1
|
Conway CR, Aaronson ST, Sackeim HA, Duffy W, Stedman M, Quevedo J, Allen RM, Riva-Posse P, Berger MA, Alva G, Malik MA, Dunner DL, Cichowicz I, Luing H, Zajecka J, Nahas Z, Mickey BJ, Kablinger AS, Kriedt CL, Bunker MT, Lee YCL, Shy O, Majewski S, Olin B, Tran Q, Rush AJ. Clinical characteristics and treatment exposure of patients with marked treatment-resistant unipolar major depressive disorder: A RECOVER trial report. Brain Stimul 2024; 17:448-459. [PMID: 38574853 DOI: 10.1016/j.brs.2024.03.016] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND RECOVER is a randomized sham-controlled trial of vagus nerve stimulation and the largest such trial conducted with a psychiatric neuromodulation intervention. OBJECTIVE To describe pre-implantation baseline clinical characteristics and treatment history of patients with unipolar, major depressive disorder (MDD), overall and as a function of exposure to interventional psychiatric treatments (INTs), including electroconvulsive therapy, transcranial magnetic stimulation, and esketamine. METHODS Medical, psychiatric, and treatment records were reviewed by study investigators and an independent Study Eligibility Committee prior to study qualification. Clinical characteristics and treatment history (using Antidepressant Treatment History [Short] Form) were compared in those qualified (N = 493) versus not qualified (N = 228) for RECOVER, and among the qualified group as a function of exposure to INTs during the current major depressive episode (MDE). RESULTS Unipolar MDD patients who qualified for RECOVER had marked TRD (median of 11.0 lifetime failed antidepressant treatments), severe disability (median WHODAS score of 50.0), and high rate of baseline suicidality (77% suicidal ideation, 40% previous suicide attempts). Overall, 71% had received at least one INT. Compared to the no INT group, INT recipients were younger and more severely depressed (QIDS-C, QIDS-SR), had greater suicidal ideation, earlier diagnosis of MDD, and failed more antidepressant medication trials. CONCLUSIONS RECOVER-qualified unipolar patients had marked TRD and marked treatment resistance with most failing one or more prior INTs. Treatment with ≥1 INTs in the current MDE was associated with earlier age of MDD onset, more severe clinical presentation, and greater treatment resistance relative to patients without a history of INT. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03887715.
Collapse
Affiliation(s)
- Charles R Conway
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA.
| | - Scott T Aaronson
- Department of Clinical Research, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Harold A Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY, USA
| | | | | | - João Quevedo
- Center for Interventional Psychiatry, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, TX, USA
| | | | - Patricio Riva-Posse
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Gustavo Alva
- ATP Clinical Research, Senior Brain Health, Hoag Hospital, Newport Beach, CA and Department of Psychiatry and Neuroscience, University of California, Riverside, CA, USA
| | | | - David L Dunner
- Center for Anxiety and Depression, Mercer Island, WA, USA
| | | | | | - John Zajecka
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA; Psychiatric Medicine Associates, LLC, Skokie, IL, USA
| | - Ziad Nahas
- Department of Psychiatry & Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Brian J Mickey
- Department of Psychiatry, Huntsman Mental Health Institute, University of Utah, Salt Lake City, UT, USA
| | - Anita S Kablinger
- Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Christopher L Kriedt
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA
| | - Mark T Bunker
- LivaNova PLC (or a Subsidiary), London, Great Britain, United Kingdom
| | | | - Olivia Shy
- LivaNova PLC (or a Subsidiary), London, Great Britain, United Kingdom
| | - Shannon Majewski
- LivaNova PLC (or a Subsidiary), London, Great Britain, United Kingdom
| | - Bryan Olin
- LivaNova PLC (or a Subsidiary), London, Great Britain, United Kingdom
| | - Quyen Tran
- LivaNova PLC (or a Subsidiary), London, Great Britain, United Kingdom
| | - A John Rush
- Duke-NUS Medical School, Singapore; Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| |
Collapse
|
2
|
Aaronson ST, Sackeim HA, Jiang M, Badejo S, Greco T, Bunker MT, Conway CR, Demyttenaere K, Young AH, McAllister-Williams RH, Rush AJ. Alternative metrics for characterizing longer-term clinical outcomes in difficult-to-treat depression: II. Sensitivity to treatment effects. Aust N Z J Psychiatry 2024; 58:250-259. [PMID: 37927051 PMCID: PMC10903145 DOI: 10.1177/00048674231209837] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Characteristics of difficult-to-treat depression (DTD), including infrequent symptom remission and poor durability of benefit, compel reconsideration of the outcome metrics historically used to gauge the effectiveness of antidepressant interventions. METHODS Self-report and clinician assessments of depression symptom severity were obtained regularly over a 2-year period in a difficult-to-treat depression registry sample receiving treatment as usual (TAU), with or without vagus nerve stimulation (VNS). Alternative outcome metrics for characterizing symptom change were compared in effect size and discriminating power in distinguishing the vagus nerve stimulation + treatment as usual and treatment as usual treatment groups. We expected metrics based on remission status to produce weaker between-group separation than those based on the classifications of partial response or response and metrics that integrate information over time to produce greater separation than those based on single endpoint assessment. RESULTS Metrics based on remission status had smaller effect size and poorer discrimination in separating the treatment groups than metrics based on partial response or response classifications. Metrics that integrated information over the 2-year observation period had stronger performance characteristics than those based on symptom scores at single endpoint assessment. For both the clinician-rated and self-report depression ratings, the metrics with the strongest performance characteristics were the median percentage change in symptom scores over the observation period and the proportion of the observation period in partial response or better. CONCLUSION In difficult-to-treat depression, integrative symptom severity-based and time-based measures are sensitive and informative outcomes for assessing between-group treatment effects, while metrics based on remission status are not.
Collapse
Affiliation(s)
- Scott T Aaronson
- Department of Clinical Research, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Harold A Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY, USA
| | - Mei Jiang
- LivaNova USA PLC, Minneapolis, MN, USA
| | | | - Teresa Greco
- Jazz Pharmaceuticals PLC, Milan, Italy
- LivaNova USA PLC, Houston, TX, USA
| | | | - Charles R Conway
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA
| | - Koen Demyttenaere
- Psychiatry, Leuven Brain Institute, University Psychiatric Center KU Leuven, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- National Mood Disorders Service, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - R Hamish McAllister-Williams
- Northern Centre for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Regional Affective Disorders Service, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A John Rush
- Duke-NUS Medical School, National University of Singapore, Singapore
- Department of Psychiatry & Behavioral Sciences, Duke University, Durham, NC, USA
| |
Collapse
|
3
|
Palanca BJA, Conway CR, Zeffiro T, Gott BM, Nguyen T, Janski A, Jain N, Komen H, Burke BA, Zorumski CF, Nagele P. Persistent Brain Connectivity Changes in Healthy Volunteers Following Nitrous Oxide Inhalation. Biol Psychiatry Glob Open Sci 2023; 3:698-704. [PMID: 37881568 PMCID: PMC10593877 DOI: 10.1016/j.bpsgos.2023.01.006] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 01/15/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Background Nitrous oxide holds promise in the treatment of major depressive disorder. Its psychotropic effects and NMDA receptor antagonism have led to comparisons with ketamine. Despite longstanding use, persistent effects of nitrous oxide on the brain have not been characterized. Methods Sixteen healthy volunteers were recruited in a double-blind crossover study. In randomized order, individuals underwent a 1-hour inhalation of either 50% nitrous oxide/oxygen or air/oxygen mixtures. At least two 7.5-minute echo-planar resting-state functional magnetic resonance imaging scans were obtained before and at 2 and 24 hours after each inhalation (average 130 min/participant). Using the time series of preprocessed, motion artifact-scrubbed, and nuisance covariate-regressed imaging data, interregional signal correlations were measured and converted to T scores. Hierarchical clustering and linear mixed-effects models were employed. Results Nitrous oxide inhalation produced changes in global brain connectivity that persisted in the occipital cortex at 2 and 24 hours postinhalation (p < .05, false discovery rate-corrected). Analysis of resting-state networks demonstrated robust strengthening of connectivity between regions of the visual network and those of the dorsal attention network, across 2 and 24 hours after inhalation (p < .05, false discovery rate-corrected). Weaker changes in connectivity were found between the visual cortex and regions of the frontoparietal and default mode networks. Parallel analyses following air/oxygen inhalation yielded no significant changes in functional connectivity. Conclusions Nitrous oxide inhalation in healthy volunteers revealed persistent increases in global connectivity between regions of primary visual cortex and dorsal attention network. These findings suggest that nitrous oxide inhalation induces neurophysiological cortical changes that persist for at least 24 hours.
Collapse
Affiliation(s)
- Ben Julian A. Palanca
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
- Division of Biology and Biomedical Sciences, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Center on Biological Rhythms and Sleep, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charles R. Conway
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Thomas Zeffiro
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Britt M. Gott
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Neuroimaging Labs Research Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Thomas Nguyen
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alvin Janski
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Nisha Jain
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Illinois
| | - Helga Komen
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Broc A. Burke
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Charles F. Zorumski
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Illinois
| |
Collapse
|
4
|
de Leon VC, Kumar A, Nagele P, Palanca BJ, Gott B, Janski A, Zorumski CF, Conway CR. Nitrous Oxide Reduced Suicidal Ideation in Treatment-Resistant Major Depression in Exploratory Analysis. J Clin Psychiatry 2023; 84:22br14725. [PMID: 37585253 DOI: 10.4088/jcp.22br14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Affiliation(s)
- Victoria C de Leon
- Department of Psychiatry, Washington University School of Medicine in St Louis, Missouri
- Corresponding Author: Victoria C. de Leon, MD, 660 South Euclid Ave, MSC 8134-0017-04, St Louis, MO 63110
| | - Arun Kumar
- Bristol Myers Squibb, Lawrenceville, New Jersey
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Illinois
| | - Ben J Palanca
- Department of Anesthesiology and Department of Psychiatry, Washington University School of Medicine in St Louis, Missouri
| | - Britt Gott
- Department of Psychiatry, Washington University School of Medicine in St Louis, Missouri
| | - Alvin Janski
- Department of Psychiatry, Washington University School of Medicine in St Louis, Missouri
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine in St Louis and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St Louis, Missouri
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine in St Louis and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St Louis, Missouri
| |
Collapse
|
5
|
Sackeim HA, Rush AJ, Greco T, Jiang M, Badejo S, Bunker MT, Aaronson ST, Conway CR, Demyttenaere K, Young AH, McAllister-Williams RH. Alternative metrics for characterizing longer-term clinical outcomes in difficult-to-treat depression: I. Association with change in quality of life. Psychol Med 2023; 53:1-13. [PMID: 36601813 PMCID: PMC10600942 DOI: 10.1017/s0033291722003798] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/24/2022] [Accepted: 11/29/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND In difficult-to-treat depression (DTD) the outcome metrics historically used to evaluate treatment effectiveness may be suboptimal. Metrics based on remission status and on single end-point (SEP) assessment may be problematic given infrequent symptom remission, temporal instability, and poor durability of benefit in DTD. METHODS Self-report and clinician assessment of depression symptom severity were regularly obtained over a 2-year period in a chronic and highly treatment-resistant registry sample (N = 406) receiving treatment as usual, with or without vagus nerve stimulation. Twenty alternative metrics for characterizing symptomatic improvement were evaluated, contrasting SEP metrics with integrative (INT) metrics that aggregated information over time. Metrics were compared in effect size and discriminating power when contrasting groups that did (N = 153) and did not (N = 253) achieve a threshold level of improvement in end-point quality-of-life (QoL) scores, and in their association with continuous QoL scores. RESULTS Metrics based on remission status had smaller effect size and poorer discrimination of the binary QoL outcome and weaker associations with the continuous end-point QoL scores than metrics based on partial response or response. The metrics with the strongest performance characteristics were the SEP measure of percentage change in symptom severity and the INT metric quantifying the proportion of the observation period in partial response or better. Both metrics contributed independent variance when predicting end-point QoL scores. CONCLUSIONS Revision is needed in the metrics used to quantify symptomatic change in DTD with consideration of INT time-based measures as primary or secondary outcomes. Metrics based on remission status may not be useful.
