin transporter (SERT) in HCASMCs. The mRNA transcripts by qPCR and protein expression by Western blot of TPH1 and SERT were examined. The specificity and accuracy of the primers were verified using DNA gel electrophoresis and sequencing of qPCR products. The functionality of SERT was examined using a fluorescence dye-based serotonin transporter assay. The enzymatic activity of TPH was evaluated using UPLC. The HCASMCs expressed both mRNA transcripts and protein of SERT and TPH. The qPCR showed a single melt curve peak for both transcripts and in sequence analysis the amplicons were aligned with the respective genes. SERT and TPH enzymatic activity was present in the HCASMCs. Taken together, both TPH and SERT are functionally expressed in HCASMCs. These findings are novel and represent an initial step in examining the clinical relevance of the serotonergic system in HCASMCs and its role in the pathogenesis of coronary atherosclerosis and CAD.

The contribution of platelet studies to the understanding of disease mechanisms in complex and monogenetic neurological disorders

Platelets, known for their role in primary haemostasis, prevent excessive bleeding after injury. The study of platelets has, therefore, traditionally focused on bleeding disorders. It has recently become evident, however, that platelet research can contribute to unravelling the disease mechanisms that underlie neuropathological disorders that have a subtle subclinical platelet phenotype. Platelets and neurosecretory cells have common gene expression profiles and share several biological features. This review provides a literature update on the use of platelets as easily accessible cells to study neurological disorders. We provide examples of the use of different platelet-based tests to understand the underlying pathophysiological mechanisms for both complex and monogenetic neuropathological disorders. In addition to the well-studied regulated granule secretion and serotonin metabolism, more recent studies have shown that defects in transcription factors, membrane transporters, G-protein signal transduction, and cytoskeletal proteins can be investigated using platelets to gain information on their role in neuropathology.

Pharmacometabolomics reveals that serotonin is implicated in aspirin response variability

While aspirin is generally effective for prevention of cardiovascular disease, considerable variation in drug response exists, resulting in some individuals displaying high on-treatment platelet reactivity. We used pharmacometabolomics to define pathways implicated in variation of response to treatment. We profiled serum samples from healthy subjects pre- and postaspirin (14 days, 81 mg/day) using mass spectrometry. We established a strong signature of aspirin exposure independent of response (15/34 metabolites changed). In our discovery (N = 80) and replication (N = 125) cohorts, higher serotonin levels pre- and postaspirin correlated with high, postaspirin, collagen-induced platelet aggregation. In a third cohort, platelets from subjects with the highest levels of serotonin preaspirin retained higher reactivity after incubation with aspirin than platelets from subjects with the lowest serotonin levels preaspirin (72 ± 8 vs. 61 ± 11%, P = 0.02, N = 20). Finally, ex vivo, serotonin strongly increased platelet reactivity after platelet incubation with aspirin (+20%, P = 4.9 × 10⁻⁴, N = 12). These results suggest that serotonin is implicated in aspirin response variability.

Antidepressant use and risk of adverse outcomes in older people: population based cohort study

OBJECTIVES

To investigate the association between antidepressant treatment and risk of several potential adverse outcomes in older people with depression and to examine risks by class of antidepressant, duration of use, and dose.

DESIGN

Cohort study of people aged 65 and over diagnosed as having depression.

SETTING

570 general practices in the United Kingdom supplying data to the QResearch primary care database.

PARTICIPANTS

60,746 patients diagnosed as having a new episode of depression between the ages of 65 and 100 years from 1 January 1996 to 31 December 2007 and followed up until 31 December 2008.

MAIN OUTCOME MEASURES

Hazard ratios associated with antidepressant use for all cause mortality, attempted suicide/self harm, myocardial infarction, stroke/transient ischaemic attack, falls, fractures, upper gastrointestinal bleeding, epilepsy/seizures, road traffic accidents, adverse drug reactions, and hyponatraemia, adjusted for a range of potential confounding variables. Hazard ratios were calculated for antidepressant class (tricyclic and related antidepressants, selective serotonin reuptake inhibitors, other antidepressants), dose, and duration of use and for commonly prescribed individual drugs.

