1
|
Maletic V, Mattingly GW, Earnest J. Viloxazine extended-release capsules as an emerging treatment for attention-deficit/hyperactivity disorder in children and adolescents. Expert Rev Neurother 2024; 24:443-455. [PMID: 38502148 DOI: 10.1080/14737175.2024.2327533] [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] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention and/or hyperactivity and impulsivity. Viloxazine extended-release (ER) capsules (Qelbree®) is a US Food and Drug Administration-approved nonstimulant treatment option for children, adolescents, and adults with ADHD. AREAS COVERED This review manuscript summarizes the neurobiology of ADHD and currently available treatment options before discussing viloxazine pharmacology, efficacy, safety, and tolerability data from phase II and III trials in children and adolescents (6-17 years old). Viloxazine clinical efficacy has also been further demonstrated by post hoc analyses of pediatric clinical trial results. EXPERT OPINION Current stimulant and nonstimulant treatments for ADHD may be suboptimal given low response rates and that tolerability issues are frequently experienced. Preclinical and clinical evidence has implicated both the role of catecholamine and serotonin signaling in the pathophysiology of ADHD and the pharmacologic effect of viloxazine on these critical neurotransmitter systems. With a relatively rapid onset of action, sustained symptom improvement, and clinical benefit in ADHD-associated impairments (functional and social), viloxazine ER represents a novel and emerging ADHD treatment option.
Collapse
Affiliation(s)
- Vladimir Maletic
- Department of Psychiatry and Behavioral Science, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Gregory W Mattingly
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO, USA
| | - Jami Earnest
- Medical Affairs, Supernus Pharmaceuticals, Inc, Rockville, MD, USA
| |
Collapse
|
2
|
Cutler AJ, Mattingly GW, Maletic V. Understanding the mechanism of action and clinical effects of neuroactive steroids and GABAergic compounds in major depressive disorder. Transl Psychiatry 2023; 13:228. [PMID: 37365161 DOI: 10.1038/s41398-023-02514-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 11/16/2022] [Revised: 05/12/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
The pathophysiology of major depressive disorder (MDD) is thought to result from impaired connectivity between key brain networks. Gamma-aminobutyric acid (GABA) is the key inhibitory neurotransmitter in the brain, working primarily via GABAA receptors, with an important role in virtually all physiologic functions in the brain. Some neuroactive steroids (NASs) are positive allosteric modulators (PAMs) of GABAA receptors and potentiate phasic and tonic inhibitory responses via activation of synaptic and extrasynaptic GABAA receptors, respectively. This review first discusses preclinical and clinical data that support the association of depression with diverse defects in the GABAergic system of neurotransmission. Decreased levels of GABA and NASs have been observed in adults with depression compared with healthy controls, while treatment with antidepressants normalized the altered levels of GABA and NASs. Second, as there has been intense interest in treatment approaches for depression that target dysregulated GABAergic neurotransmission, we discuss NASs approved or currently in clinical development for the treatment of depression. Brexanolone, an intravenous NAS and a GABAA receptor PAM, is approved by the U.S. Food and Drug Administration for the treatment of postpartum depression (PPD) in patients 15 years and older. Other NASs include zuranolone, an investigational oral GABAA receptor PAM, and PH10, which acts on nasal chemosensory receptors; clinical data to date have shown improvement in depressive symptoms with these investigational NASs in adults with MDD or PPD. Finally, the review discusses how NAS GABAA receptor PAMs may potentially address the unmet need for novel and effective treatments with rapid and sustained antidepressant effects in patients with MDD.