Collapse
Affiliation(s)
- Harold A. Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY, USA
| | - A. John Rush
- Duke-NUS Medical School, Singapore
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Teresa Greco
- LivaNova PLC, Milan, Italy
- Jazz Pharmaceuticals PLC, Milan, Italy
| | - Mei Jiang
- LivaNova USA PLC, Minneapolis, MN, USA
| | | | | | - Scott T. Aaronson
- Department of Clinical Research, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Charles R. Conway
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA
| | - Koen Demyttenaere
- Faculty of Medicine KU Leuven, University Psychiatric Center KU Leuven, Leuven, Belgium
| | - Allan H. Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - R. Hamish McAllister-Williams
- Northern Centre for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, UK, and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
6
|
Izumi Y, Hsu FF, Conway CR, Nagele P, Mennerick SJ, Zorumski CF. Nitrous Oxide, a Rapid Antidepressant, Has Ketamine-like Effects on Excitatory Transmission in the Adult Hippocampus. Biol Psychiatry 2022; 92:964-972. [PMID: 36050137 PMCID: PMC10107749 DOI: 10.1016/j.biopsych.2022.06.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 02/16/2022] [Revised: 06/03/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Nitrous oxide (N2O) is a noncompetitive inhibitor of NMDA receptors that appears to have ketamine-like rapid antidepressant effects in patients with treatment-resistant major depression. In preclinical studies, ketamine enhances glutamate-mediated synaptic transmission in the hippocampus and prefrontal cortex. In this study, we examined the effects of N2O on glutamate transmission in the hippocampus and compared its effects to those of ketamine. METHODS Glutamate-mediated synaptic transmission was studied in the CA1 region of hippocampal slices from adult albino rats using standard extracellular recording methods. Effects of N2O and ketamine at subanesthetic concentrations were evaluated by acute administration. RESULTS Akin to 1 μM ketamine, 30% N2O administered for 15-20 minutes resulted in persistent enhancement of synaptic responses mediated by both AMPA receptors and NMDA receptors. Synaptic enhancement by both N2O and ketamine was blocked by co-administration of a competitive NMDA receptor antagonist at saturating concentration, but only ketamine was blocked by an AMPA receptor antagonist. Synaptic enhancement by both agents involved TrkB (tropomyosin receptor kinase B), mTOR (mechanistic target of rapamycin), and NOS (nitric oxide synthase) with some differences between N2O and ketamine. N2O potentiation occluded enhancement by ketamine, and in vivo N2O exposure occluded further potentiation by both N2O and ketamine. CONCLUSIONS These results indicate that N2O has ketamine-like effects on hippocampal synaptic function at a subanesthetic, but therapeutically relevant concentration. These 2 rapid antidepressants have similar, but not identical mechanisms that result in persisting synaptic enhancement, possibly contributing to psychotropic actions.
Collapse
Affiliation(s)
- Yukitoshi Izumi
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, Missouri; Center for Brain Research in Mood Disorders, Washington University School of Medicine, St. Louis, Missouri
| | - Fong-Fu Hsu
- Department of Medicine and Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Charles R Conway
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, Missouri; Center for Brain Research in Mood Disorders, Washington University School of Medicine, St. Louis, Missouri
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Steven J Mennerick
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, Missouri; Center for Brain Research in Mood Disorders, Washington University School of Medicine, St. Louis, Missouri
| | - Charles F Zorumski
- Department of Psychiatry and Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, Missouri; Center for Brain Research in Mood Disorders, Washington University School of Medicine, St. Louis, Missouri.
| |
Collapse
|
7
|
Conway CR, Sackeim HA. Interventional psychiatry: the revolution has arrived. Braz J Psychiatry 2022; 44:570-571. [PMID: 36099314 PMCID: PMC9851766 DOI: 10.47626/1516-4446-2022-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Charles R. Conway
- School of Medicine, Department of Psychiatry, Washington University, St. Louis, MO, USA,Correspondence: Charles R. Conway, Department of Psychiatry, School of Medicine, Washington University, MSC 8134-17-04, 660 South Euclid Ave, Saint Louis, MO 63110, USA. E-mail:
| | - Harold A. Sackeim
- Department of Psychiatry, Columbia University, New York, NY, USA,Department of Radiology, Columbia University, New York, NY, USA
| |
Collapse
|
8
|
Conway CR, Hristidis VC, Gott BM, Willie J. Vagus Nerve Stimulation for Treatment-Resistant Depression: Current Status of This Novel Treatment. Psychiatr Ann 2022. [DOI: 10.3928/00485713-20220620-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
9
|
Rush AJ, Sackeim HA, Conway CR, Bunker MT, Hollon SD, Demyttenaere K, Young AH, Aaronson ST, Dibué M, Thase ME, McAllister-Williams RH. Clinical research challenges posed by difficult-to-treat depression. Psychol Med 2022; 52:419-432. [PMID: 34991768 PMCID: PMC8883824 DOI: 10.1017/s0033291721004943] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [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] [Received: 06/30/2021] [Revised: 11/02/2021] [Accepted: 11/09/2021] [Indexed: 12/13/2022]
Abstract
Approximately one-third of individuals in a major depressive episode will not achieve sustained remission despite multiple, well-delivered treatments. These patients experience prolonged suffering and disproportionately utilize mental and general health care resources. The recently proposed clinical heuristic of 'difficult-to-treat depression' (DTD) aims to broaden our understanding and focus attention on the identification, clinical management, treatment selection, and outcomes of such individuals. Clinical trial methodologies developed to detect short-term therapeutic effects in treatment-responsive populations may not be appropriate in DTD. This report reviews three essential challenges for clinical intervention research in DTD: (1) how to define and subtype this heterogeneous group of patients; (2) how, when, and by what methods to select, acquire, compile, and interpret clinically meaningful outcome metrics; and (3) how to choose among alternative clinical trial design options to promote causal inference and generalizability. The boundaries of DTD are uncertain, and an evidence-based taxonomy and reliable assessment tools are preconditions for clinical research and subtyping. Traditional outcome metrics in treatment-responsive depression may not apply to DTD, as they largely reflect the only short-term symptomatic change and do not incorporate durability of benefit, side effect burden, or sustained impact on quality of life or daily function. The trial methodology will also require modification as trials will likely be of longer duration to examine the sustained impact, raising complex issues regarding control group selection, blinding and its integrity, and concomitant treatments.
Collapse
Affiliation(s)
- A. John Rush
- Duke-NUS Medical School, Singapore
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Psychiatry, Texas Tech University, Permian Basin, TX, USA
| | - Harold A. Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY, USA
| | - Charles R. Conway
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Steven D. Hollon
- Departments of Psychology and Psychiatry, Vanderbilt University, Nashville, TN, USA
| | - Koen Demyttenaere
- University Psychiatric Center, KU Leuven, Leuven, Belgium
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Allan H. Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
| | - Scott T. Aaronson
- Department of Clinical Research, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Maxine Dibué
- Department of Neurosurgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Medical Affairs Europe, LivaNova Deutschland GmbH, Munich, Germany
| | - Michael E. Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - R. Hamish McAllister-Williams
- Northern Centre for Mood Disorders, Newcastle University, Newcastle upon Tyne, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
10
|
Kamel LY, Xiong W, Gott BM, Kumar A, Conway CR. Vagus nerve stimulation: An update on a novel treatment for treatment-resistant depression. J Neurol Sci 2022; 434:120171. [DOI: 10.1016/j.jns.2022.120171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/21/2021] [Accepted: 01/21/2022] [Indexed: 12/11/2022]
|
11
|
Quach DF, de Leon VC, Conway CR. Nitrous Oxide: an emerging novel treatment for treatment-resistant depression. J Neurol Sci 2021; 434:120092. [PMID: 34953347 DOI: 10.1016/j.jns.2021.120092] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/03/2021] [Accepted: 12/12/2021] [Indexed: 10/19/2022]
Abstract
Stemming from the results of the historic STAR-D trial, it is evident that a significant subset of individuals (20-25%) with major depressive disorder (MDD) do not respond to conventional antidepressant medications. As a result, an emphasis has been placed on the development of novel therapeutics for MDD over the last two decades. Recently, substantial research efforts have been focused on the use of ketamine as an antidepressant whose mechanism of action is via the N-methyl-d-aspartate (NMDA) receptor. Another potential therapeutic compound of interest is nitrous oxide, which has been utilized for more than a century in multiple fields of medicine for its analgesic and anesthetic properties. Recent clinical studies suggest that nitrous oxide may be effective for treatment-resistant depression. In this review, we will discuss the administration of nitrous oxide as a psychiatric intervention, current use in psychiatry, putative mechanisms of action, and future directions highlighting knowledge gaps and other potential utilities in the field of psychiatry.
Collapse
Affiliation(s)
- Darin F Quach
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, United States of America
| | - Victoria C de Leon
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, United States of America
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, United States of America.
| |
Collapse
|
12
|
Rush AJ, Sackeim HA, Conway CR, Bunker MT, Hollon SD, Demyttenaere K, Young AH, Aaronson ST, Dibue M, Thase ME. Research challenges in chronic diseases: Difficult to treat depression. Brain Stimul 2021. [DOI: 10.1016/j.brs.2021.10.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
13
|
McAllister-Williams RH, Aaronson ST, Conway CR, Demyttenaere K, Fitzgerald PB, Loo CK, Mitchell PB, Rush AJ, Sackeim HA, Young AH. The ‘difficult-to-treat depression’ and the ‘response paradigm’ models: Implications and relevance to patient management. Aust N Z J Psychiatry 2021; 55:824-825. [PMID: 33971766 PMCID: PMC8317230 DOI: 10.1177/00048674211013090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- RH McAllister-Williams
- Northern Centre for Mood Disorders, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK,Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK,RH McAllister-Williams, Northern Centre for Mood Disorders, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK.
| | - ST Aaronson
- Department of Clinical Research, Sheppard Pratt Health System, Baltimore, MD, USA
| | - CR Conway
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MI, USA
| | - K Demyttenaere
- Faculty of Medicine, University Psychiatric Center, KU Leuven, Leuven, Belgium
| | - PB Fitzgerald
- Epworth Healthcare, The Epworth Clinic, Melbourne, VIC, Australia,Department of Psychiatry, Monash University, Melbourne, VIC, Australia
| | - CK Loo
- School of Psychiatry, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia,Black Dog Institute, Sydney, NSW, Australia
| | - PB Mitchell
- School of Psychiatry, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - AJ Rush
- Duke University School of Medicine, Durham, NC, USA,Texas Tech University Health Sciences Center, Midland, TX, USA,Duke-NUS Medical School, Singapore
| | - HA Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY, USA
| | - AH Young
- Department of Psychological Medicine, South London and Maudsley NHS Foundation Trust, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| |
Collapse
|
14
|
Nagele P, Palanca BJ, Gott B, Brown F, Barnes L, Nguyen T, Xiong W, Salloum NC, Espejo GD, Lessov-Schlaggar CN, Jain N, Cheng WWL, Komen H, Yee B, Bolzenius JD, Janski A, Gibbons R, Zorumski CF, Conway CR. A phase 2 trial of inhaled nitrous oxide for treatment-resistant major depression. Sci Transl Med 2021; 13:13/597/eabe1376. [PMID: 34108247 DOI: 10.1126/scitranslmed.abe1376] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/19/2020] [Accepted: 04/23/2021] [Indexed: 12/26/2022]
Abstract
Nitrous oxide at 50% inhaled concentration has been shown to improve depressive symptoms in patients with treatment-resistant major depression (TRMD). Whether a lower concentration of 25% nitrous oxide provides similar efficacy and persistence of antidepressant effects while reducing the risk of adverse side effects is unknown. In this phase 2 clinical trial (NCT03283670), 24 patients with severe TRMD were randomly assigned in a crossover fashion to three treatments consisting of a single 1-hour inhalation with (i) 50% nitrous oxide, (ii) 25% nitrous oxide, or (iii) placebo (air/oxygen). The primary outcome was the change on the Hamilton Depression Rating Scale (HDRS-21). Whereas nitrous oxide significantly improved depressive symptoms versus placebo (P = 0.01), there was no difference between 25 and 50% nitrous oxide (P = 0.58). The estimated differences between 25% and placebo were -0.75 points on the HDRS-21 at 2 hours (P = 0.73), -1.41 points at 24 hours (P = 0.52), -4.35 points at week 1 (P = 0.05), and -5.19 points at week 2 (P = 0.02), and the estimated differences between 50% and placebo were -0.87 points at 2 hours (P = 0.69), -1.93 points at 24 hours (P = 0.37), -2.44 points at week 1 (P = 0.25), and -7.00 points at week 2 (P = 0.001). Adverse events declined substantially with dose (P < 0.001). These results suggest that 25% nitrous oxide has comparable efficacy to 50% nitrous oxide in improving TRMD but with a markedly lower rate of adverse effects.
