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Surjan J, Grossi JD, Del Porto JA, Delfino RS, de Oliveira Cerqueira R, Lucchese AC, Magalhães E, Del Sant LC, Tuena MA, Nakahira C, Fava VAR, Steglich MS, Abdo GL, Barbosa MG, Sarin LM, Lacerda ALT. Efficacy and Safety of Subcutaneous Esketamine in the Treatment of Suicidality in Major Depressive Disorder and Bipolar Depression. Clin Drug Investig 2022; 42:865-873. [PMID: 36044154 DOI: 10.1007/s40261-022-01193-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Affective disorders account for most cases of suicide. The pharmacological arsenal to treat suicidality is limited and available agents take too long to take effect. A large body of evidence shows optimal results of ketamine for treating depression, but the evidence concerning suicidality has not been fully described. We report the first real-world study of severely depressed patients presenting with suicide ideation who were treated with repeated administration of subcutaneous esketamine. METHODS We analyzed data from 70 acutely depressed subjects diagnosed with resistant major depressive disorder or bipolar depression. Subjects were administered subcutaneous esketamine once a week for 6 weeks. The primary efficacy endpoint, the change from baseline to 24-h post-administration 6 in the item 10 Montgomery-Åsberg Depression Rating Scale score, was analyzed using a mixed-effects repeated-measures model. RESULTS There were significant effects for time on item 10 Montgomery-Åsberg Depression Rating Scale scores (p < 0.0001) but not for a time × diagnosis interaction (p = 0.164) from baseline to the end of the study. Efficacy of esketamine did not differ between groups (major depressive disorder vs bipolar depression) at any timepoint. Statistical significance on suicidality scores was observed from 24 h after the first administration (p < 0.001), and a further reduction was observed with repeated administrations. Esketamine was safe and well tolerated. Mean heart rate remained stable during the administrations and the blood pressure increase was self-limited. CONCLUSIONS Repeated subcutaneous esketamine administration had significant anti-suicidality effects in both major depressive disorder and bipolar groups, with a rapid onset of action and a good tolerability profile. Large randomized controlled trials are warranted to confirm these preliminary findings.
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Affiliation(s)
- Juliana Surjan
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | | | - José Alberto Del Porto
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Rodrigo Simonini Delfino
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Raphael de Oliveira Cerqueira
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Ana Cecília Lucchese
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Magalhães
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lorena Catarina Del Sant
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Aurélio Tuena
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Matheus Souza Steglich
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Guilherme Lozi Abdo
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil
| | - Matheus Ghossain Barbosa
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luciana Maria Sarin
- Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241, Vila Mariana, Sao Paulo, SP, 04017-030, Brazil. .,CNS Unit, BR Trials, Sao Paulo, Brazil. .,LiNC-Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Fava VAR, Sarin LM, Lucchese AC, Del Sant L, Magalhães E, Delfino RS, Tuena MA, Nakahira C, Jackowski AP, Abdo G, Surjan J, Steiglich M, Barbosa MG, Porto JAD, Lacerda ALT, Cogo-Moreira H. The probability of response after each subcutaneous injection of esketamine in treatment-resistant depression. Rev Psiquiatr Salud Ment (Engl Ed) 2021; 14:212-217. [PMID: 34861929 DOI: 10.1016/j.rpsmen.2021.11.003] [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] [Received: 06/17/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The administration of multiple esketamine doses has shown efficacy for unipolar and bipolar treatment-resistant depression (TRD). Nevertheless, the probability of responding or not after each dose in the real-world remains unknown. This study aimed to estimate it throughout four doses of esketamine, administrated via subcutaneous (SC). MATERIAL AND METHODS We conducted a retrospective analysis of a case series of 70 patients with TRD who received treatment from the esketamine assistance program at Federal University of Sao Paulo, between April 2017 and December 2018. The SC injections were administrated weekly at a dose of 0.5-1.0mg/kg, in conjunction with patients' psychotropic drugs. Response was defined as a decrease of at least 50% in the Montgomery-Åsberg Depression Rating Scale between baseline and 24h after dose. We used hidden Markov modeling in order to estimate de probability of response after each esketamine injection. RESULTS The probability of a patient that was a "non-responder" to become a "responder" following a SC injection of esketamine was 17.30% and the probability that this patient remains a "non-responder" was 82.70%. The probability of a patient that was a "responder" to remain as a "responder" was 95%. CONCLUSIONS Patients with TRD who had not responded after the first dose of esketamine, still had a chance of responding after the subsequent dose administrated via SC.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Cecília Lucchese
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lorena Del Sant
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Magalhães
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Simonini Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Andrea Parolin Jackowski
- LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - José Alberto Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; School of Public Health, University of Hong Kong, Hong Kong, SAR, China.
