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Heesbeen EJ, Bijlsma EY, Verdouw PM, van Lissa C, Hooijmans C, Groenink L. The effect of SSRIs on fear learning: a systematic review and meta-analysis. Psychopharmacology (Berl) 2023; 240:2335-2359. [PMID: 36847831 PMCID: PMC10593621 DOI: 10.1007/s00213-023-06333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 01/31/2023] [Indexed: 03/01/2023]
Abstract
RATIONALE Selective serotonin reuptake inhibitors (SSRIs) are considered first-line medication for anxiety-like disorders such as panic disorder, generalized anxiety disorder, and post-traumatic stress disorder. Fear learning plays an important role in the development and treatment of these disorders. Yet, the effect of SSRIs on fear learning are not well known. OBJECTIVE We aimed to systematically review the effect of six clinically effective SSRIs on acquisition, expression, and extinction of cued and contextual conditioned fear. METHODS We searched the Medline and Embase databases, which yielded 128 articles that met the inclusion criteria and reported on 9 human and 275 animal experiments. RESULTS Meta-analysis showed that SSRIs significantly reduced contextual fear expression and facilitated extinction learning to cue. Bayesian-regularized meta-regression further suggested that chronic treatment exerts a stronger anxiolytic effect on cued fear expression than acute treatment. Type of SSRI, species, disease-induction model, and type of anxiety test used did not seem to moderate the effect of SSRIs. The number of studies was relatively small, the level of heterogeneity was high, and publication bias has likely occurred which may have resulted in an overestimation of the overall effect sizes. CONCLUSIONS This review suggests that the efficacy of SSRIs may be related to their effects on contextual fear expression and extinction to cue, rather than fear acquisition. However, these effects of SSRIs may be due to a more general inhibition of fear-related emotions. Therefore, additional meta-analyses on the effects of SSRIs on unconditioned fear responses may provide further insight into the actions of SSRIs.
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Affiliation(s)
- Elise J Heesbeen
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Elisabeth Y Bijlsma
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - P Monika Verdouw
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Caspar van Lissa
- Department of Methodology, Tilburg University, Tilburg, Netherlands
| | - Carlijn Hooijmans
- Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lucianne Groenink
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.
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2
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Flynn LT, Gao WJ. DNA methylation and the opposing NMDAR dysfunction in schizophrenia and major depression disorders: a converging model for the therapeutic effects of psychedelic compounds in the treatment of psychiatric illness. Mol Psychiatry 2023; 28:4553-4567. [PMID: 37679470 PMCID: PMC11034997 DOI: 10.1038/s41380-023-02235-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
Psychedelic compounds are being increasingly explored as a potential therapeutic option for treating several psychiatric conditions, despite relatively little being known about their mechanism of action. One such possible mechanism, DNA methylation, is a process of epigenetic regulation that changes gene expression via chemical modification of nitrogenous bases. DNA methylation has been implicated in the pathophysiology of several psychiatric conditions, including schizophrenia (SZ) and major depressive disorder (MDD). In this review, we propose alterations to DNA methylation as a converging model for the therapeutic effects of psychedelic compounds, highlighting the N-methyl D-aspartate receptor (NMDAR), a crucial mediator of synaptic plasticity with known dysfunction in both diseases, as an example and anchoring point. We review the established evidence relating aberrant DNA methylation to NMDAR dysfunction in SZ and MDD and provide a model asserting that psychedelic substances may act through an epigenetic mechanism to provide therapeutic effects in the context of these disorders.
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Affiliation(s)
- L Taylor Flynn
- Department of Neurobiology & Anatomy, Drexel University College of Medicine, Philadelphia, PA, USA
- MD/PhD program, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Wen-Jun Gao
- Department of Neurobiology & Anatomy, Drexel University College of Medicine, Philadelphia, PA, USA.
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3
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Lepow L, Morishita H, Yehuda R. Critical Period Plasticity as a Framework for Psychedelic-Assisted Psychotherapy. Focus (Am Psychiatr Publ) 2023; 21:329-336. [PMID: 37404962 PMCID: PMC10316207 DOI: 10.1176/appi.focus.23021012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
As psychedelic compounds gain traction in psychiatry, there is a need to consider the active mechanism to explain the effect observed in randomized clinical trials. Traditionally, biological psychiatry has asked how compounds affect the causal pathways of illness to reduce symptoms and therefore focus on analysis of the pharmacologic properties. In psychedelic-assisted psychotherapy (PAP), there is debate about whether ingestion of the psychedelic alone is thought to be responsible for the clinical outcome. A question arises how the medication and psychotherapeutic intervention together might lead to neurobiological changes that underlie recovery from illness such as post-traumatic stress disorder (PTSD). This paper offers a framework for investigating the neurobiological basis of PAP by extrapolating from models used to explain how a pharmacologic intervention might create an optimal brain state during which environmental input has enduring effects. Specifically, there are developmental "critical" periods (CP) with exquisite sensitivity to environmental input; the biological characteristics are largely unknown. We discuss a hypothesis that psychedelics may remove the brakes on adult neuroplasticity, inducing a state similar to that of neurodevelopment. In the visual system, progress has been made both in identifying the biological conditions which distinguishes the CP and in manipulating the active ingredients with the idea that we might pharmacologically reopen a critical period in adulthood. We highlight ocular dominance plasticity (ODP) in the visual system as a model for characterizing CP in limbic systems relevant to psychiatry. A CP framework may help to integrate the neuroscientific inquiry with the influence of the environment both in development and in PAP. Appeared originally in Front Neurosci 2021; 15:710004.