Collapse
Affiliation(s)
- Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA.
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Britt Gott
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Frank Brown
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA
| | - Linda Barnes
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Thomas Nguyen
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Willa Xiong
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Naji C Salloum
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gemma D Espejo
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | | | - Nisha Jain
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL 60637, USA
| | - Wayland W L Cheng
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Helga Komen
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Branden Yee
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jacob D Bolzenius
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Alvin Janski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Robert Gibbons
- Center for Health Statistics, University of Chicago, Chicago, IL 60637, USA
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA.,Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA.,Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO 63110, USA
| |
Collapse
|
15
|
Rothschild AJ, Parikh SV, Hain D, Law R, Thase ME, Dunlop BW, DeBattista C, Conway CR, Forester BP, Shelton RC, Macaluso M, Brown K, Lewis D, Gutin A, Jablonski MR, Greden JF. Clinical validation of combinatorial pharmacogenomic testing and single-gene guidelines in predicting psychotropic medication blood levels and clinical outcomes in patients with depression. Psychiatry Res 2021; 296:113649. [PMID: 33360967 DOI: 10.1016/j.psychres.2020.113649] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 09/25/2020] [Accepted: 12/12/2020] [Indexed: 12/13/2022]
Abstract
We evaluated the clinical validity of a combinatorial pharmacogenomic test and single-gene Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines against patient outcomes and medication blood levels to assess their ability to inform prescribing in major depressive disorder (MDD). This is a secondary analysis of the Genomics Used to Improve DEpression Decisions (GUIDED) randomized-controlled trial, which included patients with a diagnosis of MDD, and ≥1 prior medication failure. The ability to predict increased/decreased medication metabolism was validated against blood levels at screening (adjusted for age, sex, smoking status). The ability of predicted gene-drug interactions (pharmacogenomic test) or therapeutic recommendations (single-gene guidelines) to predict patient outcomes was validated against week 8 outcomes (17-item Hamilton Depression Rating Scale; symptom improvement, response, remission). Analyses were performed for patients taking any eligible medication (outcomes N=1,022, blood levels N=1,034) and the subset taking medications with single-gene guidelines (outcomes N=584, blood levels N=372). The combinatorial pharmacogenomic test was the only significant predictor of patient outcomes. Both the combinatorial pharmacogenomic test and single-gene guidelines were significant predictors of blood levels for all medications when evaluated separately; however, only the combinatorial pharmacogenomic test remained significant when both were included in the multivariate model. There were no substantial differences when all medications were evaluated or for the subset with single-gene guidelines. Overall, this evaluation of clinical validity demonstrates that the combinatorial pharmacogenomic test was a superior predictor of patient outcomes and medication blood levels when compared with guidelines based on individual genes.
Collapse
Affiliation(s)
- Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester, MA 01655, United States.
| | - Sagar V Parikh
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, Ann Arbor, MI 48109, United States
| | - Daniel Hain
- Myriad Neuroscience, Mason, OH 45040, United States
| | - Rebecca Law
- Myriad Neuroscience, Mason, OH 45040, United States
| | - Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania and the Corporal Michael Crescenz VAMC, Philadelphia, PA 19104, United States
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, and the John Cochran Veteran's Administration Hospital, St. Louis, MO 63110, United States
| | - Brent P Forester
- McLean Hospital, Division of Geriatric Psychiatry, Belmont, MA 02478, United States; Harvard Medical School, Boston, MA, United States
| | - Richard C Shelton
- Department of Psychiatry and Behavioral Neurobiology and School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew Macaluso
- Department of Psychiatry and Behavioral Neurobiology and School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Krystal Brown
- Myriad Genetics, Inc., Salt Lake City, UT 84108, United States
| | - David Lewis
- Myriad Neuroscience, Mason, OH 45040, United States
| | - Alexander Gutin
- Myriad Genetics, Inc., Salt Lake City, UT 84108, United States
| | | | - John F Greden
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, Ann Arbor, MI 48109, United States
| |
Collapse
|
16
|
Forester BP, Parikh SV, Weisenbach S, Ajilore O, Vahia I, Rothschild AJ, Thase ME, Dunlop BW, DeBattista C, Conway CR, Shelton RC, Macaluso M, Li J, Traxler P, Logan J, Brown L, Dechairo B, Greden JF. Combinatorial Pharmacogenomic Testing Improves Outcomes for Older Adults With Depression. Focus (Am Psychiatr Publ) 2021; 19:76-85. [PMID: 34483773 PMCID: PMC8412149 DOI: 10.1176/appi.focus.19107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
(Reprinted with permission from Am J Geriatr Psychiatry 2020; 28:933-945).
Collapse
|
17
|
Forester BP, Parikh SV, Weisenbach S, Ajilore O, Vahia I, Rothschild AJ, Thase ME, Dunlop BW, DeBattista C, Conway CR, Shelton RC, Macaluso M, Li J, Traxler P, Logan J, Brown L, Dechairo B, Greden JF. Combinatorial Pharmacogenomic Testing Improves Outcomes for Older Adults With Depression. Am J Geriatr Psychiatry 2020; 28:933-945. [PMID: 32513518 DOI: 10.1016/j.jagp.2020.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 12/30/2019] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Evaluate the clinical utility of combinatorial pharmacogenomic testing for informing medication selection among older adults who have experienced antidepressant medication failure for major depressive disorder (MDD). DESIGN Post hoc analysis of data from a blinded, randomized controlled trial comparing two active treatment arms. SETTING Psychiatry specialty and primary care clinics across 60 U.S. community and academic sites. PARTICIPANTS Adults age 65 years or older at baseline (n = 206), diagnosed with MDD and inadequate response to at least one medication on the combinatorial pharmacogenomic test report during the current depressive episode. INTERVENTION Combinatorial pharmacogenomic testing to inform medication selection (guided-care), compared with treatment as usual (TAU). OUTCOMES Mean percent symptom improvement, response rate, and remission rateat week 8, measured using the 17-item Hamilton Depression Rating Scale; medication switching; and comorbidity moderator analysis. RESULTS At week 8, symptom improvement was not significantly different for guided-care than for TAU (∆ = 8.1%, t = 1.64, df = 187; p = 0.102); however, guided-care showed significantly improved response (∆ = 13.6%, t = 2.16, df = 187; p = 0.032) and remission (∆ = 12.7%, t = 2.49, df = 189; p = 0.014) relative to TAU. By week 8, more than twice as many patients in guided-care than in TAU were on medications predicted to have no gene-drug interactions (χ2 = 19.3, df = 2; p <0.001). Outcomes in the guided-care arm showed consistent improvement through the end of the open-design 24-week trial, indicating durability of the effect. Differences in outcomes between arms were not significantly impacted by comorbidities. CONCLUSIONS Combinatorial pharmacogenomic test-informed medication selection improved outcomes over TAU among older adults with depression.
Collapse
Affiliation(s)
- Brent P Forester
- Division of Geriatric Psychiatry (BPF, IV), McLean Hospital, Harvard Medical School, Belmont, MA.
| | - Sagar V Parikh
- University of Michigan Comprehensive Depression Center and Department of Psychiatry (SVP, JFG), National Network of Depression Centers, Ann Arbor, MI
| | - Sara Weisenbach
- Stony Brook University, Department of Psychiatry & Behavioral Health (SW), Stony Brook, NY
| | - Olusola Ajilore
- University of Illinois at Chicago, School of Public Health/Psychiatric Institute (OJ), Chicago, IL
| | - Ipsit Vahia
- Division of Geriatric Psychiatry (BPF, IV), McLean Hospital, Harvard Medical School, Belmont, MA
| | - Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial Healthcare (AJR), Worcester, MA
| | - Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania, the Corporal Michael Crescenz VAMC (MET), Philadelphia, PA
| | - Boadie W Dunlop
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences (BWD), Atlanta, GA
| | - Charles DeBattista
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences (CDB), Stanford, CA
| | - Charles R Conway
- Washington University School of Medicine, Department of Psychiatry, and the John Cochran Veteran's Administration Hospital (CRC), St. Louis, MO
| | - Richard C Shelton
- The University of Alabama at Birmingham, Department of Psychiatry and School of Medicine (RCS), Birmingham, AL
| | - Matthew Macaluso
- University of Kansas School of Medicine-Wichita, Department of Psychiatry and Behavioral Sciences (MM), Wichita, KS
| | - James Li
- Assurex Health, Inc./Myriad Neuroscience (PT, LB), Mason, OH
| | - Paul Traxler
- Assurex Health, Inc./Myriad Neuroscience (PT, LB), Mason, OH
| | | | - Lisa Brown
- Assurex Health, Inc./Myriad Neuroscience (PT, LB), Mason, OH
| | | | - John F Greden
- University of Michigan Comprehensive Depression Center and Department of Psychiatry (SVP, JFG), National Network of Depression Centers, Ann Arbor, MI
| |
Collapse
|
18
|
Conway CR, Olin B, Aaronson ST, Sackeim HA, Bunker M, Kriedt C, Greco T, Broglio K, Vestrucci M, Rush AJ. A prospective, multi-center randomized, controlled, blinded trial of vagus nerve stimulation for difficult to treat depression: A novel design for a novel treatment. Contemp Clin Trials 2020; 95:106066. [DOI: 10.1016/j.cct.2020.106066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 02/07/2023]
|
19
|
Shelton RC, Parikh SV, Law RA, Rothschild AJ, Thase ME, Dunlop BW, DeBattista C, Conway CR, Forester BP, Macaluso M, Hain DT, Aguilar AL, Brown K, Lewis DJ, Jablonski MR, Greden JF. Combinatorial Pharmacogenomic Algorithm is Predictive of Citalopram and Escitalopram Metabolism in Patients with Major Depressive Disorder. Psychiatry Res 2020; 290:113017. [PMID: 32485484 DOI: 10.1016/j.psychres.2020.113017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 12/04/2019] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/16/2022]
Abstract
Pharmacogenomic tests used to guide clinical treatment for major depressive disorder (MDD) must be thoroughly validated. One important assessment of validity is the ability to predict medication blood levels, which reflect altered metabolism. Historically, the metabolic impact of individual genes has been evaluated; however, we now know that multiple genes are often involved in medication metabolism. Here, we evaluated the ability of individual pharmacokinetic genes (CYP2C19, CYP2D6, CYP3A4) and a combinatorial pharmacogenomic test (GeneSight Psychotropic®; weighted assessment of all three genes) to predict citalopram/escitalopram blood levels in patients with MDD. Patients from the Genomics Used to Improve DEpression Decisions (GUIDED) trial who were taking citalopram/escitalopram at screening and had available blood level data were included (N=191). In multivariate analysis of the individual genes and combinatorial pharmacogenomic test separately (adjusted for age, smoking status), the F statistic for the combinatorial pharmacogenomic test was 1.7 to 2.9-times higher than the individual genes, showing that it explained more variance in citalopram/escitalopram blood levels. In multivariate analysis of the individual genes and combinatorial pharmacogenomic test together, only the combinatorial pharmacogenomic test remained significant. Overall, this demonstrates that the combinatorial pharmacogenomic test was a superior predictor of citalopram/escitalopram blood levels compared to individual genes.