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Lucchese AC, Sarin LM, Magalhães EJM, Del Sant LC, B Puertas C, Tuena MA, Nakahira C, Fava VA, Delfino R, Surjan J, Steiglich MS, Barbosa M, Abdo G, Cohrs FM, Liberatori A, Del Porto JA, Lacerda AL, B Andreoli S. Repeated subcutaneous esketamine for treatment-resistant depression: Impact of the degree of treatment resistance and anxiety comorbidity. J Psychopharmacol 2021; 35:142-149. [PMID: 33427015 DOI: 10.1177/0269881120978398] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 12/19/2022]
Abstract
BACKGROUND A large number of studies indicate that subanesthetic doses of ketamine induce a fast antidepressant effect. Limited studies have investigated the subcutaneous (SC) route, and it remains unclear for whom this treatment is most suitable. AIMS The aim of this study was to examine the effect on depressive symptoms of repeated subanesthetic doses of SC esketamine in unipolar and bipolar treatment-resistant depression (TRD) and clinical predictors of response. METHODS A retrospective analysis of 70 patients who received six SC esketamine doses weekly as an adjunctive treatment was carried out. Doses started at 0.5 mg/kg and it could be titrated up to 1 mg/kg, according to response. The primary outcome was reduction in depressive symptoms. Statistical analysis to investigate clinical predictors of effectiveness included logistic regression analysis using a dependent variable of a 50% reduction in rating scale scores at the end of treatment. Comparisons between groups were made through analysis of variance and treatment effects. RESULTS At baseline, our sample presented with severe treatment resistance in 65.7%, as assessed by the Maudsley Staging Method (MSM), and 47.1% had anxiety disorder comorbidity. The response rate was 50%. A better outcome was predicted by mild and moderate MSM scores (OR = 3.162, p = 0.041) and anxiety disorder comorbidity (OR = 3.149, p = 0.028). CONCLUSIONS Our results suggest that higher levels of treatment resistance may be associated with a poor response to SC esketamine. Unlike traditional pharmacotherapies, it might benefit those with poor prognosis such as patients with depression and comorbid anxiety. Therefore, future research could investigate whether esketamine should receive a more prominent place in the treatment algorithm for TRD.