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Affiliation(s)
- Lauren Lepow
- Department of Psychiatry, Icahn School of Medicine Mount Sinai, New York, NY, United States (all authors). Department of Neuroscience, Icahn School of Medicine Mount Sinai, New York, NY, United States (Lepow, Morishita). Department of Ophthalmology, Icahn School of Medicine Mount Sinai, New York, NY, United States (Morishita). Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States (Yehuda)
| | - Hirofumi Morishita
- Department of Psychiatry, Icahn School of Medicine Mount Sinai, New York, NY, United States (all authors). Department of Neuroscience, Icahn School of Medicine Mount Sinai, New York, NY, United States (Lepow, Morishita). Department of Ophthalmology, Icahn School of Medicine Mount Sinai, New York, NY, United States (Morishita). Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States (Yehuda)
| | - Rachel Yehuda
- Department of Psychiatry, Icahn School of Medicine Mount Sinai, New York, NY, United States (all authors). Department of Neuroscience, Icahn School of Medicine Mount Sinai, New York, NY, United States (Lepow, Morishita). Department of Ophthalmology, Icahn School of Medicine Mount Sinai, New York, NY, United States (Morishita). Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States (Yehuda)
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4
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Abdolmaleky HM, Martin M, Zhou JR, Thiagalingam S. Epigenetic Alterations of Brain Non-Neuronal Cells in Major Mental Diseases. Genes (Basel) 2023; 14:896. [PMID: 37107654 PMCID: PMC10137903 DOI: 10.3390/genes14040896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/22/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
The tissue-specific expression and epigenetic dysregulation of many genes in cells derived from the postmortem brains of patients have been reported to provide a fundamental biological framework for major mental diseases such as autism, schizophrenia, bipolar disorder, and major depression. However, until recently, the impact of non-neuronal brain cells, which arises due to cell-type-specific alterations, has not been adequately scrutinized; this is because of the absence of techniques that directly evaluate their functionality. With the emergence of single-cell technologies, such as RNA sequencing (RNA-seq) and other novel techniques, various studies have now started to uncover the cell-type-specific expression and DNA methylation regulation of many genes (e.g., TREM2, MECP2, SLC1A2, TGFB2, NTRK2, S100B, KCNJ10, and HMGB1, and several complement genes such as C1q, C3, C3R, and C4) in the non-neuronal brain cells involved in the pathogenesis of mental diseases. Additionally, several lines of experimental evidence indicate that inflammation and inflammation-induced oxidative stress, as well as many insidious/latent infectious elements including the gut microbiome, alter the expression status and the epigenetic landscapes of brain non-neuronal cells. Here, we present supporting evidence highlighting the importance of the contribution of the brain's non-neuronal cells (in particular, microglia and different types of astrocytes) in the pathogenesis of mental diseases. Furthermore, we also address the potential impacts of the gut microbiome in the dysfunction of enteric and brain glia, as well as astrocytes, which, in turn, may affect neuronal functions in mental disorders. Finally, we present evidence that supports that microbiota transplantations from the affected individuals or mice provoke the corresponding disease-like behavior in the recipient mice, while specific bacterial species may have beneficial effects.