Collapse
Affiliation(s)
- Richard C Shelton
- Department of Psychiatry and School of Medicine, The University of Alabama at Birmingham, Birmingham, AL.
| | - Sagar V Parikh
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, Ann Arbor, MI
| | | | - Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester, MA
| | - Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania and the Corporal Michael Crescenz VAMC, Philadelphia, PA
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Charles DeBattista
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, CA
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, and the John Cochran Veteran's Administration Hospital, St. Louis, MO
| | - Brent P Forester
- McLean Hospital, Division of Geriatric Psychiatry, Belmont, MA; Harvard Medical School
| | - Matthew Macaluso
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS
| | | | | | | | | | | | - John F Greden
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, Ann Arbor, MI
| |
Collapse
|
20
|
McAllister-Williams RH, Sousa S, Kumar A, Greco T, Bunker MT, Aaronson ST, Conway CR, Rush AJ. The effects of vagus nerve stimulation on the course and outcomes of patients with bipolar disorder in a treatment-resistant depressive episode: a 5-year prospective registry. Int J Bipolar Disord 2020; 8:13. [PMID: 32358769 PMCID: PMC7195501 DOI: 10.1186/s40345-020-0178-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 09/03/2019] [Accepted: 01/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare illness characteristics, treatment history, response and durability, and suicidality scores over a 5-year period in patients with treatment-resistant bipolar depression participating in a prospective, multicenter, open-label registry and receiving Vagus Nerve Stimulation Therapy (VNS Therapy) plus treatment-as-usual (VNS + TAU) or TAU alone. METHODS Response was defined as ≥ 50% decrease from baseline Montgomery-Åsberg Depression Rating Scale (MADRS) total score at 3, 6, 9, or 12 months post-baseline. Response was retained while MADRS score remained ≥ 40% lower than baseline. Time-to-events was estimated using Kaplan-Meier (KM) analysis and compared using log-rank test. Suicidality was assessed using the MADRS Item 10 score. RESULTS At baseline (entry into registry), the VNS + TAU group (N = 97) had more episodes of depression, psychiatric hospitalizations, lifetime suicide attempts and higher suicidality score, more severe symptoms (based on MADRS and other scales), and higher rate of prior electroconvulsive therapy than TAU group (N = 59). Lifetime use of medications was similar between the groups (a mean of 9) and was consistent with the severe treatment-resistant nature of their depression. Over 5 years, 63% (61/97) in VNS + TAU had an initial response compared with 39% (23/59) in TAU. The time-to-initial response was significantly quicker for VNS + TAU than for TAU (p < 0.03). Among responders in the first year after implant, the KM estimate of the median time-to-relapse from initial response was 15.2 vs 7.6 months for VNS + TAU compared with TAU (difference was not statistically significant). The mean reduction in suicidality score across the study visits was significantly greater in the VNS + TAU than in the TAU group (p < 0.001). CONCLUSIONS The patients who received VNS + TAU included in this analysis had severe bipolar depression that had proved extremely difficult to treat. The TAU comparator group were similar though had slightly less severe illnesses on some measures and had less history of suicide attempts. Treatment with VNS + TAU was associated with a higher likelihood of attaining a response compared to TAU alone. VNS + TAU was also associated with a significantly greater mean reduction in suicidality. LIMITATIONS In this registry study, participants were not randomized to the study treatment group, VNS Therapy stimulation parameters were not controlled, and there was a high attrition rate over 5 years. Trial registration ClinicalTrials.gov NCT00320372. Registered 3 May 2006, https://clinicaltrials.gov/ct2/show/NCT00320372 (retrospectively registered).
Collapse
Affiliation(s)
- R Hamish McAllister-Williams
- Northern Centre for Mood Disorders, Newcastle University, Newcastle upon Tyne, UK. .,Regional Affective Disorders Service, Cumbria, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Soraia Sousa
- Northern Centre for Mood Disorders, Newcastle University, Newcastle upon Tyne, UK.,Regional Affective Disorders Service, Cumbria, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | | | - Scott T Aaronson
- Department of Clinical Research, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - A John Rush
- Duke-National University of Singapore, Singapore, Singapore.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Psychiatry, Health Sciences Center, Texas Tech University Permian Basin, Midland, TX, USA
| |
Collapse
|
21
|
Kalmoe MC, Janski AM, Zorumski CF, Nagele P, Palanca BJ, Conway CR. Ketamine and nitrous oxide: The evolution of NMDA receptor antagonists as antidepressant agents. J Neurol Sci 2020; 412:116778. [PMID: 32240970 DOI: 10.1016/j.jns.2020.116778] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [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: 08/23/2019] [Revised: 02/20/2020] [Accepted: 03/14/2020] [Indexed: 12/19/2022]
Abstract
N-methyl-d-aspartate receptor (NMDAR) antagonists, including ketamine and nitrous oxide, are currently intensely studied as rapid-acting antidepressant agents. Interestingly, both of these compounds are also drugs of abuse. Intravenous ketamine, a dissociative anesthetic that induces complex downstream effects via NMDARs, rapidly reduces depressive and suicidal symptoms in treatment-resistant depression (TRD), as demonstrated by several trials. Recently, the United States Food and Drug Administration (FDA) approved an intranasal version of ketamine (esketamine) for TRD. The United States Drug Enforcement Agency (DEA) lists ketamine as a Class III scheduled drug (moderate-low potential for physical and psychological abuse). The FDA has established a Risk Evaluation and Management Strategy (REMS) program to ensure proper drug storage, handling, dispensing, and monitoring intranasal esketamine to minimize misuse/abuse opportunities. Nitrous Oxide is a colorless, odorless, gas that has been in medical use for over 150 years. The mechanisms of action of nitrous oxide are not fully understood; however, it is known to act as a non-competitive inhibitor of NMDA-type glutamate receptors. Currently, nitrous oxide is used for inhalational general anesthesia and analgesia for short procedures. Inhaled nitrous oxide is also used recreationally, primarily by teens and young adults, but is not believed to have strong addiction potential. In contrast to ketamine, nitrous oxide is not a controlled substance and can be legally purchased without a prescription. A recent double-blind, prospective, cross-over study demonstrated that nitrous oxide reduced depressive symptoms in a group of severely ill TRD patients. Though this is a promising initial study, further investigation is needed.
Collapse
Affiliation(s)
- Molly C Kalmoe
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Alvin M Janski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Peter Nagele
- Department of Anesthesia and Critical Care, The University of Chicago Medical Center, Chicago, IL, United States of America
| | - Ben J Palanca
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States of America.
| |
Collapse
|
22
|
Dunlop BW, Parikh SV, Rothschild AJ, Thase ME, DeBattista C, Conway CR, Forester BP, Mondimore FM, Shelton RC, Macaluso M, Logan J, Traxler P, Li J, Johnson H, Greden JF. Comparing sensitivity to change using the 6-item versus the 17-item Hamilton depression rating scale in the GUIDED randomized controlled trial. BMC Psychiatry 2019; 19:420. [PMID: 31881956 PMCID: PMC6935147 DOI: 10.1186/s12888-019-2410-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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] [Received: 06/28/2019] [Accepted: 12/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Previous research suggests that the 17-item Hamilton Depression Rating Scale (HAM-D17) is less sensitive in detecting differences between active treatment and placebo for major depressive disorder (MDD) than is the HAM-D6 scale, which focuses on six core depression symptoms. Whether HAM-D6 shows greater sensitivity when comparing two active MDD treatment arms is unknown. METHODS This post hoc analysis used data from the intent-to-treat (ITT) cohort (N = 1541) of the Genomics Used to Improve DEpression Decisions (GUIDED) trial, a rater- and patient-blinded randomized controlled trial. GUIDED compared combinatorial pharmacogenomics-guided care with treatment as usual (TAU) in patients with MDD. Percent of symptom improvement, response rate and remission rate from baseline to week 8 were evaluated using both scales. Analyses were performed for the full cohort and for the subset of patients who at baseline were taking medications predicted by the test to have moderate or significant gene-drug interactions. A Mokken scale analysis was conducted to compare the homogeneity of HAM-D17 with that of HAM-D6. RESULTS At week 8, the guided-care arm demonstrated statistically significant benefit over TAU when the HAM-D6 (∆ = 4.4%, p = 0.023) was used as the continuous measure of symptom improvement, but not when using the HAM-D17 (∆ = 3.2%, p = 0.069). Response rates increased significantly for guided-care compared with TAU when evaluated using both HAM-D6 (∆ = 7.0%, p = 0.004) and HAM-D17 (∆ = 6.3%, p = 0.007). Remission rates also were significantly greater for guided-care versus TAU using both measures (HAM-D6 ∆ = 4.6%, p = 0.031; HAM-D17 ∆ = 5.5%, p = 0.005). Patients in the guided-care arm who at baseline were taking medications predicted to have gene-drug interactions showed further increased benefit over TAU at week 8 for symptom improvement (∆ = 7.3%, p = 0.004) response (∆ = 10.0%, p = 0.001) and remission (∆ = 7.9%, p = 0.005) using HAM-D6. All outcomes showed continued improvement through week 24. Mokken scale analysis demonstrated the homogeneity and unidimensionality of HAM-D6, but not of HAM-D17, across treatment arms. CONCLUSIONS The HAM-D6 scale identified a statistically significant difference in symptom improvement between combinatorial pharmacogenomics-guided care and TAU, whereas the HAM-D17 did not. The demonstrated utility of pharmacogenomics-guided treatment over TAU as detected by the HAM-D6 highlights its value for future biomarker-guided trials comparing active treatment arms. TRIAL REGISTRATION Clinicaltrials.gov: NCT02109939. Registered 10 April 2014.