RESULTS

54,038 (89.0%) patients received at least one prescription for an antidepressant during follow-up. A total of 1,398,359 antidepressant prescriptions were issued: 764,659 (54.7%) for selective serotonin reuptake inhibitors, 442,192 (31.6%) for tricyclic antidepressants, 2203 (0.2%) for monoamine oxidase inhibitors, and 189,305 (13.5%) for the group of other antidepressants. The associations with the adverse outcomes differed significantly between the antidepressant classes for seven outcomes. Selective serotonin reuptake inhibitors were associated with the highest adjusted hazard ratios for falls (1.66, 95% confidence interval 1.58 to 1.73) and hyponatraemia (1.52, 1.33 to 1.75) compared with when antidepressants were not being used. The group of other antidepressants was associated with the highest adjusted hazard ratios for all cause mortality (1.66, 1.56 to 1.77), attempted suicide/self harm (5.16, 3.90 to 6.83), stroke/transient ischaemic attack (1.37, 1.22 to 1.55), fracture (1.64, 1.46 to 1.84), and epilepsy/seizures (2.24, 1.60 to 3.15), compared with when antidepressants were not being used. Tricyclic antidepressants did not have the highest hazard ratio for any of the outcomes. Significantly different associations also existed between the individual drugs for the same seven outcomes; trazodone (tricyclic antidepressant), mirtazapine, and venlafaxine (both in the group of other antidepressants) were associated with the highest rates for some of these outcomes. Absolute risks over 1 year for all cause mortality were 7.04% for patients while not taking antidepressants, 8.12% for those taking tricyclic antidepressants, 10.61% for selective serotonin reuptake inhibitors, and 11.43% for other antidepressants.

CONCLUSIONS

Selective serotonin reuptake inhibitors and drugs in the group of other antidepressants were associated with an increased risk of several adverse outcomes compared with tricyclic antidepressants. Among individual drugs, trazodone, mirtazapine, and venlafaxine were associated with the highest risks for some outcomes. As this is an observational study, it is susceptible to confounding by indication, channelling bias, and residual confounding, so differences in characteristics between patients prescribed different antidepressant drugs that could account for some of the associations between the drugs and the adverse outcomes may remain. Further research is needed to confirm these findings, but the risks and benefits of different antidepressants should be carefully evaluated when these drugs are prescribed to older people.

Changes in plasma and platelet BDNF levels induced by S-citalopram in major depression

BACKGROUND

Neuroplastic processes are thought to be involved in the pathophysiology of major depression. It has been reported that serum brain-derived neurotrophic factor (BDNF) is decreased in depressed patients.

OBJECTIVES

Compare BDNF levels in depressed patients and healthy controls in platelet poor plasma and in washed platelets. Observe the effects of 8- and 24-week treatment with S-citalopram on these levels.

METHODS

We assessed the levels of BDNF in platelet poor plasma and in washed platelets from 18 major depression patients, and compared them with 14 healthy controls. Blood samples were obtained from patients before and during treatment (8 and 24 weeks) with a selective serotonin reuptake inhibitor, S-citalopram.

RESULTS

A significant decrease in severity of depressive symptoms was observed from the first month of treatment with S-citalopram, and symptoms continued decreasing until the 6th month. Plasma BDNF levels in untreated patients appeared significantly increased (p<0.01) but reached values similar to those of controls at the 24th week. In contrast, levels of platelet BDNF appeared significantly decreased (p<0.05), but treatment also normalized levels so that values obtained were equivalent to those of controls.

CONCLUSIONS

Untreated depressed patients showed increased plasma BDNF levels and decreased platelet BDNF levels, as compared with control subjects, and tend to normalize during treatment with S-citalopram for 24 weeks, with BDNF reaching levels similar to those in healthy controls at the 24th week in both samples. We observed that improvement in depressive symptoms was accompanied by normalization of plasma and platelet BDNF levels.

Effects of dipping and psychological traits on morning surge in blood pressure in healthy people

Despite the role of anxiety, depression and hostility in the pathogenesis of cardiovascular diseases, their impact on two significant cardiovascular risk factors, nocturnal dipping and morning surge in blood pressure (MSBP), are largely ignored and primarily studied in clinical populations. This study examined the effects of dipping and psychological traits on MSBP in healthy people. Nocturnal dipping and MSBP were derived from 24-h ambulatory BP obtained in 77 men and 79 women, mean age 32.8 (s.d.: 7.4). Differences in depression, anxiety and hostility were examined by questionnaires. Higher levels of dipping (P<0.0001) and depressive symptoms (P=0.01) independently contributed to increased MSBP. Dipping interacts with depression (P=0.04), hostility (P=0.01) and anxiety (P=0.04) in determining MSBP. Low dippers with higher scores on the psychological traits showed higher MSBP than high dippers. A significant MSBP interaction was found between sex and depressive symptoms (P=0.05), anxiety (P<0.0001) and hostility (P=0.01) with higher scores associated with increased MSBP observed in males. Findings underscore depression as a predictor of MSBP independent of dipping. The clinically significant relationship between dipping and non-dipping patters, psychological traits and MSBP requires further investigation.