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Affiliation(s)
- Hamid Mostafavi Abdolmaleky
- Department of Medicine (Biomedical Genetics), Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA;
- Department of Surgery, Nutrition/Metabolism Laboratory, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Marian Martin
- Department of Neurology, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Jin-Rong Zhou
- Department of Surgery, Nutrition/Metabolism Laboratory, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Sam Thiagalingam
- Department of Medicine (Biomedical Genetics), Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA;
- Department of Pathology & Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA 02118, USA
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5
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Inserra A, Campanale A, Cheishvili D, Dymov S, Wong A, Marcal N, Syme RA, Taylor L, De Gregorio D, Kennedy TE, Szyf M, Gobbi G. Modulation of DNA methylation and protein expression in the prefrontal cortex by repeated administration of D-lysergic acid diethylamide (LSD): Impact on neurotropic, neurotrophic, and neuroplasticity signaling. Prog Neuropsychopharmacol Biol Psychiatry 2022; 119:110594. [PMID: 35777526 DOI: 10.1016/j.pnpbp.2022.110594] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 11/18/2022]
Abstract
AIM Psychedelic compounds elicit relief from mental disorders. However, the underpinnings of therapeutic improvement remain poorly understood. Here, we investigated the effects of repeated lysergic acid diethylamide (LSD) on whole-genome DNA methylation and protein expression in the mouse prefrontal cortex (PFC). METHODS Whole genome bisulphite sequencing (WGBS) and proteomics profiling of the mouse prefrontal cortex (PFC) were performed to assess DNA methylation and protein expression changes following 7 days of repeated LSD administration (30 μg/kg/day); a treatment we previously found to potentiate excitatory neurotransmission and to increase dendritic spine density in the PFC in mice. qRT-PCR was employed to validate candidate genes detected in both analyses. RESULTS LSD significantly modulated DNA methylation in 635 CpG sites of the mouse PFC, and in an independent cohort the expression level of 178 proteins. Gene signaling pathways affected are involved in nervous system development, axon guidance, synaptic plasticity, quantity and cell viability of neurons and protein translation. Four genes and their protein product were detected as differentially methylated and expressed, and their transcription was increased. Specifically, Coronin 7 (Coro7), an axon guidance cue; Penta-EF-Hand Domain Containing 1 (Pef1), an mTORC1 and cell cycle modulator; Ribosomal Protein S24 (Rps24), required for pre-rRNA maturation and biogenesis of proteins involved with cell proliferation and migration, and Abhydrolase Domain Containing 6, Acylglycerol Lipase (Abhd6), a post-synaptic lipase. CONCLUSIONS LSD affects DNA methylation, altering gene expression and protein expression related to neurotropic-, neurotrophic- and neuroplasticity signaling. This could represent a core mechanism mediating the effects of psychedelics.
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Affiliation(s)
- Antonio Inserra
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Antonella Campanale
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - David Cheishvili
- Department of Oncology, McGill University, Montreal, QC, Canada; HKG Epitherapeutics, Hong Kong
| | - Sergiy Dymov
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada
| | - Amy Wong
- Proteomics Platform, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Nathalie Marcal
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | | | - Lorne Taylor
- Proteomics Platform, Research Institute of the McGill University Health Center, Montreal, QC, Canada
| | - Danilo De Gregorio
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Timothy E Kennedy
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Moshe Szyf
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada
| | - Gabriella Gobbi
- Neurobiological Psychiatry Unit, Department of Psychiatry, McGill University, Montreal, QC, Canada.
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Rump K, Adamzik M. Epigenetic Mechanisms of Postoperative Cognitive Impairment Induced by Anesthesia and Neuroinflammation. Cells 2022; 11:2954. [PMID: 36230916 PMCID: PMC9563723 DOI: 10.3390/cells11192954] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Cognitive impairment after surgery is a common problem, affects mainly the elderly, and can be divided into postoperative delirium and postoperative cognitive dysfunction. Both phenomena are accompanied by neuroinflammation; however, the precise molecular mechanisms underlying cognitive impairment after anesthesia are not yet fully understood. Anesthesiological drugs can have a longer-term influence on protein transcription, thus, epigenetics is a possible mechanism that impacts on cognitive function. Epigenetic mechanisms may be responsible for long-lasting effects and may implicate novel therapeutic approaches. Hence, we here summarize the existing literature connecting postoperative cognitive impairment to anesthesia. It becomes clear that anesthetics alter the expression of DNA and histone modifying enzymes, which, in turn, affect epigenetic markers, such as methylation, histone acetylation and histone methylation on inflammatory genes (e.g., TNF-alpha, IL-6 or IL1 beta) and genes which are responsible for neuronal development (such as brain-derived neurotrophic factor). Neuroinflammation is generally increased after anesthesia and neuronal growth decreased. All these changes can induce cognitive impairment. The inhibition of histone deacetylase especially alleviates cognitive impairment after surgery and might be a novel therapeutic option for treatment. However, further research with human subjects is necessary because most findings are from animal models.
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7
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Glavonic E, Mitic M, Adzic M. Hallucinogenic drugs and their potential for treating fear-related disorders: Through the lens of fear extinction. J Neurosci Res 2022; 100:947-969. [PMID: 35165930 DOI: 10.1002/jnr.25017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 12/29/2022]
Abstract
Fear-related disorders, mainly phobias and post-traumatic stress disorder, are highly prevalent, debilitating disorders that pose a significant public health problem. They are characterized by aberrant processing of aversive experiences and dysregulated fear extinction, leading to excessive expression of fear and diminished quality of life. The gold standard for treating fear-related disorders is extinction-based exposure therapy (ET), shown to be ineffective for up to 35% of subjects. Moreover, ET combined with traditional pharmacological treatments for fear-related disorders, such as selective serotonin reuptake inhibitors, offers no further advantage to patients. This prompted the search for ways to improve ET outcomes, with current research focused on pharmacological agents that can augment ET by strengthening fear extinction learning. Hallucinogenic drugs promote reprocessing of fear-imbued memories and induce positive mood and openness, relieving anxiety and enabling the necessary emotional engagement during psychotherapeutic interventions. Mechanistically, hallucinogens induce dynamic structural and functional neuroplastic changes across the fear extinction circuitry and temper amygdala's hyperreactivity to threat-related stimuli, effectively mitigating one of the hallmarks of fear-related disorders. This paper provides the first comprehensive review of hallucinogens' potential to alleviate symptoms of fear-related disorders by focusing on their effects on fear extinction and the underlying molecular mechanisms. We overview both preclinical and clinical studies and emphasize the advantages of hallucinogenic drugs over current first-line treatments. We highlight 3,4-methylenedioxymethamphetamine and ketamine as the most effective therapeutics for fear-related disorders and discuss the potential molecular mechanisms responsible for their potency with implications for improving hallucinogen-assisted psychotherapy.