Collapse
Affiliation(s)
- Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Dr. NE, 3rd Floor, Atlanta, GA, 30329, USA.
| | - Sagar V Parikh
- Department of Psychiatry, and National Network of Depression Centers, University of Michigan Comprehensive Depression Center, Ann Arbor, MI, USA
| | - Anthony J Rothschild
- UMass Memorial Healthcare, University of Massachusetts Medical School, Worcester, MA, USA
| | - Michael E Thase
- The Corporal Michael Crescenz VAMC, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles R Conway
- Department of Psychiatry, and the John Cochran Veteran's Administration Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Brent P Forester
- McLean Hospital, Division of Geriatric Psychiatry, Harvard Medical School, Belmont, MA, USA
| | - Francis M Mondimore
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard C Shelton
- Department of Psychiatry and School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew Macaluso
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | | | - Paul Traxler
- Assurex Health, Inc./Myriad Neuroscience, Mason, OH, USA
| | - James Li
- Assurex Health, Inc./Myriad Neuroscience, Mason, OH, USA
| | - Holly Johnson
- Assurex Health, Inc./Myriad Neuroscience, Mason, OH, USA
| | - John F Greden
- Department of Psychiatry, and National Network of Depression Centers, University of Michigan Comprehensive Depression Center, Ann Arbor, MI, USA
| |
Collapse
|
23
|
Thase ME, Parikh SV, Rothschild AJ, Dunlop BW, DeBattista C, Conway CR, Forester BP, Mondimore FM, Shelton RC, Macaluso M, Li J, Brown K, Jablonski MR, Greden JF. Impact of Pharmacogenomics on Clinical Outcomes for Patients Taking Medications With Gene-Drug Interactions in a Randomized Controlled Trial. J Clin Psychiatry 2019; 80. [PMID: 31721487 DOI: 10.4088/jcp.19m12910] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of the Genomics Used to Improve DEpression Decisions (GUIDED) trial was to evaluate the utility of pharmacogenomic testing to improve outcomes among patients with major depressive disorder (MDD) who had not responded to at least 1 prior medication trial. The objective of the present analysis was to assess outcomes for the subset of patients expected to benefit from combinatorial pharmacogenomic testing because they were taking medications with predicted gene-drug interactions. METHODS Participants (enrolled from April 14, 2014, to February 10, 2017) had an inadequate response to at least 1 psychotropic medication in the current episode of MDD. Patients were randomized to treatment as usual (TAU) or the guided-care arm, in which clinicians had access to a combinatorial pharmacogenomic test report to inform medication selection. Patients and raters were blinded to study arm through week 8. The following outcomes were assessed using the 17-item Hamilton Depression Rating Scale (HDRS-17): symptom improvement (percent change in HDRS-17 score), response (≥ 50% decrease in HDRS-17 score), and remission (HDRS-17 score ≤ 7). In the GUIDED trial, the primary endpoint of symptom improvement did not reach significance in the intent-to-treat cohort (P = .069). Here, a post hoc analysis of patients who were taking medications subject to gene-drug interactions at baseline as predicted by combinatorial pharmacogenomic testing (N = 912) is presented. RESULTS Among participants taking medications subject to gene-drug interactions at baseline, outcomes at week 8 were significantly improved for those in the guided-care arm compared to TAU (symptom improvement: 27.1% versus 22.1%, P = .029; response: 27.0% versus 19.0%, P = .008; remission: 18.2% versus 10.7%, P = .003). When patients who switched medications were assessed, all outcomes were significantly improved in the guided-care arm compared to TAU (P = .011 for symptom improvement, P = .011 for response, P = .008 for remission). CONCLUSIONS By identifying and focusing on the patients with predicted gene-drug interactions, use of a combinatorial pharmacogenomic test significantly improved outcomes among patients with MDD who had at least 1 prior medication failure. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02109939.
Collapse
Affiliation(s)
- Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania, The Corporal Michael Crescenz VAMC, 3535 Market Street, Room 689, Philadelphia, PA 19104. .,Perelman School of Medicine of the University of Pennsylvania and the Corporal Michael Crescenz VAMC, Philadelphia, Pennsylvania, USA
| | - Sagar V Parikh
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, Ann Arbor, Michigan, USA
| | - Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial Healthcare, Worcester, Massachusetts, USA
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine, and the John Cochran Veteran's Administration Hospital, St Louis, Missouri, USA
| | - Brent P Forester
- Division of Geriatric Psychiatry, McLean Hospital, Harvard Medical School, Belmont, Massachusetts, USA
| | - Francis M Mondimore
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard C Shelton
- Department of Psychiatry and School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matthew Macaluso
- Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| | - James Li
- Assurex Health, Inc, Mason, Ohio, USA
| | | | | | - John F Greden
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, Ann Arbor, Michigan, USA
| |
Collapse
|
24
|
Abstract
Depression is one of the most disabling conditions in the world. In many cases patients continue to suffer with depressive disorders despite a series of adequate trials of medication and psychotherapy. Neuromodulation treatments offer a qualitatively different modality of treatment that can frequently prove efficacious in these treatment-refractory patients. The field of neuromodulation focuses on the use of electrical/electromagnetic energy, both invasively and noninvasively, to interface with and ultimately alter activity within the human brain for therapeutic purposes. These treatments provide another set of options to offer patients when clinically indicated, and knowledge of their safety, risks and benefits, and appropriate clinical application is essential for modern psychiatrists and other mental health professionals. Although neuromodulation techniques hold tremendous promise, only three such treatments are currently approved by the United States Food and Drug Administration (FDA) for the treatment of major depressive disorder: electroconvulsive therapy (ECT), vagus nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS). Additionally, numerous other neurostimulation modalities (deep brain stimulation [DBS], magnetic seizure therapy [MST], transcranial electric stimulation [tES], and trigeminal nerve stimulation [TNS]), though currently experimental, show considerable therapeutic promise. Researchers are actively looking for ways to optimize outcomes and clinical benefits by making neuromodulation treatments safer, more efficacious, and more durable.
Collapse
Affiliation(s)
| | - Willa Xiong
- Washington University School of Medicine, St. Louis, MO, USA
| | - Charles R Conway
- Washington University School of Medicine, St. Louis, MO, USA. .,John Cochran Division, VA St. Louis Health Care System, St. Louis, MO, USA.
| |
Collapse
|
25
|
Greden JF, Parikh SV, Rothschild AJ, Thase ME, Dunlop BW, DeBattista C, Conway CR, Forester BP, Mondimore FM, Shelton RC, Macaluso M, Li J, Brown K, Gilbert A, Burns L, Jablonski MR, Dechairo B. Response to: Goldberg et al. and Severance et al. Letters to the Editor: The clinical significance of improving remission over standard of care - The reality of treatment resistant-based therapies. J Psychiatr Res 2019; 114:211-213. [PMID: 31101328 DOI: 10.1016/j.jpsychires.2019.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- John F Greden
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, 4250 Plymouth Rd, Ann Arbor, MI, 48109, USA.
| | - Sagar V Parikh
- University of Michigan Comprehensive Depression Center and Department of Psychiatry, and National Network of Depression Centers, 4250 Plymouth Rd, Ann Arbor, MI, 48109, USA
| | - Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial Healthcare, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania and the Corporal Michael Crescenz VAMC, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Boadie W Dunlop
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park Dr NE #200, Atlanta, GA, 30329, USA
| | - Charles DeBattista
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 401 Quarry Rd, Stanford, CA, 94305, USA
| | - Charles R Conway
- Washington University School of Medicine, Department of Psychiatry, and the John Cochran Veteran's Administration Hospital, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Brent P Forester
- McLean Hospital, Division of Geriatric Psychiatry, Harvard Medical School, 115 Mill St, Belmont, MA, 02478, USA
| | - Francis M Mondimore
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Richard C Shelton
- The University of Alabama at Birmingham, Department of Psychiatry and School of Medicine, 1720 2nd Ave S, Birmingham, AL, USA
| | - Matthew Macaluso
- University of Kansas School of Medicine-Wichita, Department of Psychiatry and Behavioral Sciences, 1010 N Kansas St, Wichita, KS, 67214, USA
| | - James Li
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA
| | - Krystal Brown
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Alexa Gilbert
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA
| | - Lindsey Burns
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA
| | | | - Bryan Dechairo
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA; Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, 84108, USA
| |
Collapse
|
26
|
Sackeim HA, Aaronson ST, Bunker MT, Conway CR, Demitrack MA, George MS, Prudic J, Thase ME, Rush AJ. The assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF). J Psychiatr Res 2019; 113:125-136. [PMID: 30974339 DOI: 10.1016/j.jpsychires.2019.03.021] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [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] [Received: 12/18/2018] [Revised: 03/11/2019] [Accepted: 03/21/2019] [Indexed: 12/26/2022]
Abstract
There is considerable diversity in how treatment-resistant depression (TRD) is defined. However, every definition incorporates the concept that patients with TRD have not benefited sufficiently from one or more adequate trials of antidepressant treatment. This review examines the issues fundamental to the systematic evaluation of antidepressant treatment adequacy and resistance. These issues include the domains of interventions deemed effective in treatment of major depressive episodes (e.g., pharmacotherapy, brain stimulation, and psychotherapy), the subgroups of patients for whom distinct adequacy criteria are needed (e.g., bipolar vs. unipolar depression, psychotic vs. nonpsychotic depression), whether trials should be rated dichotomously as adequate or inadequate or on a potency continuum, whether combination and augmentation strategies require specific consideration, and the criteria used to evaluate the adequacy of treatment delivery (e.g., dose, duration), trial adherence, and clinical outcome. This review also presents the Antidepressant Treatment History Form: Short-Form (ATHF-SF), a completely revised version of an earlier instrument, and details how these fundamental issues were addressed in the ATHF-SF.
Collapse
Affiliation(s)
- Harold A Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY, USA.
| | - Scott T Aaronson
- Sheppard Pratt Health System and Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| | | | - Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | | | - Mark S George
- Departments of Psychiatry, Neurology, and Neuroscience, Medical University of South Carolina, Charleston, SC, USA
| | - Joan Prudic
- New York State Psychiatric Institute and Department of Psychiatry, Columbia University, New York, NY, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - A John Rush
- Duke-NUS Medical School, Singapore; Duke University, Durham, NC, USA; Texas Tech University, Permian Basin, TX, USA
| |
Collapse
|
27
|
O'Connor BJ, Conway CR. Continuation Therapies After Successful Treatment with Electroconvulsive Therapy in Major Depressive Disorder. Psychiatr Ann 2019. [DOI: 10.3928/00485713-20190314-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
28
|
Greden JF, Parikh SV, Rothschild AJ, Thase ME, Dunlop BW, DeBattista C, Conway CR, Forester BP, Mondimore FM, Shelton RC, Macaluso M, Li J, Brown K, Gilbert A, Burns L, Jablonski MR, Dechairo B. Impact of pharmacogenomics on clinical outcomes in major depressive disorder in the GUIDED trial: A large, patient- and rater-blinded, randomized, controlled study. J Psychiatr Res 2019; 111:59-67. [PMID: 30677646 DOI: 10.1016/j.jpsychires.2019.01.003] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/13/2018] [Accepted: 01/02/2019] [Indexed: 12/20/2022]
Abstract
Current prescribing practices for major depressive disorder (MDD) produce limited treatment success. Although pharmacogenomics may improve outcomes by identifying genetically inappropriate medications, studies to date were limited in scope. Outpatients (N = 1167) diagnosed with MDD and with a patient- or clinician-reported inadequate response to at least one antidepressant were enrolled in the Genomics Used to Improve DEpression Decisions (GUIDED) trial - a rater- and patient-blind randomized controlled trial. Patients were randomized to treatment as usual (TAU) or a pharmacogenomics-guided intervention arm in which clinicians had access to a pharmacogenomic test report to inform medication selections (guided-care). Medications were considered congruent ('use as directed' or 'use with caution' test categories) or incongruent ('use with increased caution and with more frequent monitoring' test category) with test results. Unblinding occurred after week 8. Primary outcome was symptom improvement [change in 17-item Hamilton Depression Rating Scale (HAM-D17)] at week 8; secondary outcomes were response (≥50% decrease in HAM-D17) and remission (HAM-D17 ≤ 7) at week 8. At week 8, symptom improvement for guided-care was not significantly different than TAU (27.2% versus 24.4%, p = 0.107); however, improvements in response (26.0% versus 19.9%, p = 0.013) and remission (15.3% versus 10.1%, p = 0.007) were statistically significant. Patients taking incongruent medications prior to baseline who switched to congruent medications by week 8 experienced greater symptom improvement (33.5% versus 21.1%, p = 0.002), response (28.5% versus 16.7%, p = 0.036), and remission (21.5% versus 8.5%, p = 0.007) compared to those remaining incongruent. Pharmacogenomic testing did not significantly improve mean symptoms but did significantly improve response and remission rates for difficult-to-treat depression patients over standard of care (ClinicalTrials.gov NCT02109939).