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Affiliation(s)
- Ana C Lucchese
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luciana M Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Lorena C Del Sant
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Camila B Puertas
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco A Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Victor Ar Fava
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus S Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Barbosa
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Frederico M Cohrs
- Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Aroldo Liberatori
- Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - José A Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Lt Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, PRODAF - Programa de Transtornos Afetivos, Federal University of Sao Paulo, Sao Paulo, Brazil
- Department of Psychiatry, LiNC - Laboratory of Integrative Neuroscience, Federal University of Sao Paulo, Sao Paulo, Brazil
- Center for Interventional Psychiatry, Hospital Sao Marcos, Jaboticabal, Brazil
| | - Sergio B Andreoli
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
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Barbosa MG, Sarin LM, Tuena MA, Del Sant LC, Nakahira C, Magalhães EJM, Fava VAR, Delfino RS, Steglich MS, Puertas C, Lucchese AC, Surjan JC, Abdo GL, Cogo-Moreira H, Del Porto JA, Lacerda ALTD, Jackowski AP. Heterogeneous trajectory of depressive symptoms after repeated subcutaneous esketamine injections. Journal of Affective Disorders Reports 2021. [DOI: 10.1016/j.jadr.2020.100053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Magalhães EJM, Sarin LM, Del Sant LC, Lucchese AC, Nakahira C, Tuena MA, Puertas CB, Rodovalho Fava VA, Delfino RS, Surjan J, Steglich MS, Barbosa MG, Abdo G, Del Porto JA, Nemeroff CB, Cogo-Moreira H, Lacerda ALT, Mello AF. A Clinical Rationale for Assessing the Impact of Childhood Sexual Abuse on Adjunctive Subcutaneous Esketamine for Treatment-Resistant Depression. Front Psychiatry 2021; 12:608499. [PMID: 34483976 PMCID: PMC8415867 DOI: 10.3389/fpsyt.2021.608499] [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: 09/20/2020] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: A history of child sexual abuse (CSA) is related to higher suicide rates and poor treatment outcomes in depressed adult patients. Twenty years after the first study investigating the effects of ketamine/esketamine on depression and suicide, there is a lack of data on the CSA effects on this emerging treatment. Here, we assess the impact of CSA on adjunctive subcutaneous (SC) esketamine for treatment-resistant depression (TRD). Methods: A directed acyclic graphic (DAG) was designed to identify clinical confounders between CSA and esketamine predictors of response. The confounders were applied in a statistical model to predict depression symptom trajectory in a sample of 67 TRD outpatients. Results: The patient sample had a relatively high prevalence rate of CSA (35.82%). Positive family history of first-degree relatives with alcohol use disorder and sex were clinical mediators of the effects of esketamine in a CSA adult population. Overall, the presence of at least one CSA event was unrelated to esketamine symptom reduction. Conclusions: Unlike responses to conventional antidepressants and psychotherapy, CSA does not appear to predict poor response to esketamine.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Carolina Nakahira
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Rodrigo Simonini Delfino
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Matheus Souza Steglich
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | | | - Guilherme Abdo
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - José Alberto Del Porto
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, Institute of Early Life Adversity Research, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Department of Education, ICT and Learning, Faculty of Teacher Education and Languages, Østfold University College, Halden, Norway
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Care on Affective Disorders, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,CNS Unit, BR Trials, São Paulo, Brazil
| | - Andrea Feijo Mello
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.,Program for Research and Care on Violence and Post-traumatic Stress Disorder, Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
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Delfino RS, Del-Porto JA, Surjan J, Magalhães E, Sant LCD, Lucchese AC, Tuena MA, Nakahira C, Fava VAR, Steglich MS, Barbosa MG, Sarin LM, Lacerda ALT. Comparative effectiveness of esketamine in the treatment of anhedonia in bipolar and unipolar depression. J Affect Disord 2021; 278:515-518. [PMID: 33017679 DOI: 10.1016/j.jad.2020.09.056] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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: 06/06/2020] [Revised: 09/06/2020] [Accepted: 09/11/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anhedonia is a symptom associated with poorer outcomes in depression treatment, including resistance to treatment, higher functional impact and suicidality. Few drugs are known to adequately treat anhedonia in both unipolar and bipolar depression. The NMDA antagonist ketamine has been demonstrated to be effective in rapidly ameliorating anhedonia in depressive episodes. The main aim of present study is to evaluate the anti-anhedonic effect of esketamine, the S-enantiomer of ketamine recently approved for treatment-resistant depression, in unipolar and bipolar depression. METHODS 70 patients with unipolar or bipolar depression were treated with 6 weekly subcutaneous esketamine infusions (0.5-1mg/kg). Anhedonia was measured through MADRS item 8 before and 24h after each infusion. RESULTS A significant reduction in anhedonia severity was observed (p<0.0001) after 6 infusions. The effect was statistically significant 24h after the first infusion (p<0.001) in both unipolar and bipolar groups and increased with repeated infusions. Anti-anhedonic effect of esketamine did not differ between groups. LIMITATIONS This is an open-label, real-world study. Lack of blinding and of a placebo arm may limit the interpretation of findings. CONCLUSION Although preliminary, present findings suggest that repeated subcutaneous esketamine infusions are effective for the treatment of anhedonia in both unipolar and bipolar depressed patients. These results need to be confirmed through replication in larger double-blinded controlled trials.