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Affiliation(s)
- Emilija Glavonic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Milos Mitic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
| | - Miroslav Adzic
- Department of Molecular Biology and Endocrinology, "VINČA" Institute of Nuclear Sciences-National Institute of thе Republic of Serbia, University of Belgrade, Belgrade, Serbia
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8
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Jumaili WA, Trivedi C, Chao T, Kubosumi A, Jain S. The safety and efficacy of Ketamine NMDA receptor blocker as a therapeutic intervention for PTSD review of a randomized clinical trial. Behav Brain Res 2022; 424:113804. [PMID: 35181391 DOI: 10.1016/j.bbr.2022.113804] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/02/2022] [Accepted: 02/14/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) has long-lasting debilitating symptoms. PTSD causes a significant burden on healthcare workers and victims' families. The US Food Drug Administration (FDA) has approved only two Serotonin Selective Reuptake Inhibitors (SSRI), sertraline, and paroxetine as pharmacological interventions for PTSD. SSRI has a 50-60% response rate and up to 30% remission rate with a high relapse rate. Ketamine is an NMDA receptor blocker, has a rapid effective onset, a potent antidepressant with anti-suicidal, neuroprotective, and cognitive-enhancement properties. METHOD We retrieved randomized clinical trials (RCT) on PubMed, PubMed Central, and Medline Database of clinical trial studies until Jan/2022. We used the following keywords: "posttraumatic stress disorder. "AND "Ketamine." AND "Esketamine" AND "NMDA receptor antagonist" AND "treatment, pharmacological intervention, management. ". We used Medical Subject Heading [Mesh] Term for "ketamine" and "Esketamine" And "Receptors, N-Methyl-D-Aspartate" and "Stress Disorders, Post-Traumatic" and "Disease management.". RESULT All qualified five randomized clinical studies showed rapid and clear benefits of Ketamine infusion for PTSD symptoms resistant to conventional medications. The clinical improvements were evident in three of the four PTSD symptom categories, intrusions, avoidance, and negative alterations in cognitions and mood. In addition, Ketamine administration was safe well-tolerated, with transient dissociation as the main side effect reported. Ketamine infusion also positively affects comorbidities like chronic pain, alcohol use disorder, and major depression. CONCLUSION Ketamine showed fast, safe, highly effective pharmaceutical intervention for chronic PTSD symptoms. No correlation between ketamine potency and patient age, sex and/or body mass index. Further studies are needed to understand the appropriate therapeutic dose, onset, route of administration, duration of the treatment and comorbidity benefit.
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Affiliation(s)
- Wisam Al Jumaili
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA.
| | - Chintan Trivedi
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
| | - Timothy Chao
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
| | - Aaron Kubosumi
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
| | - Shailesh Jain
- Texas Tech University Health Science Center at Odessa/Permian Basin, Odessa, TX, USA
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9
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Lepow L, Morishita H, Yehuda R. Critical Period Plasticity as a Framework for Psychedelic-Assisted Psychotherapy. Front Neurosci 2021; 15:710004. [PMID: 34616272 PMCID: PMC8488335 DOI: 10.3389/fnins.2021.710004] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/17/2021] [Indexed: 12/28/2022] Open
Abstract
As psychedelic compounds gain traction in psychiatry, there is a need to consider the active mechanism to explain the effect observed in randomized clinical trials. Traditionally, biological psychiatry has asked how compounds affect the causal pathways of illness to reduce symptoms and therefore focus on analysis of the pharmacologic properties. In psychedelic-assisted psychotherapy (PAP), there is debate about whether ingestion of the psychedelic alone is thought to be responsible for the clinical outcome. A question arises how the medication and psychotherapeutic intervention together might lead to neurobiological changes that underlie recovery from illness such as post-traumatic stress disorder (PTSD). This paper offers a framework for investigating the neurobiological basis of PAP by extrapolating from models used to explain how a pharmacologic intervention might create an optimal brain state during which environmental input has enduring effects. Specifically, there are developmental "critical" periods (CP) with exquisite sensitivity to environmental input; the biological characteristics are largely unknown. We discuss a hypothesis that psychedelics may remove the brakes on adult neuroplasticity, inducing a state similar to that of neurodevelopment. In the visual system, progress has been made both in identifying the biological conditions which distinguishes the CP and in manipulating the active ingredients with the idea that we might pharmacologically reopen a critical period in adulthood. We highlight ocular dominance plasticity (ODP) in the visual system as a model for characterizing CP in limbic systems relevant to psychiatry. A CP framework may help to integrate the neuroscientific inquiry with the influence of the environment both in development and in PAP.