Collapse
Affiliation(s)
- John F Greden
- University of Michigan Department of Psychiatry and Comprehensive Depression Center 4250 Plymouth Rd, Ann Arbor, MI, 48109, USA.
| | - Sagar V Parikh
- University of Michigan Department of Psychiatry and Comprehensive Depression Center 4250 Plymouth Rd, Ann Arbor, MI, 48109, USA
| | - Anthony J Rothschild
- University of Massachusetts Medical School and UMass Memorial Healthcare, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Michael E Thase
- Perelman School of Medicine of the University of Pennsylvania and the Corporal Michael Crescenz VAMC, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Boadie W Dunlop
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park Dr NE #200, Atlanta, GA, 30329, USA
| | - Charles DeBattista
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 401 Quarry Rd, Stanford, CA, 94305, USA
| | - Charles R Conway
- Washington University School of Medicine, Department of Psychiatry, The John Cochran Veteran's Administration Hospital, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Brent P Forester
- McLean Hospital, Division of Geriatric Psychiatry, Harvard Medical School, 115 Mill St, Belmont, MA, 02478, USA
| | - Francis M Mondimore
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Richard C Shelton
- The University of Alabama at Birmingham, Department of Psychiatry and School of Medicine, 1720 2nd Ave S, Birmingham, AL, USA
| | - Matthew Macaluso
- University of Kansas School of Medicine-Wichita, Department of Psychiatry and Behavioral Sciences, 1010 N Kansas St, Wichita, KS, 67214, USA
| | - James Li
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA
| | - Krystal Brown
- Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Alexa Gilbert
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA
| | - Lindsey Burns
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA
| | | | - Bryan Dechairo
- Assurex Health, Inc., 6960 Cintas Blvd, Mason, OH, 45040, USA; Myriad Genetics, Inc., 320 Wakara Way, Salt Lake City, UT, 84108, USA
| |
Collapse
|
29
|
Trapp NT, Xiong W, Gott BM, Espejo GD, Bikson M, Conway CR. Proceedings #51: 4 mA Adaptive Transcranial Direct Current Stimulation for Treatment-Resistant Depression: Early Demonstration of Feasibility with a 20-Session Course. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
30
|
Kumar A, Bunker MT, Aaronson ST, Conway CR, Rothschild AJ, Mordenti G, Rush AJ. Durability of symptomatic responses obtained with adjunctive vagus nerve stimulation in treatment-resistant depression. Neuropsychiatr Dis Treat 2019; 15:457-468. [PMID: 30858703 PMCID: PMC6387594 DOI: 10.2147/ndt.s196665] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To compare the durations of response achieved with adjunctive vagus nerve stimulation (VNS + TAU) vs treatment as usual (TAU) alone in treatment-resistant depression (TRD) over a 5-year period in the TRD registry. MATERIALS AND METHODS Data from 271 participants on TAU and 328 participants on VNS + TAU were analyzed. Response was defined as ≥50% decrease in baseline Montgomery-Åsberg Depression Rating Scale (MADRS) score at postbaseline visit and was considered retained until the decrease was <40%. MADRS was obtained quarterly in year 1 and biannually thereafter. Time-to-events were estimated using Kaplan-Meier method and compared using log-rank test. HR was estimated using Cox proportion hazard model. RESULTS In the VNS + TAU arm, 62.5% (205/328) of participants had a first response over 5 years compared with 39.9% (108/271) in TAU. The time to first response was significantly shorter for VNS + TAU than for TAU (P<0.01). For responders in the first year, median time to relapse from first response was 10.1 months (Q1=4.2, Q3=31.5) for VNS + TAU vs 7.3 months (Q1=3.1, Q3=17.6) for TAU (P<0.01). HR=0.6 (95% CI: 0.4, 0.9) revealed a significantly lower chance for relapse in VNS + TAU. Probability of retaining first response for a year was 0.39 (0.27, 0.51) for TAU and 0.47 (0.38, 0.56) for VNS + TAU. Timing of the onset of the response did not impact the durability of the response. CONCLUSION VNS therapy added to TAU in severe TRD leads to rapid onset and higher likelihood of response, and a greater durability of the response as compared to TAU alone.
Collapse
Affiliation(s)
| | | | - Scott T Aaronson
- Department of Clinical Research, Sheppard Pratt Health System, Baltimore, MD, USA
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Anthony J Rothschild
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Psychiatry, UMass Memorial Medical Center, Worcester, MA, USA
| | | | - Augustus J Rush
- Department of Psychiatry and Behavioral Sciences, National University of Singapore, Singapore.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
31
|
Conway CR, Kumar A, Xiong W, Bunker M, Aaronson ST, Rush AJ. Chronic Vagus Nerve Stimulation Significantly Improves Quality of Life in Treatment-Resistant Major Depression. J Clin Psychiatry 2018; 79. [PMID: 30152645 DOI: 10.4088/jcp.18m12178] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To compare quality-of-life (QOL) change associated with treatment as usual (TAU, any antidepressant treatment) versus adjunctive vagus nerve stimulation treatment (VNS + TAU) in a population of patients with treatment-resistant depression (TRD) for 5 years. METHODS Self-reported QOL assessments, using the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF), were gathered in a multicenter, longitudinal registry (January 2006-May 2015) comparing the antidepressant efficacy of VNS + TAU versus TAU in TRD. All depressed patients (N = 599), with either unipolar or bipolar depression, met DSM-IV-TR major depressive episode criteria and failed at least 4 adequate antidepressant trials. The Montgomery-Asberg Depression Rating Scale (MADRS) was administered by blinded raters. Q-LES-Q-SF scores in the treatment arms were compared via linear regression; linear regression was employed to compare QOL differences with percent decrease in MADRS. A subanalysis comparing Q-LES-Q-SF functional domain change was performed. RESULTS 328 VNS + TAU and 271 TAU patients with TRD were compared. On average, VNS + TAU demonstrated a significant, comparative QOL advantage over TAU (as demonstrated via non-overlapping 95% confidence bands) that began at 3 months and was sustained through 5 years and was reinforced using a clinical global improvement measure. Patients receiving VNS + TAU, but not TAU alone, demonstrated a clinically meaningful QOL improvement (34% MADRS decrease) well below the classically defined antidepressant response (50% MADRS decrease). Exploratory post hoc subanalysis demonstrated that VNS + TAU had a significant advantage in multiple Q-LES-Q domains. CONCLUSION Compared to TAU, adjunctive VNS significantly improved QOL in TRD, and this QOL advantage was sustained. Further, TRD patients treated with VNS experienced clinically meaningful QOL improvements even with depression symptom reduction less than the conventional 50% reduction used to ascribe "response."
Collapse
Affiliation(s)
- Charles R Conway
- Department of Psychiatry, Washington University School of Medicine in St Louis, 660 S. Euclid Ave, Campus Box 8134, St Louis, MO 63110. .,Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Arun Kumar
- LivaNova PLC (Cyberonics, Inc), Houston, Texas, USA
| | - Willa Xiong
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Mark Bunker
- LivaNova PLC (Cyberonics, Inc), Houston, Texas, USA
| | - Scott T Aaronson
- Sheppard Pratt Health System Clinical Research Programs, Baltimore, Maryland, USA
| | - A John Rush
- Duke-National University of Singapore, Singapore.,Department of Psychiatry, Duke Medical School, Durham, North Carolina, USA.,Texas Tech University-Health Sciences Center, Permian Basin, Texas, USA
| |
Collapse
|
32
|
Bridgeman M, Prete D, Rolston N, Abazia D, Sturgill M, Finn L, Summers D, Marvanova M, Henkel P, Thompson J, Dewey M, Friesner D, Marvanova M, Alessi C, Cuellar L, Yamagishi L, O'Neil C, Erickson O, Mazzei K, Kamal K, Early N, Bainter B, Hanson L, Schmitz E, Loomis A, Norberto M, Hume A, Meyer M, Batra R, Likar D, Enguidanos S, Liu C, Kotansky B, Fisher A, Ruby CM, Pruskowski J, Karim SNA, Yong BSW, Alessi C, Cuellar L, Slattum P, Crouse E, Delafuente J, Donohoe K, Ogbonna K, Peron E, Powers K, Price E, Zimmerman K, Rahim S, Gendron T, Slattum P, Donohoe K, Cho C, Zimmerman K, Crouse E, Peron E, Powers K, Price E, Slattum P, Donohoe K, Elliott L, Minter C, Morin M, Marshall L, Stevens G, Cordaro C, Hill M, Nagy K, Kroustos KR, Sobota KF, Mahan R, Bailey T, Ioannou K, Mansour D, Thompson T, Chatellier K, Schwenk A, Ruby C, Chen TS, Li S, James M, Spilios M, Leschak A, Levine A, Forgette S, Oluigbo N, Szollosi D, Avalime D, Weaver SB, Maneno M, Ettienne E, Yi JY, Hart L, Gray S, Ozalas S, Miller K, Dave R, Bork J, Emmelhainz J, Adams K, Postolski J, Willoughby M, Feldman E, Braham K, Miller C, Barbagallo D, Seabury R, Noviasky J, Alessi C, Cuellar L, Dabhi J, Bartlett D, Le T, Simoni-Wastila L, Kuzucan A, Simoni-Wastila L, Le T, Park S, Simoni-Wastila L, Le T, Park S, Choi M, Simoni-Wastila L, Park S, Le T, Choi M, Simoni-Wastila L, Khokhar B, Choi M, Le T, Simoni-Wastila L, Brody P, Hejna M, Mason J, Graham M, Micceri J, Lypska R, Quinn B, Wilson H, Wahler R, Aloyo M, Tomm V, Hill A, Obringer A, Butterfoss K, Blak J, Balcer R, Boza J, Foster A, Shafique E, Kleven C, Wigle P, Brown B, Alessi C, Cuellar L, Meyer K, Mobley-Bukstein W, Singh H, Perez E, Mira AE, Kuehner W, Czechowski L, Cook H, Brandt N, Parson J, Fornaro R, Brandt N, Claeys K, Zarowitz B, Mansour D, McFadden C, Simpkins S, Ojowa F, Klutts A, Holmes S, Smith E, Cornman JR, Doran K, Resnick B, Brandt N, Umeozulu C, Williams A, Brandt N, Hennawi G, Thomas D, Gerber DK, Meyer K, Sharma K, Cooke C, Howard A, Chater R, Vogler A, Brandt N, Kennett-Hayes K, Elliott L, Engelbert J, Hargrave E, Bambico C, Patel K, Warriner C, Slattum P, Desai NR, Rowan CG, Alvarez P, Fogli J, Toto RD, Desai NR, Alvarez P, Fogli J, Reed P, Owens MK, Greden JF, Rothschild AJ, Zandy S, Thase M, Dunlop BW, DeBattista C, Conway CR, Forester BP, Mondimore FM, Shelton RC, Li J, Gilbert A, Burns L, Jablonski M, Dechairo B, Parikh S, Donohue J, Feldman G, Sethi S, Barnes C, Pendyala S, Bourdet D, Ferguson G, Barnes C, Pendyala S, Crater G, Fogli J, Mayo M, Gross C, Miyawa J, Ono R, Woods S, Garza D, Panov N, Fogli J, Moran E, Sabesan V, Wertman J, Ngim K. 2018 American Society of Consultant Pharmacists Annual Meeting & Exhibition. Consult Pharm 2017; 33:572-608. [PMID: 30322434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Poster abstracts are evaluated based on the following criteria: significance of the problem to healthy aging or medication management; innovativeness of ideas, methods, and/or approach; methodological rigor of methods and approach; presentation of finding; implications identified for future research, practice, and/or policy; and clarity of writing. Submissions are not evaluated through the peer-reviewed process used by The Consultant Pharmacist. Industry support is indicated, where applicable. Presenting author is in italics. The poster abstract presentation is supported by the ASCP Foundation.