Collapse
|
3
|
Maletic V, Shelton R, Holmes V. A Review of l-Methylfolate as Adjunctive Therapy in the Treatment of Major Depressive Disorder. Prim Care Companion CNS Disord 2023; 25. [PMID: 37192264 DOI: 10.4088/pcc.22nr03361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Objective: To examine the potential of using l-methylfolate (LMF) as an adjunctive therapy for major depressive disorder (MDD) and assess its role in filling current treatment gaps for patients who are overweight/obese and have chronic inflammation. Data Sources: The PubMed database was searched using the key words l-methylfolate, adjunctive, and depression to identify studies published from January 2000 to April 2021. Study Selection: Identified studies included 2 randomized controlled trials (RCTs), an open-label extension of these RCTs, and a real-world prospective study. Post hoc analyses that explored subgroups and their response to LMF treatment, including patients who were overweight and had elevated inflammatory biomarkers, were also included. Results: These studies support the use of LMF as an adjunctive treatment in patients with MDD not responding to antidepressant monotherapy. The most effective dose tested was 15 mg/day. Treatment response was higher in individuals with a body mass index (BMI) ≥ 30 kg/m2 and elevated levels of inflammatory biomarkers. Inflammation is associated with increased production of proinflammatory cytokines, which interferes with the synthesis and turnover of monoamine neurotransmitters, thereby contributing to expression of depressive symptomatology. LMF may mitigate these effects by facilitating the synthesis of tetrahydrobiopterin (BH4), a critical coenzyme in neurotransmitter production. Furthermore, LMF does not cause adverse reactions commonly associated with other adjunctive MDD treatment agents (eg, atypical antipsychotics), such as weight gain, metabolic perturbations, and movement disorders. Conclusion: LMF is effective as an adjunctive treatment in MDD and may especially benefit patients with higher BMI and inflammation.
Collapse
Affiliation(s)
- Vladimir Maletic
- University of South Carolina School of Medicine, Greenville, South Carolina
- Corresponding author: Vladimir Maletic, MD, University of South Carolina School of Medicine, 607 Grove Rd, Greenville, SC 29605
| | | | - Valerie Holmes
- University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
4
|
Thase ME, Stahl SM, McIntyre RS, Matthews-Hayes T, Rolin D, Patel M, Harrington A, Maletic V, Jackson WC, Vieta E. Screening for Bipolar I Disorder and the Rapid Mood Screener: Results of a Nationwide Health Care Provider Survey. Prim Care Companion CNS Disord 2023; 25. [PMID: 37115145 DOI: 10.4088/pcc.22m03322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Objective: Effective screening for bipolar I disorder can lead to enhanced assessment, improved diagnosis, and better patient outcomes. The Rapid Mood Screener (RMS), a new bipolar I disorder screening tool, was evaluated in a nationwide survey of health care providers (HCPs). Methods: Eligible HCPs were asked to describe their opinions/current use of screening tools, assess the RMS, and evaluate the RMS versus the Mood Disorder Questionnaire (MDQ). Results were stratified by primary care and psychiatric specialty. Findings were reported using descriptive statistics; statistical significance was reported at the 95% confidence level. Results: Among respondents (N = 200), 82% used a tool to screen for major depressive disorder (MDD), while 32% used a tool for bipolar disorder. Most HCPs were aware of the MDQ (85%), but only 29% reported current use. According to HCPs, the RMS was significantly better than the MDQ on all screening tool attributes (eg, sensitivity/specificity, brevity, practicality, easy scoring; P < .05 for all). Significantly more HCPs reported that they would use the RMS versus the MDQ (81% vs 19%, P < .05); 76% reported that they would screen new patients with depressive symptoms, and 68% indicated they would rescreen patients with a depression diagnosis. Most HCPs (84%) said the RMS would have a positive impact on their practice, with 46% saying they would screen more patients for bipolar disorder. Discussion: In our survey, the RMS was favorably evaluated by HCPs. A large percentage of respondents preferred the RMS over the MDQ and indicated that it would likely have a positive impact on clinicians' screening behavior.