A secondary analysis of a duration response association between selective serotonin reuptake inhibitor use and the risk of acute myocardial infarction in the aging population

PURPOSE

We assessed the risk of selective serotonin reuptake inhibitor (SSRI) use on the occurrence of acute myocardial infarction (AMI) based on duration of exposure.

METHODS

A historical pooled cohort of all elderly, community-dwelling Medicare beneficiaries not enrolled in health maintenance organizations from the 1997 to 2001 Medicare Current Beneficiary Survey was constructed. SSRI users were compared with non-antidepressant users as well as other non-SSRI antidepressant users on their risk of AMI (ICD-9: 410 or 411). Descriptive statistics and binary logistic regression models were used to assess differences between groups.

RESULTS

There were 1,052 SSRI users compared with 762 other antidepressant users and 10,856 nonantidepressant users. Logistic regression models revealed that SSRI users were found to have significantly greater odds of AMI compared with nonantidepressant users when controlling for age, gender, race, smoking history and current status, body mass index, depression, anxiety and diabetes (odds ratio 1.85; 95% confidence intervals 1.13-3.04). Stratification by prescription counts revealed those with more than three prescriptions had greater odds of AMI compared with nonusers (odds ratio 2.02, 95% confidence intervals 1.11-3.66).

CONCLUSIONS

SSRI use leads to an increased risk of AMI in comparison with nonantidepressant use in an elderly population. The odds of AMI increased in those with more than three prescriptions in the preceding year, indicating a possible duration response relationship.

Fluoxetine and nortriptyline affect NTPDase and 5′-nucleotidase activities in rat blood serum

Depression is a serious condition associated with considerable morbidity and mortality. Selective serotonin reuptake inhibitors and tricyclic antidepressants, such as fluoxetine and nortriptyline, respectively, were commonly used in treatment for depression. Selective serotonin reuptake inhibitors have been associated with increased risk of bleeding complications, possibly as a result of inhibition of platelet aggregation. ATP, ADP and adenosine are signaling molecules in the vascular system and nucleotidases activities are considered an important thromboregulatory system which functions in the maintenance of blood fluidity. Therefore, here we investigate the effect of in vivo (acute and chronic) and in vitro treatments with the antidepressant drugs on nucleotidases activities in rat blood serum. In acute treatment, nortriptyline decreased ATP hydrolysis (41%), but not altered ADP and AMP hydrolysis. In contrast, fluoxetine did not alter NTPDase and ecto-5'-nucleotidase activities. A significant inhibition of ATP, ADP, and AMP hydrolysis were observed in chronic treatment with fluoxetine (60%, 32%, and 42% for ATP, ADP, and AMP hydrolysis, respectively). Similar effects were shown in chronic treatment with nortriptyline (37%, 41%, and 30% for ATP, ADP, and AMP hydrolysis, respectively). In addition, there were no significant changes in NTPDase and ecto-5'-nucleotidase activities when fluoxetine and nortriptyline (100, 250, and 500 microM) were tested in vitro. Our results have shown that fluoxetine and nortriptyline changed the nucleotide catabolism, suggesting that homeostasis of vascular system can be altered by antidepressant treatments.

5-hydroxytryptamine in the cardiovascular system: focus on the serotonin transporter (SERT)

1. The function of the serotonin transporter (SERT) is to take up and release serotonin (5-hydroxytyptamine (5-HT)) from cells and this function of SERT in the central nervous system (CNS) is well-documented; SERT is the target of selective serotonin reuptake inhibitors used in the treatment of CNS disorders, such as depression. 2. The aim of the present review is to discuss our current knowledge of 5-HT and SERT in the cardiovascular (CV) system, as well as their function in physiological and pathophysiological states. 3. The SERT protein has been located in multiple CV tissues, including the heart, blood vessels, brain, platelets, adrenal gland and kidney. Modification of SERT function occurs at both transcriptional and translational levels. The functions of SERT in these tissues is largely unexplored, but includes modulation of cardiac and smooth muscle contractility, platelet aggregation, cellular mitogenesis, modulating neuronal activity and urinary excretion. 4. Recent studies have uncovered potential relationships between the expression of SERT gene promoter variants (long (l) or short (s)) with CV diseases. Specifically, the risk of myocardial infarction and pulmonary hypertension is increased with expression of the ll promoter, a variant associated with increased expression and function of SERT. The relationship between promoter variants and other CV diseases has not been investigated. 5. Newly available experimental tools, such as pharmacological compounds and genetically altered mice, should prove useful in the investigation of the function of SERT in the CV system. 6. In summary, the function of SERT in the CV system is just beginning to be revealed.