Collapse
|
33
|
Salloum NC, Gott BM, Conway CR. Sustained remission in patients with treatment-resistant depression receiving vagal nerve stimulation: A case series. Brain Stimul 2017. [DOI: 10.1016/j.brs.2017.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
|
34
|
Aaronson ST, Sears P, Ruvuna F, Bunker M, Conway CR, Dougherty DD, Reimherr FW, Schwartz TL, Zajecka JM. A 5-Year Observational Study of Patients With Treatment-Resistant Depression Treated With Vagus Nerve Stimulation or Treatment as Usual: Comparison of Response, Remission, and Suicidality. Am J Psychiatry 2017; 174:640-648. [PMID: 28359201 DOI: 10.1176/appi.ajp.2017.16010034] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [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: 11/30/2022]
Abstract
OBJECTIVE The Treatment-Resistant Depression Registry investigated whether adjunctive vagus nerve stimulation (VNS) with treatment as usual in depression has superior long-term outcomes compared with treatment as usual only. METHOD This 5-year, prospective, open-label, nonrandomized, observational registry study was conducted at 61 U.S. sites and included 795 patients who were experiencing a major depressive episode (unipolar or bipolar depression) of at least 2 years' duration or had three or more depressive episodes (including the current episode), and who had failed four or more depression treatments (including ECT). Patients with a history of psychosis or rapid-cycling bipolar disorder were excluded. The primary efficacy measure was response rate, defined as a decrease of ≥50% in baseline Montgomery-Åsberg Depression Rating Scale (MADRS) score at any postbaseline visit during the 5-year study. Secondary efficacy measures included remission. RESULTS Patients had chronic moderate to severe depression at baseline (the mean MADRS score was 29.3 [SD=6.9] for the treatment-as-usual group and 33.1 [SD=7.0] for the adjunctive VNS group). The registry results indicate that the adjunctive VNS group had better clinical outcomes than the treatment-as-usual group, including a significantly higher 5-year cumulative response rate (67.6% compared with 40.9%) and a significantly higher remission rate (cumulative first-time remitters, 43.3% compared with 25.7%). A subanalysis demonstrated that among patients with a history of response to ECT, those in the adjunctive VNS group had a significantly higher 5-year cumulative response rate than those in the treatment-as-usual group (71.3% compared with 56.9%). A similar significant response differential was observed among ECT nonresponders (59.6% compared with 34.1%). CONCLUSIONS This registry represents the longest and largest naturalistic study of efficacy outcomes in treatment-resistant depression, and it provides additional evidence that adjunctive VNS has enhanced antidepressant effects compared with treatment as usual in this severely ill patient population.
Collapse
Affiliation(s)
- Scott T Aaronson
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - Peter Sears
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - Francis Ruvuna
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - Mark Bunker
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - Charles R Conway
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - Darin D Dougherty
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - Frederick W Reimherr
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - Thomas L Schwartz
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| | - John M Zajecka
- From the Sheppard Pratt Health System, Baltimore; Cyberonics, Inc., Houston; the Department of Psychiatry, Washington University in St. Louis; the Psychiatric Neuroscience Program, Massachusetts General Hospital, Boston; Psychiatric Behavior Solutions, Salt Lake City; the Department of Psychiatry, State University of New York Upstate Medical University, Syracuse; and the Department of Psychiatry, Rush University Medical Center, Chicago
| |
Collapse
|
35
|
Affiliation(s)
| | - Mark S George
- Medical University of South Carolina, Charleston3Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| | | |
Collapse
|
36
|
Affiliation(s)
- Charles F Zorumski
- Center for Brain Research in Mood Disorders, Department of Psychiatry, Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St Louis, Missouri2Department of Neuroscience, Washington University School of Medicine, St Louis, Missouri
| | - Charles R Conway
- Center for Brain Research in Mood Disorders, Department of Psychiatry, Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
37
|
Salloum NC, Walker MC, Gangwani S, Conway CR. Emergence of mania in two middle-aged patients with a history of unipolar treatment-refractory depression receiving vagus nerve stimulation. Bipolar Disord 2017; 19:60-64. [PMID: 28098427 DOI: 10.1111/bdi.12463] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 11/07/2016] [Accepted: 12/13/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES We report on two patients who experienced emergence of full manic symptoms while receiving vagal nerve stimulation (VNS). METHODS Two patients, both with a well-documented and verified history of longstanding unipolar depression, were initiated on VNS for treatment of their severe major depressive episodes. RESULTS The two patients had emergence of full manic symptoms after 8 and 9 months of VNS, respectively. Manic symptoms were adequately managed with standard treatments (mood stabilizer and electroconvulsive therapy) and VNS was continued in the two subjects for up to 5 years without any further occurrences of manic/hypomanic episodes. CONCLUSIONS These cases suggest that some patients with treatment-resistant depression may have a previously unrecognized bipolar disorder, triggered only by VNS. This report also provides evidence that VNS-induced manic switches, however serious and troubling to patients, can be managed safely, and that VNS maintenance can be continued for an extended period of time without manic relapses. Although the mechanism of action of VNS is not known, emerging evidence supports central nervous system dopaminergic and possibly cholinergic system involvement.
Collapse
Affiliation(s)
- Naji C Salloum
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | - Marie C Walker
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | - Sunil Gangwani
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | - Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| |
Collapse
|
38
|
Affiliation(s)
- Charles R Conway
- Washington University School of Medicine, St Louis, Missouri2John Cochran Veterans Affairs Medical Center, St Louis, Missouri
| | - Mark S George
- Medical University of South Carolina, Charleston4Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
| | | |
Collapse
|
39
|
Conway CR, Gebara MA, Walker MC, Lessov-Schlaggar CN, Janski AM, Chibnall JT, Cristancho P, Sheline YI, Gott BM, Svrakic DM. Clinical characteristics and management of treatment-resistant depression. J Clin Psychiatry 2015; 76:1569-70. [PMID: 26646033 DOI: 10.4088/jcp.14l09462] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
40
|
Nagele P, Duma A, Kopec M, Gebara MA, Parsoei A, Walker M, Janski A, Panagopoulos VN, Cristancho P, Miller JP, Zorumski CF, Conway CR. Nitrous Oxide for Treatment-Resistant Major Depression: A Proof-of-Concept Trial. Biol Psychiatry 2015; 78:10-18. [PMID: 25577164 DOI: 10.1016/j.biopsych.2014.11.016] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [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: 09/10/2014] [Revised: 11/13/2014] [Accepted: 11/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND N-methyl-D-aspartate receptor antagonists, such as ketamine, have rapid antidepressant effects in patients with treatment-resistant depression (TRD). We hypothesized that nitrous oxide, an inhalational general anesthetic and N-methyl-D-aspartate receptor antagonist, may also be a rapidly acting treatment for TRD. METHODS In this blinded, placebo-controlled crossover trial, 20 patients with TRD were randomly assigned to 1-hour inhalation of 50% nitrous oxide/50% oxygen or 50% nitrogen/50% oxygen (placebo control). The primary endpoint was the change on the 21-item Hamilton Depression Rating Scale (HDRS-21) 24 hours after treatment. RESULTS Mean duration of nitrous oxide treatment was 55.6 ± 2.5 (SD) min at a median inspiratory concentration of 44% (interquartile range, 37%-45%). In two patients, nitrous oxide treatment was briefly interrupted, and the treatment was discontinued in three patients. Depressive symptoms improved significantly at 2 hours and 24 hours after receiving nitrous oxide compared with placebo (mean HDRS-21 difference at 2 hours, -4.8 points, 95% confidence interval [CI], -1.8 to -7.8 points, p = .002; at 24 hours, -5.5 points, 95% CI, -2.5 to -8.5 points, p < .001; comparison between nitrous oxide and placebo, p < .001). Four patients (20%) had treatment response (reduction ≥50% on HDRS-21) and three patients (15%) had a full remission (HDRS-21 ≤ 7 points) after nitrous oxide compared with one patient (5%) and none after placebo (odds ratio for response, 4.0, 95% CI, .45-35.79; OR for remission, 3.0, 95% CI, .31-28.8). No serious adverse events occurred; all adverse events were brief and of mild to moderate severity. CONCLUSIONS This proof-of-concept trial demonstrated that nitrous oxide has rapid and marked antidepressant effects in patients with TRD.
Collapse
Affiliation(s)
- Peter Nagele
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri.
| | - Andreas Duma
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Michael Kopec
- Division of Clinical and Translational Research, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Marie Anne Gebara
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alireza Parsoei
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Marie Walker
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alvin Janski
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Vassilis N Panagopoulos
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Pilar Cristancho
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - J Philip Miller
- Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| |
Collapse
|
41
|
|
42
|
Zorumski CF, Nagele P, Mennerick S, Conway CR. Treatment-Resistant Major Depression: Rationale for NMDA Receptors as Targets and Nitrous Oxide as Therapy. Front Psychiatry 2015; 6:172. [PMID: 26696909 PMCID: PMC4673867 DOI: 10.3389/fpsyt.2015.00172] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 09/03/2015] [Accepted: 11/23/2015] [Indexed: 11/13/2022] Open
Abstract
Major depressive disorder (MDD) remains a huge personal and societal encumbrance. Particularly burdensome is a virulent subtype of MDD, treatment resistant major depression (TMRD), which afflicts 15-30% of MDD patients. There has been recent interest in N-methyl-d-aspartate receptors (NMDARs) as targets for treatment of MDD and perhaps TMRD. To date, most pre-clinical and clinical studies have focused on ketamine, although psychotomimetic and other side effects may limit ketamine's utility. These considerations prompted a recent promising pilot clinical trial of nitrous oxide, an NMDAR antagonist that acts through a mechanism distinct from that of ketamine, in patients with severe TRMD. In this paper, we review the clinical picture of TRMD as a subtype of MDD, the evolution of ketamine as a fast-acting antidepressant, and clinical and basic science studies supporting the possible use of nitrous oxide as a rapid antidepressant.
Collapse
Affiliation(s)
- Charles F Zorumski
- Department of Psychiatry, Washington University School of Medicine , St. Louis, MO , USA ; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine , St. Louis, MO , USA
| | - Peter Nagele
- Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine , St. Louis, MO , USA ; Department of Anesthesiology, Washington University School of Medicine , St. Louis, MO , USA
| | - Steven Mennerick
- Department of Psychiatry, Washington University School of Medicine , St. Louis, MO , USA ; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine , St. Louis, MO , USA
| | - Charles R Conway
- Department of Psychiatry, Washington University School of Medicine , St. Louis, MO , USA ; Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine , St. Louis, MO , USA
| |
Collapse
|
43
|
Conway CR, Chibnall JT, Cumming P, Mintun MA, Gebara MAI, Perantie DC, Price JL, Cornell ME, McConathy JE, Gangwani S, Sheline YI. Antidepressant response to aripiprazole augmentation associated with enhanced FDOPA utilization in striatum: a preliminary PET study. Psychiatry Res 2014; 221:231-9. [PMID: 24468015 PMCID: PMC3982608 DOI: 10.1016/j.pscychresns.2014.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 06/13/2013] [Revised: 01/03/2014] [Accepted: 01/07/2014] [Indexed: 01/28/2023]
Abstract
Several double blind, prospective trials have demonstrated an antidepressant augmentation efficacy of aripiprazole in depressed patients unresponsive to standard antidepressant therapy. Although aripiprazole is now widely used for this indication, and much is known about its receptor-binding properties, the mechanism of its antidepressant augmentation remains ill-defined. In vivo animal studies and in vitro human studies using cloned dopamine dopamine D2 receptors suggest aripiprazole is a partial dopamine agonist; in this preliminary neuroimaging trial, we hypothesized that aripiprazole's antidepressant augmentation efficacy arises from dopamine partial agonist activity. To test this, we assessed the effects of aripiprazole augmentation on the cerebral utilization of 6-[(18)F]-fluoro-3,4-dihydroxy-l-phenylalanine (FDOPA) using positron emission tomography (PET). Fourteen depressed patients, who had failed 8 weeks of antidepressant therapy with selective serotonin reuptake inhibitors, underwent FDOPA PET scans before and after aripiprazole augmentation; 11 responded to augmentation. Whole brain, voxel-wise comparisons of pre- and post-aripiprazole scans revealed increased FDOPA trapping in the right medial caudate of augmentation responders. An exploratory analysis of depressive symptoms revealed that responders experienced large improvements only in putatively dopaminergic symptoms of lassitude and inability to feel. These preliminary findings suggest that augmentation of antidepressant response by aripiprazole may be associated with potentiation of dopaminergic activity.