Collapse
Affiliation(s)
- Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
- Corresponding author: Michael E. Thase, MD, Department of Psychiatry, Mood and Anxiety Disorders Treatment and Research Program, 3535 Market St, Ste 670, Philadelphia, PA 19104-3309
| | - Stephen M Stahl
- Department of Psychiatry and Neuroscience, University of California Riverside School of Medicine, California
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Donna Rolin
- School of Nursing, the University of Texas at Austin, School of Nursing, Austin, Texas
| | - Mehul Patel
- AbbVie, North Chicago, Illinois (at the time of the study)
| | | | - Vladimir Maletic
- Department of Psychiatry/Behavioral Science, University of South Carolina School of Medicine, Greenville, South Carolina
| | - W Clay Jackson
- Department of Family Medicine and Department of Psychiatry, University of Tennessee College of Medicine, Memphis, Tennessee
| | - Eduard Vieta
- University of Barcelona, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| |
Collapse
|
5
|
Ceban F, Ling S, Lui LM, Lee Y, Gill H, Teopiz KM, Rodrigues NB, Subramaniapillai M, Di Vincenzo JD, Cao B, Lin K, Mansur RB, Ho RC, Rosenblat JD, Miskowiak KW, Vinberg M, Maletic V, McIntyre RS. Fatigue and cognitive impairment in Post-COVID-19 Syndrome: A systematic review and meta-analysis. Brain Behav Immun 2022; 101:93-135. [PMID: 34973396 PMCID: PMC8715665 DOI: 10.1016/j.bbi.2021.12.020] [Citation(s) in RCA: 505] [Impact Index Per Article: 252.5] [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: 11/05/2021] [Revised: 12/08/2021] [Accepted: 12/24/2021] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE COVID-19 is associated with clinically significant symptoms despite resolution of the acute infection (i.e., post-COVID-19 syndrome). Fatigue and cognitive impairment are amongst the most common and debilitating symptoms of post-COVID-19 syndrome. OBJECTIVE To quantify the proportion of individuals experiencing fatigue and cognitive impairment 12 or more weeks following COVID-19 diagnosis, and to characterize the inflammatory correlates and functional consequences of post-COVID-19 syndrome. DATA SOURCES Systematic searches were conducted without language restrictions from database inception to June 8, 2021 on PubMed/MEDLINE, The Cochrane Library, PsycInfo, Embase, Web of Science, Google/Google Scholar, and select reference lists. STUDY SELECTION Primary research articles which evaluated individuals at least 12 weeks after confirmed COVID-19 diagnosis and specifically reported on fatigue, cognitive impairment, inflammatory parameters, and/or functional outcomes were selected. DATA EXTRACTION & SYNTHESIS Two reviewers independently extracted published summary data and assessed methodological quality and risk of bias. A meta-analysis of proportions was conducted to pool Freeman-Tukey double arcsine transformed proportions using the random-effects restricted maximum-likelihood model. MAIN OUTCOMES & MEASURES The co-primary outcomes were the proportions of individuals reporting fatigue and cognitive impairment, respectively, 12 or more weeks following COVID-19 infection. The secondary outcomes were inflammatory correlates and functional consequences associated with post-COVID-19 syndrome. RESULTS The literature search yielded 10,979 studies, and 81 studies were selected for inclusion. The fatigue meta-analysis comprised 68 studies, the cognitive impairment meta-analysis comprised 43 studies, and 48 studies were included in the narrative synthesis. Meta-analysis revealed that the proportion of individuals experiencing fatigue 12 or more weeks following COVID-19 diagnosis was 0.32 (95% CI, 0.27, 0.37; p < 0.001; n = 25,268; I2 = 99.1%). The proportion of individuals exhibiting cognitive impairment was 0.22 (95% CI, 0.17, 0.28; p < 0.001; n = 13,232; I2 = 98.0). Moreover, narrative synthesis revealed elevations in proinflammatory markers and considerable functional impairment in a subset of individuals. CONCLUSIONS & RELEVANCE A significant proportion of individuals experience persistent fatigue and/or cognitive impairment following resolution of acute COVID-19. The frequency and debilitating nature of the foregoing symptoms provides the impetus to characterize the underlying neurobiological substrates and how to best treat these phenomena. STUDY REGISTRATION PROSPERO (CRD42021256965).