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Affiliation(s)
- Rodrigo Simonini Delfino
- PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241. Vila Mariana, Sao Paulo 04017-030, Brazil
| | - José Alberto Del-Porto
- PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241. Vila Mariana, Sao Paulo 04017-030, Brazil
| | - Juliana Surjan
- PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241. Vila Mariana, Sao Paulo 04017-030, Brazil
| | - Eduardo Magalhães
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lorena Catarina Del Sant
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Cecílica Lucchese
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Victor Augusto Rodoalho Fava
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Souza Steglich
- PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241. Vila Mariana, Sao Paulo 04017-030, Brazil
| | - Matheus Ghossain Barbosa
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of Sao Paulo; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Rua Major Maragliano, 241. Vila Mariana, Sao Paulo 04017-030, Brazil; LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; CNS Unit, BR Trials - Clinical Research, Sao Paulo, Brazil.
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7
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Fava VAR, Sarin LM, Lucchese AC, Del Sant L, Magalhães E, Delfino RS, Tuena MA, Nakahira C, Jackowski AP, Abdo G, Surjan J, Steiglich M, Barbosa MG, Porto JAD, Lacerda ALT, Cogo-Moreira H. The probability of response after each subcutaneous injection of esketamine in treatment-resistant depression. Rev Psiquiatr Salud Ment (Engl Ed) 2020; 14:S1888-9891(20)30117-8. [PMID: 33075541 DOI: 10.1016/j.rpsm.2020.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/12/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The administration of multiple esketamine doses has shown efficacy for unipolar and bipolar treatment-resistant depression (TRD). Nevertheless, the probability of responding or not after each dose in the real-world remains unknown. This study aimed to estimate it throughout four doses of esketamine, administrated via subcutaneous (SC). MATERIAL AND METHODS We conducted a retrospective analysis of a case series of 70 patients with TRD who received treatment from the esketamine assistance program at Federal University of Sao Paulo, between April 2017 and December 2018. The SC injections were administrated weekly at a dose of 0.5-1.0mg/kg, in conjunction with patients' psychotropic drugs. Response was defined as a decrease of at least 50% in the Montgomery-Åsberg Depression Rating Scale between baseline and 24h after dose. We used hidden Markov modeling in order to estimate de probability of response after each esketamine injection. RESULTS The probability of a patient that was a "non-responder" to become a "responder" following a SC injection of esketamine was 17.30% and the probability that this patient remains a "non-responder" was 82.70%. The probability of a patient that was a "responder" to remain as a "responder" was 95%. CONCLUSIONS Patients with TRD who had not responded after the first dose of esketamine, still had a chance of responding after the subsequent dose administrated via SC.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ana Cecília Lucchese
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lorena Del Sant
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Magalhães
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; Centro Alfa de Humanização, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Simonini Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Andrea Parolin Jackowski
- LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - José Alberto Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; PRODAF - Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; LiNC - Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil; School of Public Health, University of Hong Kong, Hong Kong, SAR, China.