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Affiliation(s)
- Lauren Lepow
- Department of Psychiatry, Icahn School of Medicine Mount Sinai, New York, NY, United States.,Department of Neuroscience, Icahn School of Medicine Mount Sinai, New York, NY, United States
| | - Hirofumi Morishita
- Department of Psychiatry, Icahn School of Medicine Mount Sinai, New York, NY, United States.,Department of Neuroscience, Icahn School of Medicine Mount Sinai, New York, NY, United States.,Department of Ophthalmology, Icahn School of Medicine Mount Sinai, New York, NY, United States
| | - Rachel Yehuda
- Department of Psychiatry, Icahn School of Medicine Mount Sinai, New York, NY, United States.,Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, NY, United States
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10
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Cholewinski T, Pereira D, Moerland M, Jacobs GE. MTORC1 signaling as a biomarker in major depressive disorder and its pharmacological modulation by novel rapid-acting antidepressants. Ther Adv Psychopharmacol 2021; 11:20451253211036814. [PMID: 34733478 PMCID: PMC8558816 DOI: 10.1177/20451253211036814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/16/2021] [Indexed: 12/15/2022] Open
Abstract
Major depressive disorder (MDD) is a multifactorial psychiatric disorder with obscure pathophysiology. A biomarker-based approach in combination with standardized interview-based instruments is needed to identify MDD subtypes and novel therapeutic targets. Recent findings support the impairment of the mammalian target of rapamycin complex 1 (mTORC1) in MDD. No well-established biomarkers of mTORC1 disease- and treatment-modulated activity are currently available for use in early phase antidepressant drug (AD) development. This review aims to summarize biomarkers of mTORC1 activity in MDD and to suggest how these could be implemented in future early clinical trials on mTORC1 modulating ADs. Therefore, a PubMed-based narrative literature review of the mTORC1 involvement in MDD was performed. We have summarized recent pre-clinical and clinical findings linking the MDD to the impaired activity of several key biomarkers related to mTORC1. Also, cases of restoration of these impairments by classical ADs and novel fast-acting investigational ADs are summarized. The presented biomarkers may be used to monitor pharmacological effects by novel rapid-acting mTORC1-targeting ADs. Based on findings in the peripheral blood mononuclear cells, we argue that those may serve as an ex vivo model for evaluation of mTORC1 activity and propose the use of the summarized biomarkers for this purpose. This could both facilitate the selection of a pharmacodynamically active dose and guide future early clinical efficacy studies in MDD. In conclusion, this review provides a blueprint for the rational development of rapid-acting mTORC1-targeting ADs.
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Affiliation(s)
| | - Diana Pereira
- Centre for Human Drug Research, Leiden, The Netherlands
| | | | - Gabriel E Jacobs
- Centre for Human Drug Research, Zernikedreef 8, 2333 CL Leiden, The Netherlands
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11
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Poon CH, Heng BC, Lim LW. New insights on brain-derived neurotrophic factor epigenetics: from depression to memory extinction. Ann N Y Acad Sci 2020; 1484:9-31. [PMID: 32808327 DOI: 10.1111/nyas.14458] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/21/2020] [Accepted: 07/14/2020] [Indexed: 12/14/2022]
Abstract
Advances in characterizing molecular profiles provide valuable insights and opportunities for deciphering the neuropathology of depression. Although abnormal brain-derived neurotrophic factor (BDNF) expression in depression has gained much support from preclinical and clinical research, how it mediates behavioral alterations in the depressed state remains largely obscure. Environmental factors contribute significantly to the onset of depression and produce robust epigenetic changes. Epigenetic regulation of BDNF, as one of the most characterized gene loci in epigenetics, has recently emerged as a target in research on memory and psychiatric disorders. Specifically, epigenetic alterations of BDNF exons are heavily involved in mediating memory functions and antidepressant effects. In this review, we discuss key research on stress-induced depression from both preclinical and clinical studies, which revealed that differential epigenetic regulation of specific BDNF exons is associated with depression pathophysiology. Considering that BDNF has a central role in depression, we argue that memory extinction, an adaptive response to fear exposure, is dependent on BDNF modulation and holds promise as a prospective target for alleviating or treating depression and anxiety disorders.