Collapse
Affiliation(s)
- Felicia Ceban
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada,Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Susan Ling
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada,Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | - Leanna M.W. Lui
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada,Braxia Health, Mississauga, ON, Canada
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Kayla M. Teopiz
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Nelson B. Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | | | - Joshua D. Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada,Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing 400715, China
| | - Kangguang Lin
- Department of Affective Disorders, The Affiliated Brain Hospital of Guangzhou Medical University, (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, China,Laboratory of Emotion and Cognition, The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou Medical University, Guangzhou, China
| | - Rodrigo B. Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roger C. Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore,Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Joshua D. Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada,Department of Pharmacology, University of Toronto, Toronto, ON, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Kamilla W. Miskowiak
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark,Mental Health Services, Capital Region of Denmark, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maj Vinberg
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark,Psychiatric Research Unit, Psychiatric Centre North Zealand, Hillerød, Denmark
| | - Vladimir Maletic
- Department of Psychiatry, University of South Carolina, Greenville, SC, USA
| | - Roger S. McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada,Brain and Cognition Discovery Foundation, Toronto, ON, Canada,Braxia Health, Mississauga, ON, Canada,Department of Pharmacology, University of Toronto, Toronto, ON, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, Canada,Corresponding author at: University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada
| |
Collapse
|
6
|
Nasser A, Kosheleff AR, Hull JT, Liranso T, Qin P, Busse GD, Fava M, Maletic V, Rubin J, Lopez F. Evaluating the likelihood to be helped or harmed after treatment with viloxazine extended-release in children and adolescents with attention-deficit/hyperactivity disorder. Int J Clin Pract 2021; 75:e14330. [PMID: 33971070 PMCID: PMC8365735 DOI: 10.1111/ijcp.14330] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/16/2021] [Accepted: 05/03/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS When clinicians evaluate potential medications for their patients, they must weigh the probability of a treatment's benefits against the possible risks. To this end, the present analyses evaluate the novel nonstimulant viloxazine extended-release (viloxazine ER) using measures of effect size to describe the potential benefits of its treatment in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) as well as the risk of discontinuation because of intolerable adverse events. METHODS These post hoc analyses use pooled data from four pivotal Phase 3 trials in paediatric patients treated with viloxazine ER. The Likelihood to be Helped or Harmed (LHH) effect size measure was calculated to describe the probability of patients benefiting from treatment vs discontinuing. The Number Needed to Treat (NNT) was calculated from frequently used thresholds of response. The Number Needed to Harm (NNH) was calculated using discontinuations because of adverse events. RESULTS LHH values for viloxazine ER ranged from 5 to 13, suggesting that subjects were 5-13 times more likely to benefit from, rather than discontinue, viloxazine ER treatment. Specifically, NNT values for viloxazine ER treatment ranged from 6 to 7. NNH values for viloxazine ER treatment ranged from 31 to 74. By convention, single-digit NNTs (<10) suggest the intervention is potentially useful, while NNH values ≥10 for adverse events suggest it is potentially safe or tolerable. CONCLUSIONS These results indicate that patients with ADHD are likely to benefit from treatment with viloxazine ER, and are unlikely to discontinue, as viloxazine ER treatment was associated with favourable LHH, NNT, and NNH values. Clinicaltrials.gov: NCT03247530, NCT03247543, NCT03247517, NCT03247556.
Collapse
Affiliation(s)
- Azmi Nasser
- Supernus Pharmaceuticals, Inc.RockvilleMDUSA
| | | | | | | | - Peibing Qin
- Supernus Pharmaceuticals, Inc.RockvilleMDUSA
| | | | - Maurizio Fava
- Department of PsychiatryMassachusetts General HospitalBostonMAUSA
| | - Vladimir Maletic
- Department of Psychiatry/Behavioral ScienceUniversity of South Carolina School of MedicineGreenvilleSCUSA
| | | | - Frank Lopez
- Children’s Developmental CenterWinter ParkFLUSA
| |
Collapse
|
7
|
Lee Y, Mansur RB, Brietzke E, Kapogiannis D, Delgado-Peraza F, Boutilier JJ, Chan TC, Carmona NE, Rosenblat JD, Lee J, Maletic V, Vinberg M, Suppes T, Goldstein BI, Ravindran AV, Taylor VH, Chawla S, Nogueras-Ortiz C, Cosgrove VE, Kramer NE, Ho R, Raison CA, McIntyre RS. Peripheral inflammatory biomarkers define biotypes of bipolar depression. Mol Psychiatry 2021; 26:3395-3406. [PMID: 33658605 PMCID: PMC8413393 DOI: 10.1038/s41380-021-01051-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 01/25/2021] [Accepted: 02/12/2021] [Indexed: 12/27/2022]
Abstract
We identified biologically relevant moderators of response to tumor necrosis factor (TNF)-α inhibitor, infliximab, among 60 individuals with bipolar depression. Data were derived from a 12-week, randomized, placebo-controlled clinical trial secondarily evaluating the efficacy of infliximab on a measure of anhedonia (i.e., Snaith-Hamilton Pleasure Scale). Three inflammatory biotypes were derived from peripheral cytokine measurements using an iterative, machine learning-based approach. Infliximab-randomized participants classified as biotype 3 exhibited lower baseline concentrations of pro- and anti-inflammatory cytokines and soluble TNF receptor-1 and reported greater pro-hedonic improvements, relative to those classified as biotype 1 or 2. Pretreatment biotypes also moderated changes in neuroinflammatory substrates relevant to infliximab's hypothesized mechanism of action. Neuronal origin-enriched extracellular vesicle (NEV) protein concentrations were reduced to two factors using principal axis factoring: phosphorylated nuclear factorκB (p-NFκB), Fas-associated death domain (p-FADD), and IκB kinase (p-IKKα/β) and TNF receptor-1 (TNFR1) comprised factor "NEV1," whereas phosphorylated insulin receptor substrate-1 (p-IRS1), p38 mitogen-activated protein kinase (p-p38), and c-Jun N-terminal kinase (p-JNK) constituted "NEV2". Among infliximab-randomized subjects classified as biotype 3, NEV1 scores were decreased at weeks 2 and 6 and increased at week 12, relative to baseline, and NEV2 scores increased over time. Decreases in NEV1 scores and increases in NEV2 scores were associated with greater reductions in anhedonic symptoms in our classification and regression tree model (r2 = 0.22, RMSE = 0.08). Our findings provide preliminary evidence supporting the hypothesis that the pro-hedonic effects of infliximab require modulation of multiple TNF-α signaling pathways, including NF-κB, IRS1, and MAPK.