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8
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Del Sant LC, Sarin LM, Magalhães EJM, Lucchese AC, Tuena MA, Nakahira C, Fava VAR, Delfino R, Surjan J, Steiglich MS, Barbosa M, Abdo G, Cohrs FM, Liberatori A, Del Porto JA, Lacerda ALT, de Jesus Mari J. Effects of subcutaneous esketamine on blood pressure and heart rate in treatment-resistant depression. J Psychopharmacol 2020; 34:1155-1162. [PMID: 32638662 DOI: 10.1177/0269881120922955] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES The impact of multiple subcutaneous (s.c.) esketamine injections on the blood pressure (BP) and heart rate (HR) of patients with unipolar and bipolar treatment-resistant depression (TRD) is poorly understood. This study aimed to assess the cardiovascular safety of multiple s.c. doses of esketamine in patients with TRD. METHODS Seventy TRD patients received 394 weekly s.c. esketamine injections in conjunction with oral antidepressant therapy for up to six weeks. Weekly esketamine doses were 0.5, 0.75 or 1.0 mg/kg according to each patient's response to treatment. Participants were monitored before each treatment and every 15 minutes thereafter for 120 minutes. We assessed systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR measurements for the entire treatment course. RESULTS BP increased after the first s.c. esketamine injection, reaching maximum mean SBP/DBP levels of 4.87/5.54 mmHg within 30-45 minutes. At the end of monitoring, 120 minutes post dose, vital signs returned to pretreatment levels. We did not detect significant differences in BP between doses of 0.5, 0.75, and 1 mg/kg esketamine. Mean HR did not differ significantly between doses or before and after s.c. esketamine injection. CONCLUSIONS The BP changes observed with repeated s.c. esketamine injections were mild and well tolerated for doses up to 1 mg/kg. The s.c. route is a simple and safe method of esketamine administration, even for patients with clinical comorbidities, including obesity, hypertension, diabetes, and dyslipidemia. However, 14/70 patients experienced treatment-emergent transient hypertension (SBP >180 mmHg and/or a DBP >110 mmHg). Therefore, we strongly recommend monitoring BP for 90 minutes after esketamine dosing. Since s.c. esketamine is cheap, requires less frequent dosing (once a week), and is a simpler procedure compared to intravenous infusions, it might have an impact on public health.
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Affiliation(s)
| | - Luciana Maria Sarin
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Marco Aurélio Tuena
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Rodrigo Delfino
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Juliana Surjan
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Souza Steiglich
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Barbosa
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Abdo
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | - Aroldo Liberatori
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - José Alberto Del Porto
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Acioly Luiz Tavares Lacerda
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,PRODAF-Programa de Transtornos Afetivos, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,LiNC-Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,Center for Interventional Psychiatry, Hospital Sao Marcos, Jaboticabal, Brazil
| | - Jair de Jesus Mari
- Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil.,LiNC-Laboratory of Integrative Neuroscience, Department of Psychiatry, Federal University of Sao Paulo, Sao Paulo, Brazil
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9
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Correia-Melo FS, Leal GC, Vieira F, Jesus-Nunes AP, Mello RP, Magnavita G, Caliman-Fontes AT, Echegaray MVF, Bandeira ID, Silva SS, Cavalcanti DE, Araújo-de-Freitas L, Sarin LM, Tuena MA, Nakahira C, Sampaio AS, Del-Porto JA, Turecki G, Loo C, Lacerda ALT, Quarantini LC. Efficacy and safety of adjunctive therapy using esketamine or racemic ketamine for adult treatment-resistant depression: A randomized, double-blind, non-inferiority study. J Affect Disord 2020; 264:527-534. [PMID: 31786030 DOI: 10.1016/j.jad.2019.11.086] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [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: 07/29/2019] [Revised: 10/08/2019] [Accepted: 11/12/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Ketamine and its enantiomers have recently been highlighted as one of the most effective therapeutic options in refractory depression. However, racemic ketamine and esketamine have not been directly compared. The aim of this study is to assess the efficacy and safety of esketamine compared to ketamine in patients with treatment-resistant depression (TRD). METHODS This is a randomized, double-blind, active-controlled, bicentre, non-inferiority clinical trial, with two parallel groups. Participants were randomly assigned to a 40-min single intravenous infusion of ketamine 0.5 mg/kg or esketamine 0.25 mg/kg. The primary outcome was the difference in remission rates for depression 24 h following intervention using the Montgomery-Åsberg Depression Rating Scale (MADRS), with a non-inferiority margin of 20%. RESULTS 63 subjects were included and randomly assigned (29 to receive ketamine and 34 to receive esketamine). At 24 h, 24.1% of participants in the ketamine group and 29.4% of participants in the esketamine group showed remission, with a difference of 5.3% (95% CILB -13.6%), confirming non-inferiority. MADRS scores improved from 33 (SD 9.3) to 16.2 (SD 10.7) in the ketamine group and from 33 (SD 5.3) to 17.5 (SD 12.2) in the esketamine one, with a difference of -5.27% (95% CILB, -13.6). Both groups presented similar mild side effects. CONCLUSIONS Esketamine was non-inferior to ketamine for TRD 24 h following infusion. Both treatments were effective, safe, and well tolerated. TRIAL REGISTRATION Registered in Japan Primary Registries Network: UMIN000032355.