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Affiliation(s)
- Chi Him Poon
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Boon Chin Heng
- Peking University School of Stomatology, Beijing, China.,Department of Biological Sciences, Sunway University, Selangor, Malaysia
| | - Lee Wei Lim
- Neuromodulation Laboratory, School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.,Department of Biological Sciences, Sunway University, Selangor, Malaysia
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Zhao M, Wang W, Jiang Z, Zhu Z, Liu D, Pan F. Long-Term Effect of Post-traumatic Stress in Adolescence on Dendrite Development and H3K9me2/BDNF Expression in Male Rat Hippocampus and Prefrontal Cortex. Front Cell Dev Biol 2020; 8:682. [PMID: 32850808 PMCID: PMC7412801 DOI: 10.3389/fcell.2020.00682] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/06/2020] [Indexed: 01/10/2023] Open
Abstract
Exposure to a harsh environment in early life increases in the risk of post-traumatic stress disorder (PTSD) of an individual. Brain derived neurotrophic factor (BDNF) plays an important role in neurodevelopment in developmental stages. Both chronic and traumatic stresses induce a decrease in the level of BDNF and reduce neural plasticity, which is linked to the pathogenesis of PTSD. Also, studies have shown that stress alters the epigenetic marker H3K9me2, which can bind to the promoter region of the Bdnf gene and reduce BDNF protein level. However, the long-term effects of traumatic stress during adolescence on H3K9me2, BDNF expression and dendrite development are not well-known. The present study established a model of PTSD in adolescent rats using an inescapable foot shock (IFS) procedure. Anxiety-like behaviors, social interaction behavior and memory function were assessed by the open field test, elevated plus maze test, three-chamber sociability test and Morris water maze test. In addition, neuronal development and H3K9me2/BDNF expression in hippocampus (HIP) and prefrontal cortex (PFC) were evaluated by Golgi staining, western blotting, qRT-PCR analysis and CHIP-qPCR analysis. Additionally, the Unc0642, a small molecule inhibitor of histone methyltransferase (EHMT2) was used for intervention. The results showed that the IFS procedure induced the PTSD-like behaviors in rats, resulted in fewer dendrite branches and shorter dendrite length in CA1 of HIP and PFC, increased H3K9me2 level and decreased BDNF expression in HIP and PFC. Also, although all the changes can persist to adulthood, Unc0642 administration relieved most of alterations. Our study suggests that traumatic stress in adolescence leads to immediate and long-term mental disorders, neuronal morphological changes, lower BDNF level and increased H3K9me2 level in the HIP and PFC, indicating that H3K9me2/BDNF dysfunction plays a key role in pathogenesis of PTSD.
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Affiliation(s)
- Mingyue Zhao
- Department of Medical Psychology and Medical Ethics, School of Basic Medicine Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Wang
- Department of Medical Psychology and Medical Ethics, School of Basic Medicine Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhijun Jiang
- Department of Medical Psychology and Medical Ethics, School of Basic Medicine Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zemeng Zhu
- Department of Medical Psychology and Medical Ethics, School of Basic Medicine Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dexiang Liu
- Department of Medical Psychology and Medical Ethics, School of Basic Medicine Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Fang Pan
- Department of Medical Psychology and Medical Ethics, School of Basic Medicine Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
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Hastings MH, Gauthier JM, Mabry K, Tran A, Man HY, Kantak KM. Facilitative effects of environmental enrichment for cocaine relapse prevention are dependent on extinction training context and involve increased TrkB signaling in dorsal hippocampus and ventromedial prefrontal cortex. Behav Brain Res 2020; 386:112596. [PMID: 32194188 DOI: 10.1016/j.bbr.2020.112596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/08/2020] [Accepted: 02/20/2020] [Indexed: 12/16/2022]
Abstract
Cocaine-cue extinction training combined with brief interventions of environmental enrichment (EE) was shown previously to facilitate extinction and attenuate reacquisition of cocaine self-administration in rats. It is unknown whether or not the usefulness of this approach would be undermined if extinction training took place in a novel rather than familiar context. Drawing on previous studies involving pharmacological interventions, we hypothesized that the facilitative effects of EE for cocaine relapse prevention would be independent of the context used for extinction training. Rats trained to self-administer cocaine underwent cocaine-cue extinction training in either the familiar self-administration context or a novel context, with or without EE. Rats then were tested for reacquisition of cocaine self-administration in the familiar context. Target brain regions were lysed and probed for memory-related changes in receptors for glutamate and BDNF by western blotting. Contrary to our hypothesis, the facilitative effects of EE for cocaine relapse prevention were dependent on the context used for extinction training. While EE facilitated extinction regardless of context used, it inhibited cocaine relapse only after extinction training in the familiar context. EE was associated with increased GluA2 in nucleus accumbens, TrkB in dorsal hippocampus and activated TrkB in ventromedial prefrontal cortex. Of these, the changes in dorsal hippocampus and ventromedial prefrontal cortex mirrored outcomes of the cocaine relapse tests in that these changes were specific to rats receiving EE plus extinction training in the familiar context. These findings support a role for hippocampal-prefrontal BDNF-TrkB signaling in extinction-based relapse prevention strategies involving EE.