Collapse
Affiliation(s)
- Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada. .,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
| | - Rodrigo B. Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Elisa Brietzke
- Department of Psychiatry, Queen’s University School of Medicine; Centre for Neuroscience Studies, Queen’s University, Kingston, ON, K7L 3N6, Canada
| | - Dimitrios Kapogiannis
- Laboratory of Clinical Investigation, Intramural Research Program, National Institute on Aging, National Institutes of Health (NIA/NIH), Baltimore, MD, 20814, USA
| | - Francheska Delgado-Peraza
- Laboratory of Clinical Investigation, Intramural Research Program, National Institute on Aging, National Institutes of Health (NIA/NIH), Baltimore, MD, 20814, USA
| | - Justin J. Boutilier
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, 53706, USA
| | - Timothy C.Y. Chan
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, M5S 3G8, Canada
| | - Nicole E. Carmona
- Department of Psychology, Ryerson University, Toronto, ON, M5B 2K3, Canada
| | - Joshua D. Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - JungGoo Lee
- Department of Psychiatry, College of Medicine, Haeundae Paik Hospital; Paik Institute for Clinical Research; Department of Health Science and Technology, Graduate School, Inje University, Busan, 47392, Republic of Korea
| | - Vladimir Maletic
- Department of Neuropsychiatry and Behavioral Sciences, University of South Carolina School of Medicine, Greer, SC, 29203, USA
| | - Maj Vinberg
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Psychiatric Research Unit, Psychiatric Centre North Zealand, Dyrehavevej 48, 3400 Hillerød, Denmark
| | - Trisha Suppes
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, USA,VA Palo Alto Health Care System, 3801 Miranda Ave. (151T), Palo Alto, CA, 94304, USA
| | - Benjamin I. Goldstein
- Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A8, Canada,Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, Toronto, ON, M5T 1R7, Canada,Department of Pharmacology, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Arun V. Ravindran
- Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Valerie H. Taylor
- Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A8, Canada,Department of Psychiatry, Foothills Medical Centre, University of Calgary, AB, T2N 2T9, Canada
| | - Sahil Chawla
- Laboratory of Clinical Investigation, Intramural Research Program, National Institute on Aging, National Institutes of Health (NIA/NIH), Baltimore, MD, 20814, USA
| | - Carlos Nogueras-Ortiz
- Laboratory of Clinical Investigation, Intramural Research Program, National Institute on Aging, National Institutes of Health (NIA/NIH), Baltimore, MD, 20814, USA
| | - Victoria E. Cosgrove
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Nicole E. Kramer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Roger Ho
- Department of Psychological Medicine, National University of Singapore, Singapore, 119228, Singapore
| | - Charles A. Raison
- School of Human Ecology, University of Wisconsin-Madison, Madison, WI, 53706, USA
| | - Roger S. McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON, M5T 2S8, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, M5S 1A8, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A8, Canada,Department of Pharmacology, University of Toronto, Toronto, ON, M5S 1A8, Canada,Brain and Cognition Discovery Foundation, Toronto, ON, L5C 4E7, Canada
| |
Collapse
|
8
|
Wang Z, Kosheleff AR, Adeojo LW, Odebo O, Adewole T, Qin P, Maletic V, Schwabe S, Nasser A. Impact of Paroxetine, a Strong CYP2D6 Inhibitor, on SPN-812 (Viloxazine Extended-Release) Pharmacokinetics in Healthy Adults. Clin Pharmacol Drug Dev 2021; 10:1365-1374. [PMID: 33943033 PMCID: PMC8597116 DOI: 10.1002/cpdd.948] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/10/2021] [Indexed: 01/18/2023]