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Affiliation(s)
- Fernanda S Correia-Melo
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil.
| | - Gustavo C Leal
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil; Division of Psychiatry, Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador, Brazil
| | - Flávia Vieira
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil
| | - Ana Paula Jesus-Nunes
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil
| | - Rodrigo P Mello
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil
| | - Guilherme Magnavita
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil
| | | | - Mariana V F Echegaray
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil
| | - Igor D Bandeira
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil
| | - Samantha S Silva
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil
| | - Diogo E Cavalcanti
- Division of Psychiatry, Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador, Brazil
| | - Lucas Araújo-de-Freitas
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil
| | - Luciana M Sarin
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Marco A Tuena
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Carolina Nakahira
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Aline S Sampaio
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Department of Neuroscience and Mental Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil
| | - José A Del-Porto
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Gustavo Turecki
- McGill Group for Suicide Studies, Douglas Mental Health University Institute & Department of Psychiatry, McGill University, Montreal, Canada
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia; Black Dog Institute, Sydney, Australia; St George Hospital, South Eastern Sydney Health, Sydney, Australia
| | - Acioly L T Lacerda
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil; Interdisciplinary Laboratory of Clinical Neurosciences, Federal University of São Paulo, São Paulo, Brazil; Sinapse Institute of Clinical Neurosciences, Campinas, Brazil
| | - Lucas C Quarantini
- Laboratory of Neuropsychopharmacology, Federal University of Bahia, Salvador, Brazil; Postgraduate Program in Medicine and Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil; Division of Psychiatry, Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador, Brazil; Department of Neuroscience and Mental Health, Medical School of Bahia, Federal University of Bahia, Salvador, Brazil
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10
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Correia-Melo FS, Leal GC, Carvalho MS, Jesus-Nunes AP, Ferreira CB, Vieira F, Magnavita G, Vale LA, Mello RP, Nakahira C, Argolo FC, Cardoso T, Souza CD, Fontes ATC, Ferreira MB, Araújo-de-Freitas L, Tuena MA, Echegaray MV, Cavalcanti DE, Lucchese AC, Bandeira ID, Telles M, Lima CS, Sampaio AS, Silva SS, Marback RF, Del-Porto JA, Abreu JN, Sarin LM, Paixão CS, Carvalho LP, Machado PR, Turecki G, Lacerda AL, Quarantini LC. Comparative study of esketamine and racemic ketamine in treatment-resistant depression: Protocol for a non-inferiority clinical trial. Medicine (Baltimore) 2018; 97:e12414. [PMID: 30235716 PMCID: PMC6160185 DOI: 10.1097/md.0000000000012414] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The use of ketamine as an option in the treatment of depressive disorder is growing rapidly, supported by numerous clinical trials attesting its efficacy and safety. Esketamine, the S (+) enantiomer of ketamine, is the most widely used form in the anesthetic environment in some countries, and new studies have shown that it may also be effective in depression and with better tolerability. However, no study so far has directly compared esketamine with racemic ketamine. Here we propose a protocol of a clinical trial to evaluate esketamine as a noninferior medication when compared to ketamine in the treatment of patients with treatment-resistant depression. METHODS/DESIGN This