Depression and associated physical diseases and symptoms

Depression can occur in association with virtually all the other psychiatric and physical diagnoses. Physical illness increases the risk of developing severe depressive illness. There are two broadly different mechanisms. The most obvious has a psychological or cognitive mechanism. Thus, the illness may provide the life event or chronic difficulty that triggers a depressive episode in a vulnerable Individual. Secondly more specific associations appear to exist between depression and particular physical disorders. These may turn out to be of particular etiological interest. The best examples are probably stroke and cardiovascular disease. Finally major depression, but especially minor depression, dysthymia, and depressive symptoms merge with other manifestations of human distress with which patients present to their doctors, Such somatic presentations test the conventional distinction between physical and mental disorder, and are a perennial source of controversy.

Anti-depressive Therapies After Heart Transplantation

OBJECTIVE

Despite an improved quality of life, about 33% of heart transplant recipients will develop depressive symptoms post-operatively. To date, no review has explored the efficacy and safety of pharmacologic or psychologic interventions in this patient group.

METHODS

We conducted a comprehensive Medline, EmBase, Psycinfo search for studies of the treatment of depression in heart transplant recipients.

RESULTS

We identified 34 studies of variable methodologic quality. Selective serotonin re-uptake inhibitors (SSRIs), particularly citalopram and new-generation anti-depressants (mirtazapine), seem to represent the best therapeutic choices for this population. Tricyclic anti-depressants (TCAs), and electroconvulsive therapy (ECT) should be reserved for severe depression unresponsive to other treatments, whereas monoamine oxidase inhibitors (MAOIs) should be avoided. St John's wort, an alternative herbal drug, has been associated with life-threatening immunosuppression. Psychologic therapy offers further advantages after heart transplantation.

CONCLUSIONS

Further well-conducted, randomized, controlled trials are needed to clarify the efficacy and the safety of pharmacologic (SSRIs and atypical anti-depressants) and psychologic interventions in the management of depression after heart transplantation.

Antiplatelet activity of [5-(2-methoxy-5-chlorophenyl)furan-2-ylcarbonyl]guanidine (KR-32570), a novel sodium/hydrogen exchanger-1 and its mechanism of action

The antiplatelet effects of a novel guanidine derivative, KR-32570 ([5-(2-methoxy-5-chlorophenyl) furan-2-ylcarbonyl]guanidine), were investigated with an emphasis on the mechanisms underlying its inhibition of collagen-induced platelet aggregation. KR-32570 significantly inhibited the aggregation of washed rabbit platelets induced by collagen (10 microg/mL), thrombin (0.05 U/mL), arachidonic acid (100 microM), a thromboxane (TX) A2 mimetic agent U46619 (9,11-dideoxy-9,11-methanoepoxy-prostaglandin F2, 1 microM) and a Ca2+ ATPase inhibitor thapsigargin (0.5 microM) (IC50 values: 13.8 +/- 1.8, 26.3 +/- 1.2, 8.5 +/- 0.9, 4.3 +/- 1.7 and 49.8 +/- 1.4 microM, respectively). KR-32570 inhibited the collagen-induced liberation of [3H]arachidonic acid from the platelets in a concentration dependent manner with complete inhibition being observed at 50 microM. The TXA2 synthase assay showed that KR-32570 also inhibited the conversion of the substrate PGH2 to TXB2 at all concentrations. Furthermore, KR-32570 significantly inhibited the [Ca2+]i mobilization induced by collagen at 50 microM, which is the concentration that completely inhibits platelet aggregation. KR-32570 also decreased the level of collagen (10 microg/mL)-induced secretion of serotonin from the dense-granule contents of platelets, and inhibited the NHE-1-mediated rabbit platelet swelling induced by intracellular acidification. These results suggest that the antiplatelet activity of KR-32570 against collagen-induced platelet aggregation is mediated mainly by inhibiting the release of arachidonic acid, TXA2 synthase, the mobilization of cytosolic Ca2+ and NHE-1.