Abstract
SPN‐812 (viloxazine extended‐release) is a novel nonstimulant recently approved as a treatment for attention‐deficit/hyperactivity disorder in children and adolescents. Given that SPN‐812 is metabolized by CYP2D6 and may be coadministered with CYP2D6 inhibitors, this trial investigated the pharmacokinetics and safety of SPN‐812 coadministered with the potent CYP2D6 inhibitor paroxetine. In this single‐sequence, 3‐treatment period study in healthy volunteers, subjects received a single oral dose of 700 mg SPN‐812 alone (period 1), 20 mg daily paroxetine (10 days, period 2), followed by concurrent administration of SPN‐812 and paroxetine (period 3). Blood samples were collected for 72 hours post‐SPN‐812 dosing and analyzed for viloxazine and its primary metabolite, 5‐HVLX‐gluc. Twenty‐two healthy adults were enrolled; all completed the trial. The potential for drug interaction between SPN‐812 and paroxetine was assessed using analysis of variance on the log‐transformed pharmacokinetic parameters Cmax, AUC0‐t, and AUCinf. The least‐squares geometric mean ratios for viloxazine were (reported as the ratio of combination/SPN‐812 alone) Cmax, 116.04%; 90%CI, 109.49%‐122.99%; AUC0‐t, 134.65%; 90%CI, 127.65‐142.03; and AUCinf, 134.80%; 90%CI, 127.94%‐142.03%. CYP2D6 inhibition resulted in a modest change (<35%) on viloxazine AUCs with no change in Cmax. All adverse events were mild in severity.
Collapse
Affiliation(s)
- Zhao Wang
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | | | | | | | - Toyin Adewole
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | - Peibing Qin
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | - Vladimir Maletic
- Department of Psychiatry/Behavioral Science, University of South Carolina School of Medicine, Greenville, South Carolina, USA
| | - Stefan Schwabe
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| | - Azmi Nasser
- Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
| |
Collapse
|
9
|
Patel M, Jain R, Tohen M, Maletic V, Earley WR, Yatham LN. Efficacy of cariprazine in bipolar I depression across patient characteristics: a post hoc analysis of pooled randomized, placebo-controlled studies. Int Clin Psychopharmacol 2021; 36:76-83. [PMID: 33230026 PMCID: PMC7846289 DOI: 10.1097/yic.0000000000000344] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022]
Abstract
Patients who experience bipolar depression have diverse demographic and clinical characteristics that have the potential to impact treatment. The efficacy of cariprazine in bipolar I depression was evaluated in patient subgroups defined by baseline demographic and clinical characteristics. Post hoc analyses of data from three randomized, double-blind, placebo-controlled trials in bipolar I depression (NCT01396447, NCT02670538 and NCT02670551) evaluated mean change from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) total scores for pooled cariprazine 1.5-3 mg/d versus placebo in subgroups defined by demographic and clinical characteristics. The least-squares mean difference in MADRS total score change from baseline was statistically significant for cariprazine 1.5-3 mg/d versus placebo in all patient subgroups analyzed (P < 0.05 all subgroups): demographic characteristics (age, sex, white or black race and obese/nonobese BMI); episode characteristics (defined by current episode duration, number of previous manic/mixed and depressive episodes, and prior bipolar disorder medication use) and disease severity (groups above and below Clinical Global Impressions-Severity and MADRS cutoff scores). Cariprazine 1.5-3 mg/d consistently improved depressive symptoms in all patient subgroups without regard to differences in baseline demographic and clinical characteristics, suggesting broad efficacy across a spectrum of patients with bipolar I depression.