study protocol is for a randomized, controlled, double-blind noninferiority clinical trial. Subjects will be 18 years or older, with major depression characterized as treatment-resistant. Participants will receive a single infusion of either esketamine (0.25 mg/kg) or ketamine (0.5 mg/kg) over 40 minutes. The primary outcome will be the difference in remission rates between the 2 treatment arms at 24 and 72 hours after drug infusion. Secondary outcomes will include other timepoints, measurements of cognition, dissociation, and blood biomarkers. DISCUSSION A head-to-head study is the best way to evaluate whether the esketamine is in fact comparable to the racemic ketamine in terms of both efficacy and safety, and, if positive, it would be an initial step to increase the access to that type of treatment worldwide. ETHICS AND DISSEMINATION The study was approved by the local Institutional Review Board (University Hospital Professor Edgard Santos-Federal University of Bahia-Number: 46657415.0.0000.0049). Subjects will only participate after voluntarily agreeing and signing the Informed Consent Form. The study findings will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION This trial has been registered in the Japan Primary Registries Network (JPRN): UMIN000032355, which is affiliated with the World Health Organization.
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Affiliation(s)
| | - Gustavo C. Leal
- Postgraduate Program in Medicine and Health
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | | | | | | | | | - Guilherme Magnavita
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | | | - Rodrigo P. Mello
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | - Carolina Nakahira
- PRODAF—Programa de Transtornos Afetivos, Universidade Federal de São Paulo, São Paulo
| | | | - Tanise Cardoso
- Postgraduate Program in Psychology, Institute of Psychology
| | | | - Ana Teresa C. Fontes
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | | | | | - Marco A. Tuena
- PRODAF—Programa de Transtornos Afetivos, Universidade Federal de São Paulo, São Paulo
| | | | - Diogo E. Cavalcanti
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | - Ana C. Lucchese
- PRODAF—Programa de Transtornos Afetivos, Universidade Federal de São Paulo, São Paulo
| | - Igor D. Bandeira
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | - Manuela Telles
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | - Cássio S. Lima
- Postgraduate Program in Psychology, Institute of Psychology
| | - Aline S. Sampaio
- Postgraduate Program in Medicine and Health
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | - Samantha S. Silva
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | - Roberta F. Marback
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
| | - José A. Del-Porto
- PRODAF—Programa de Transtornos Afetivos, Universidade Federal de São Paulo, São Paulo
| | | | - Luciana M. Sarin
- PRODAF—Programa de Transtornos Afetivos, Universidade Federal de São Paulo, São Paulo
| | - Camilla S. Paixão
- Immunology Service, Universidade Federal da Bahial
- Clinical Research Laboratory (LAPEC), Gonçalo Moniz Institute, Fiocruz-Bahia, Salvador, Brazil
| | - Lucas P. Carvalho
- Immunology Service, Universidade Federal da Bahial
- Clinical Research Laboratory (LAPEC), Gonçalo Moniz Institute, Fiocruz-Bahia, Salvador, Brazil
| | | | - Gustavo Turecki
- McGill Group for Suicide Studies, Douglas Mental Health University Institute & Department of Psychiatry, McGill University, Montreal, Canada
| | - Acioly L.T. Lacerda
- LiNC—Laboratório Interdisciplinar de Neurociências Clínicas
- PRODAF—Programa de Transtornos Afetivos, Universidade Federal de São Paulo, São Paulo
- Center for Research and Clinical Trials Sinapse-Bairral, Instituto Bairral de Psiquiatria, Itapira, Brazil
| | - Lucas C. Quarantini
- Postgraduate Program in Medicine and Health
- Psychiatry Service, University Hospital, Universidade Federal da Bahia, Salvador
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