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Affiliation(s)
- Margaret H Hastings
- Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, USA; Department of Biology, Boston University, Boston, USA
| | - Jamie M Gauthier
- Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, USA
| | - Kyle Mabry
- Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, USA
| | - Audrey Tran
- Department of Biology, Boston University, Boston, USA
| | - Heng-Ye Man
- Department of Biology, Boston University, Boston, USA; Center for Systems Neuroscience, Boston University, Boston, USA
| | - Kathleen M Kantak
- Department of Psychological and Brain Sciences, Boston University, 64 Cummington Mall, Boston, USA; Center for Systems Neuroscience, Boston University, Boston, USA.
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Feder A, Rutter SB, Schiller D, Charney DS. The emergence of ketamine as a novel treatment for posttraumatic stress disorder. Rapid Acting Antidepressants 2020; 89:261-286. [DOI: 10.1016/bs.apha.2020.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Souza RR, Robertson NM, Pruitt DT, Gonzales PA, Hays SA, Rennaker RL, Kilgard MP, McIntyre CK. Vagus nerve stimulation reverses the extinction impairments in a model of PTSD with prolonged and repeated trauma. Stress 2019; 22:509-520. [PMID: 31010369 DOI: 10.1080/10253890.2019.1602604] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We have shown that vagus nerve stimulation (VNS) enhances extinction of conditioned fear and reduces anxiety in rat models of PTSD using moderate stress. However, it is still unclear if VNS can be effective in enhancing extinction of severe fear after prolonged and repeated trauma. Severe fear was induced in adult male rats by combining single prolonged stress (SPS) and protracted aversive conditioning (PAC). After SPS and PAC procedures, rats were implanted with stimulating cuff electrodes, exposed to five days of extinction training with or without VNS, and then tested for extinction retention, return of fear in a new context and reinstatement. The elevated plus maze, open field and startle were used to test anxiety. Sham rats showed no reduction of fear during extensive extinction training. VNS-paired with extinction training reduced freezing at the last extinction session by 70% compared to sham rats. VNS rats exhibited half as much fear as shams, as well as less fear renewal. Sham rats exhibited significantly more anxiety than naive controls, whereas VNS rats did not. These results demonstrate that VNS enhances extinction and reduces anxiety in a severe model of PTSD that combined SPS and a conditioning procedure that is 30 times more intense than the conditioning procedures in previous VNS studies. The broad utility of VNS in enhancing extinction learning in rats and the strong clinical safety record of VNS suggest that VNS holds promise as an adjuvant to exposure-based therapy in people with PTSD and other complex forms of this condition.
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Affiliation(s)
- Rimenez R Souza
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
- b School of Behavioral Brain Sciences , The University of Texas at Dallas , Richardson , TX , USA
| | - Nicole M Robertson
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
| | - David T Pruitt
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
- b School of Behavioral Brain Sciences , The University of Texas at Dallas , Richardson , TX , USA
- c Erik Jonsson School of Engineering and Computer Science , The University of Texas at Dallas , Richardson , TX , USA
| | - Phillip A Gonzales
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
| | - Seth A Hays
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
- c Erik Jonsson School of Engineering and Computer Science , The University of Texas at Dallas , Richardson , TX , USA
| | - Robert L Rennaker
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
- b School of Behavioral Brain Sciences , The University of Texas at Dallas , Richardson , TX , USA
- c Erik Jonsson School of Engineering and Computer Science , The University of Texas at Dallas , Richardson , TX , USA
| | - Michael P Kilgard
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
- b School of Behavioral Brain Sciences , The University of Texas at Dallas , Richardson , TX , USA
| | - Christa K McIntyre
- a Texas Biomedical Device Center , The University of Texas at Dallas , Richardson , TX , USA
- b School of Behavioral Brain Sciences , The University of Texas at Dallas , Richardson , TX , USA
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Umemori J, Winkel F, Didio G, Llach Pou M, Castrén E. iPlasticity: Induced juvenile-like plasticity in the adult brain as a mechanism of antidepressants. Psychiatry Clin Neurosci 2018; 72:633-653. [PMID: 29802758 PMCID: PMC6174980 DOI: 10.1111/pcn.12683] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2018] [Indexed: 12/11/2022]
Abstract
The network hypothesis of depression proposes that mood disorders reflect problems in information processing within particular neural networks. Antidepressants (AD), including selective serotonin reuptake inhibitors (SSRI), function by gradually improving information processing within these networks. AD have been shown to induce a state of juvenile-like plasticity comparable to that observed during developmental critical periods: Such critical-period-like plasticity allows brain networks to better adapt to extrinsic and intrinsic signals. We have coined this drug-induced state of juvenile-like plasticity 'iPlasticity.' A combination of iPlasticity induced by chronic SSRI treatment together with training, rehabilitation, or psychotherapy improves symptoms of neuropsychiatric disorders and issues underlying the developmentally or genetically malfunctioning networks. We have proposed that iPlasticity might be a critical component of AD action. We have demonstrated that iPlasticity occurs in the visual cortex, fear erasure network, extinction of aggression caused by social isolation, and spatial reversal memory in rodent models. Chronic SSRI treatment is known to promote neurogenesis and to cause dematuration of granule cells in the dentate gyrus and of interneurons, especially parvalbumin interneurons enwrapped by perineuronal nets in the prefrontal cortex, visual cortex, and amygdala. Brain-derived neurotrophic factor (BDNF), via its receptor tropomyosin kinase receptor B, is involved in the processes of synaptic plasticity, including neurogenesis, neuronal differentiation, weight of synapses, and gene regulation of synaptic formation. BDNF can be activated by both chronic SSRI treatment and neuronal activity. Accordingly, the BDNF/tropomyosin kinase receptor B pathway is critical for iPlasticity, but further analyses will be needed to provide mechanical insight into the processes of iPlasticity.