Collapse
Affiliation(s)
- Charles R. Conway
- Washington University School of Medicine, Department of Psychiatry, 660 South Euclid, Campus Box 8134, St. Louis, MO 63110, USA,Saint Louis University School of Medicine, Department of Neurology & Psychiatry, 1438 South Grand Boulevard, St. Louis, MO 63104, USA,Corresponding author contact information: Address: Washington University Department of Psychiatry, 660 South Euclid, Campus Box 8134, St. Louis, MO 63110, Phone: 314-362-0038; Fax: 314-362-7017,
| | - John T. Chibnall
- Saint Louis University School of Medicine, Department of Neurology & Psychiatry, 1438 South Grand Boulevard, St. Louis, MO 63104, USA
| | - Paul Cumming
- Department of Nuclear Medicine, Friedrich-Alexander University, Erlangen/Nuremberg, Germany
| | - Mark A. Mintun
- Washington University School of Medicine, Departments of Radiology and Psychiatry, St. Louis, MO 63110, USA and Avid Radiopharmaceuticals, Philadelphia, PA 19104, USA
| | - Marie Anne I. Gebara
- Washington University School of Medicine, Department of Psychiatry, 660 South Euclid, Campus Box 8134, St. Louis, MO 63110, USA
| | - Dana C. Perantie
- Washington University School of Medicine, Department of Psychiatry, 660 South Euclid, Campus Box 8134, St. Louis, MO 63110, USA
| | - Joseph L. Price
- Washington University School of Medicine, Department of Anatomy and Neurobiology, St. Louis, MO 63110, USA
| | - Martha E. Cornell
- Washington University School of Medicine, Department of Psychiatry, 660 South Euclid, Campus Box 8134, St. Louis, MO 63110, USA
| | - Jonathan E. McConathy
- Washington University School of Medicine, Department of Radiology, Division of Nuclear Medicine, St. Louis, MO 63110, USA
| | - Sunil Gangwani
- Washington University School of Medicine, Department of Psychiatry, 660 South Euclid, Campus Box 8134, St. Louis, MO 63110, USA
| | - Yvette I. Sheline
- Washington University School of Medicine, Departments of Psychiatry, Neurology, and Radiology, St. Louis, MO 63110, USA
| |
Collapse
|
44
|
Conway CR, Chibnall JT, Gebara MA, Price JL, Snyder AZ, Mintun MA, Craig ADB, Cornell ME, Perantie DC, Giuffra LA, Bucholz RD, Sheline YI. Association of cerebral metabolic activity changes with vagus nerve stimulation antidepressant response in treatment-resistant depression. Brain Stimul 2013; 6:788-97. [PMID: 23485649 DOI: 10.1016/j.brs.2012.11.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [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: 06/29/2012] [Revised: 10/09/2012] [Accepted: 11/25/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Vagus nerve stimulation (VNS) has antidepressant effects in treatment resistant major depression (TRMD); these effects are poorly understood. This trial examines associations of subacute (3 months) and chronic (12 months) VNS with cerebral metabolism in TRMD. OBJECTIVE (17)Fluorodeoxyglucose positron emission tomography was used to examine associations between 12-month antidepressant VNS response and cerebral metabolic rate for glucose (CMRGlu) changes at 3 and 12 months. METHODS Thirteen TRMD patients received 12 months of VNS. Depression assessments (Hamilton Depression Rating Scale [HDRS]) and PET scans were obtained at baseline (pre-VNS) and 3/12 months. CMRGlu was assessed in eight a priori selected brain regions (bilateral anterior insular [AIC], orbitofrontal [OFC], dorsolateral prefrontal [DLPFC], and anterior cingulate cortices [ACC]). Regional CMRGlu changes over time were studied in VNS responders (decreased 12 month HDRS by ≥50%) and nonresponders. RESULTS A significant trend (decreased 3 month CMRGlu) in the right DLPFC was observed over time in VNS responders (n = 9; P = 0.006). An exploratory whole brain analysis (P(uncorrected) = 0.005) demonstrated decreased 3 month right rostral cingulate and DLPFC CMRGlu, and increased 12 month left ventral tegmental CMRGlu in responders. CONCLUSIONS/LIMITATIONS VNS response may involve gradual (months in duration) brain adaptations. Early on, this process may involve decreased right-sided DLPFC/cingulate cortical activity; longer term effects (12 months) may lead to brainstem dopaminergic activation. Study limitations included: a) a small VNS nonresponders sample (N = 4), which limited conclusions about nonresponder CMRGlu changes; b) no control group; and, c) patients maintained their psychotropic medications.
Collapse
Affiliation(s)
- Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA; Department of Neurology and Psychiatry, Saint Louis University, St. Louis, MO, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Conway CR, Chibnall JT, Gangwani S, Mintun MA, Price JL, Hershey T, Giuffra LA, Bucholz RD, Christensen JJ, Sheline YI. Pretreatment cerebral metabolic activity correlates with antidepressant efficacy of vagus nerve stimulation in treatment-resistant major depression: a potential marker for response? J Affect Disord 2012; 139:283-90. [PMID: 22397889 PMCID: PMC3598572 DOI: 10.1016/j.jad.2012.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [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: 01/25/2012] [Accepted: 02/05/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pretreatment brain activity in major depressive disorder correlates with response to antidepressant therapies, including pharmacotherapies and transcranial magnetic stimulation. The purpose of this trial was to examine whether pretreatment regional metabolic activity in selected regions of interest (ROIs) predicts antidepressant response following 12 months of vagus nerve stimulation (VNS) in 15 patients with treatment-resistant major depression (TRMD). METHODS Fluorodeoxyglucose positron emission tomography (FDG PET) was used to assess regional mean relative cerebral metabolic rate for glucose (CMRGlu) in four ROIs (anterior insular, orbitofrontal, anterior cingulate, and dorsolateral prefrontal cortices) at baseline (prior to VNS activation). Depression severity was assessed at baseline and after 12 months of VNS using the Hamilton Depression Rating Scale (HDRS), with response defined as ≥ 50% reduction in HDRS from baseline. RESULTS Baseline CMRGlu in the anterior insular cortex differentiated VNS responders (n=11) from nonresponders (n=4) and correlated with HDRS change (r=.64, p=.01). In a regression analysis, lower anterior insular cortex CMRGlu (p=.004) and higher orbitofrontal cortex CMRGlu (p=.047) together predicted HDRS change (R(2)=.58, p=.005). In a whole brain, voxel-wise analysis, baseline CMRGlu in the right anterior insular cortex correlated with HDRS change (r=.78, p=.001). LIMITATIONS Sample size was small, limiting statistical power; patients remained on their psychiatric medications; study was open-label and uncontrolled. CONCLUSIONS This preliminary study suggests that pretreatment regional CMRGlu may be useful in predicting response to VNS in TRMD patients.
Collapse
Affiliation(s)
- Charles R Conway
- Department of Psychiatry, Washington University, St. Louis, MO, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Conway CR, Sheline YI, Chibnall JT, Bucholz RD, Price JL, Gangwani S, Mintun MA. Brain blood-flow change with acute vagus nerve stimulation in treatment-refractory major depressive disorder. Brain Stimul 2011; 5:163-71. [PMID: 22037127 DOI: 10.1016/j.brs.2011.03.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 03/01/2011] [Accepted: 03/02/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Existing neuroimaging studies of vagus nerve stimulation (VNS) in treatment resistant major depression (TRMD) suggest that many brain regions (eg, prefrontal cortex, thalamus, cingulate cortex, insular cortex) associated with mood disorders undergo alterations in blood flow/metabolism. OBJECTIVE/HYPOTHESIS Positron emission tomography (PET oxygen-15 labeled water or PET [(15)O] H(2)O) was used to identify changes in regional cerebral blood flow (rCBF) in response to immediate VNS in 13 subjects with TRMD. We hypothesized rCBF changes along the afferent pathway of the vagus and in regions associated with depression (eg, orbitofrontal cortex, amygdala, insular cortex). METHODS Six 90-second PET [(15)O] H(2)O scans were performed on 13 subjects in a VNS off-on sequence. After normalization for global uptake and realignment to standard atlas space, statistical t images (P < .005) were used to evaluate rCBF change. RESULTS VNS induced significant rCBF decreases in the left and right lateral orbitofrontal cortex and left inferior temporal lobe. Significant increases were found in the right dorsal anterior cingulate, left posterior limb of the internal capsule/medial putamen, the right superior temporal gyrus, and the left cerebellar body. Post hoc analysis found small-to-moderate correlations between baseline acute change in rCBF and antidepressant response after 12 months of VNS. CONCLUSIONS Regions undergoing rCBF change in response to acute VNS are consistent with the known afferent pathway of the vagus nerve and models of brain network in depression. Larger studies assessing the correlation between acute stimulation patterns and antidepressant outcomes with VNS are needed.
Collapse
Affiliation(s)
- Charles R Conway
- Washington University School of Medicine, Department of Psychiatry, St. Louis, Missouri 63110-1093, USA.
| | | | | | | | | | | | | |
Collapse
|
47
|
Conway CR, Chibnall JT, Tait RC. Vagus nerve stimulation for depression: a case of a broken lead, depression relapse, revision surgery, and restoration of patient response. Brain Stimul 2008; 1:227-8. [PMID: 20633388 DOI: 10.1016/j.brs.2008.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 05/22/2008] [Accepted: 05/23/2008] [Indexed: 11/19/2022] Open
|
48
|
|
49
|
Conway CR, Sheline YI, Chibnall JT, George MS, Fletcher JW, Mintun MA. Cerebral blood flow changes during vagus nerve stimulation for depression. Psychiatry Res 2006; 146:179-84. [PMID: 16510266 DOI: 10.1016/j.pscychresns.2005.12.007] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Revised: 11/15/2005] [Accepted: 12/05/2005] [Indexed: 01/02/2023]
Abstract
Positron emission tomography (PET oxygen-15 labeled water or PET [15O]H2O) was used to identify changes in regional cerebral blood flow (rCBF) in response to acute vagus nerve stimulation (VNS) in four subjects with treatment-resistant major depression (TRMD). Four 90-s PET [15O]H2O scans were performed on each subject in an off-on sequence (2 VNS de-activated; 2 VNS activated). PET images were aligned, normalized for global uptake, and resampled to standard atlas space. Statistical t-images were used to evaluate change. VNS-induced increases in rCBF were found in the bilateral orbitofrontal cortex, bilateral anterior cingulate cortex, and right superior and medial frontal cortex. Decreases were found in the bilateral temporal cortex and right parietal area. Regions of change were consistent with brain structures associated with depression and the afferent pathways of the vagus nerve.
Collapse
Affiliation(s)
- Charles R Conway
- Department of Psychiatry, Saint Louis University School of Medicine, 1221 South Grand Boulevard, St. Louis, MO 63104, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Conway CR, Chibnall JT, Nelson LA, McGuire JM, Abraham PF, Baram VY, Grossberg GT, Carroll BJ. An open-label trial of adjunctive oxcarbazepine for bipolar disorder. J Clin Psychopharmacol 2006; 26:95-7. [PMID: 16415718 DOI: 10.1097/01.jcp.0000195911.13870.f3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|