Antidepressants and risk of first-time hospitalization for myocardial infarction: a population-based case-control study

PURPOSE

Several studies have found an increased risk of myocardial infarction among depressed patients. Selective serotonin reuptake inhibitors (SSRIs) appear to lack the arrhythmic adverse effects of tricyclic antidepressants, and are thought to inhibit platelet aggregation. We examined whether use of different antidepressant classes is associated with a lower risk of first-time hospitalization for myocardial infarction, as compared with nonuse.

METHODS

We identified 8887 cases of first-time hospitalization for myocardial infarction and 88,862 age- and sex-matched population-based controls during 1994-2002, using data from North Jutland County, Denmark. Cases and controls were stratified according to history of cardiovascular disease. All prescriptions for antidepressants before hospitalization for myocardial infarction were identified using a prescription database. Conditional logistic regression was used to estimate odds ratios of myocardial infarction associated with antidepressant use, adjusted for possible confounding factors.

RESULTS

In patients with a history of cardiovascular disease, we found indications of a lower risk of myocardial infarction among those who used SSRIs (adjusted odds ratio [OR] = 0.85; 95% confidence interval [CI]: 0.62 to 1.16), nonselective serotonin reuptake inhibitors (adjusted OR = 0.83; 95% CI: 0.50 to 1.38), and other antidepressants (adjusted OR = 0.55; 95% CI: 0.31 to 0.97). There were no such associations among persons without a history of cardiovascular disease.

CONCLUSION

Antidepressant use may be associated with a decreased risk of hospitalization for myocardial infarction among persons with a history of cardiovascular disease, although it remains uncertain whether there are differences by class of antidepressant.

Venous thromboembolism and escitalopram

Selective serotonin reuptake inhibitors (SSRIs) are currently used as a first-line treatment for depression, as they have a favorable side-effect profile. Escitalopram, a new SSRI, is also well-tolerated and serious side effects are rarely associated with its use. There have been several reports that SSRIs might increase bleeding tendency in some patients by affecting platelet function. However, to our knowledge, there have been no reports about their relation to thrombosis. In this brief report, we present a case of venous thromboembolism associated with escitalopram in a patient with psychotic depression without any major risk factors for thrombosis. SSRIs might have a dual effect on platelet function. The immediate and early effect of SSRI use on platelets might be an increase be an in tendency for thrombosis, whereas the late effect after repeated dosing might be an increase in tendency to bleed, as suggested by previous literature.

Current Use of Selective Serotonin Reuptake Inhibitors and Risk of Acute Myocardial Infarction

BACKGROUND

It has been suggested that increased platelet activation increases the risk of acute myocardial infarction (AMI) in patients with depression. Selective serotonin reuptake inhibitors (SSRIs) may attenuate platelet activation by serotonin depletion in platelets. Observational studies have shown discrepant results of AMI risk associated with the use of SSRIs.

OBJECTIVE

The aim of this study was to evaluate the association of exposure to different groups of antidepressants, including SSRIs, and the risk of AMI. The study also assessed in more detail the influence of timing of the exposure to antidepressants in a general adult population (<90 years of age), with or without diagnosed risk factors for AMI.

STUDY DESIGN/METHODS

We conducted a population-based case-control analysis on the UK General Practice Research Database (GPRD). The study included 8688 patients (<90 years of age), with a first-time AMI between 1995 and 2001, and 33 923 controls, who were matched by age, sex, calendar time, and general practice. Conditional logistic regression was used to estimate odds ratios (ORs).

RESULTS

Current use of an antidepressant was defined as a supply of the last prescription for an antidepressant that lasted up to the index date or beyond. Recent past use was defined as a supply of the last prescription for an antidepressant that ended 1-29 days before the index date. SSRIs investigated were citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline and venlafaxine. Non-SSRIs investigated were amitriptyline, clomipramine, dosulepin, doxepin, imipramine, lofepramine, nefazodone, trazodone and trimipramine. Other antidepressants included were amoxapine, desipramine, lithium, maprotiline, mianserin, moclobemide, nortriptyline and protriptyline. Adjusted ORs (with 95% CI) for the current use of SSRIs, non-SSRIs, or other antidepressants, compared with non-use of antidepressants, were 0.63 (95% CI 0.43, 0.91; p=0.02), 0.92 (95% CI 0.77, 1.09; p=0.32) and 0.59 (95% CI 0.29, 1.20; p=0.14), respectively. The adjusted OR of recent past use of SSRIs compared with non-use of SSRIs was 1.42 (95% CI 1.02, 1.97; p=0.04).

CONCLUSION

The present analysis provides further evidence that the current use of SSRIs is associated with a slightly decreased risk for AMI.