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Affiliation(s)
- Juzoh Umemori
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Frederike Winkel
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Giuliano Didio
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Maria Llach Pou
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Eero Castrén
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
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Nagy C, Vaillancourt K, Turecki G. A role for activity-dependent epigenetics in the development and treatment of major depressive disorder. Genes, Brain and Behavior 2018; 17:e12446. [DOI: 10.1111/gbb.12446] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/17/2017] [Accepted: 12/06/2017] [Indexed: 12/22/2022]
Affiliation(s)
- C. Nagy
- McGill Group for Suicide Studies, Department of Psychiatry; McGill University; Montreal Canada
| | - K. Vaillancourt
- McGill Group for Suicide Studies, Department of Psychiatry; McGill University; Montreal Canada
| | - G. Turecki
- McGill Group for Suicide Studies, Department of Psychiatry; McGill University; Montreal Canada
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Papolos D, Frei M, Rossignol D, Mattis S, Hernandez-Garcia LC, Teicher MH. Clinical experience using intranasal ketamine in the longitudinal treatment of juvenile bipolar disorder with fear of harm phenotype. J Affect Disord 2018; 225:545-551. [PMID: 28866299 DOI: 10.1016/j.jad.2017.08.081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 08/21/2017] [Accepted: 08/27/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Fear of Harm (FOH) is a pediatric onset phenotype of bipolar disorder (BD) characterized by BD plus treatment resistance, separation anxiety, aggressive obsessions, parasomnias, and thermal dysregulation. Intranasal ketamine (InK) in 12 youths with BD-FOH produced marked improvement during a two-week trial. Here we report on the open effectiveness and safety of InK in maintenance treatment of BD-FOH from the private practice of one author. METHODS As part of a chart review, patients 18 years or older and parents of younger children responded to a clinical effectiveness and safety survey. Effectiveness was assessed from analysis of responses to 49 questions on symptomatology plus qualitative content analyses of written reports and chart review. Adverse events (AEs) were analyzed by frequency, duration and severity. Peak InK doses ranged from 20 to 360mg per administration. RESULTS Surveys were completed on 45 patients treated with InK for 3 months to 6.5 years. Almost all patients were "much" to "very much" improved clinically and in ratings of social function and academic performance. Significant reductions were reported in all symptom categories. There were 13 reports of persistent AEs, none of which resulted in discontinuation. Acute emergence reactions were sporadically observed in up to 75%, but were mild and of brief duration. LIMITATIONS Retrospective review from a single practice without placebo control with potential for response and recall bias. CONCLUSIONS InK every 3-4 days at sub-anesthetic doses appeared to be a beneficial and well-tolerated treatment. Use of InK may be considered as a tertiary alternative in treatment refractory cases. Randomized control trials are warranted.
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Affiliation(s)
- Demitri Papolos
- Juvenile Bipolar Research Foundation, 277 Martine Avenue, Suite 226 White Plains, NY 10601, United States; Department of Psychiatry, Albert Einstein College of Medicine, New York, United States.
| | - Mark Frei
- Advanced Signal Analysis and Processing, 2360 Sterling Creek Pkwy, Oviedo, FL 32766, United States
| | - Daniel Rossignol
- Juvenile Bipolar Research Foundation, 277 Martine Avenue, White Plains, NY 10601, United States
| | - Steven Mattis
- Department of Psychiatry Cornell-Weil Medical College of Medicine, United States
| | - Laura C Hernandez-Garcia
- Developmental Biopsychiatry Research Program, McLean Hospital, Department of Psychiatry, Harvard Medical School, United States
| | - Martin H Teicher
- Developmental Biopsychiatry Research Program, McLean Hospital, Department of Psychiatry, Harvard Medical School, United States
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Règue-Guyon M, Lanfumey L, Mongeau R. Neuroepigenetics of Neurotrophin Signaling: Neurobiology of Anxiety and Affective Disorders. Progress in Molecular Biology and Translational Science 2018; 158:159-193. [DOI: 10.1016/bs.pmbts.2018.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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