Collapse
Affiliation(s)
- Mehul Patel
- Medical Afffairs, AbbVie, Madison, New Jersey
| | - Rakesh Jain
- Department of Psychiatry, Texas Tech University School of Medicine – Permian Basin, Midland, Texas
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Vladimir Maletic
- Psychiatry/Behavioral Science, University of South Carolina, Columbia, South Carolina, School of Medicine, Greenville, USA
| | | | - Lakshmi N. Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
10
|
Faison SL, Fry N, Adewole T, Odebo O, Wang Z, Maletic V, Nasser A. Pharmacokinetics of Coadministered Viloxazine Extended-Release (SPN-812) and Lisdexamfetamine in Healthy Adults. J Clin Psychopharmacol 2021; 41:155-162. [PMID: 33587403 PMCID: PMC7919699 DOI: 10.1097/jcp.0000000000001361] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 06/24/2020] [Revised: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Viloxazine extended-release is a novel nonstimulant under investigation as a potential treatment for attention-deficit/hyperactivity disorder (ADHD). Given the potential for viloxazine extended-release to be co-administered with stimulant ADHD pharmacotherapies, this trial investigated the pharmacokinetics and safety of combination viloxazine extended-release + lisdexamfetamine dimesylate (lisdexamfetamine) versus viloxazine extended-release and lisdexamfetamine alone. METHODS In this single-center, cross-over, open-label trial, healthy, non-ADHD adults received single oral doses of 700 mg viloxazine extended-release alone, 50 mg lisdexamfetamine alone, and a combination of viloxazine extended-release (700 mg) + lisdexamfetamine (50 mg), with blood samples collected over 4 days postadministration. The active drug in viloxazine extended-release (viloxazine) and primary metabolite of lisdexamfetamine (d-amphetamine) were measured using chromatographic tandem mass spectrometry. Safety assessments included adverse events, vital signs, echocardiograms, and clinical laboratory evaluations. RESULTS Thirty-six adults were enrolled, and 34 completed the trial. The least squares geometric mean ratios are reported as [combination / single drug (90% confidence intervals)]. Viloxazine extended-release: Cmax = 95.96% (91.33-100.82), area under the concentration-time curve from 0 to the last measurable time (AUC0-t) = 99.19% (96.53-101.91), and area under the concentration-time curve from 0 to infinity (AUCinf) = 99.23% (96.61-101.93). Lisdexamfetamine: Cmax = 112.78% (109.93-115.71), AUC0-t = 109.64% (105.25-114.22), and AUCinf = 109.52% (105.19-114.03). All reported adverse events, except 1 (moderate vomiting), were mild in severity. CONCLUSIONS Co-administration of viloxazine extended-release and lisdexamfetamine did not impact the pharmacokinetics of viloxazine or d-amphetamine relative to administration of either drug alone. After single dose administration, the combination appeared to be safe and well tolerated.
Collapse
Affiliation(s)
- Shamia L. Faison
- From the Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD
| | - Nicholas Fry
- From the Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD
| | - Toyin Adewole
- From the Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD
| | - Oyinkansola Odebo
- From the Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD
| | - Zhao Wang
- From the Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD
| | - Vladimir Maletic
- Department of Psychiatry/Behavioral Science, University of South Carolina School of Medicine, Greenville, SC
| | - Azmi Nasser
- From the Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, MD
| |
Collapse
|
11
|
Faison SL, Fry N, Adewole T, Odebo O, Schwabe S, Wang Z, Maletic V, Nasser A. Pharmacokinetics of Coadministered Viloxazine Extended-Release (SPN-812) and Methylphenidate in Healthy Adults. Clin Drug Investig 2020; 41:149-159. [PMID: 33368026 PMCID: PMC7886742 DOI: 10.1007/s40261-020-00992-6] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Viloxazine extended-release (viloxazine ER, SPN-812) is a novel non-stimulant with activity at serotonin receptors and the norepinephrine transporter, which is under investigation as a potential treatment for attention-deficit/hyperactivity disorder. Given the potential for viloxazine ER to be coadministered with other pharmacotherapies, this trial investigated the pharmacokinetics and safety of combination viloxazine ER + methylphenidate versus viloxazine ER or methylphenidate alone. METHODS In this single-center, crossover, open-label trial, healthy adult participants received oral administration of 700 mg viloxazine ER alone, 36 mg methylphenidate alone, and combination viloxazine ER (700 mg) + methylphenidate (36 mg), with blood samples collected over 4 days post-administration. The active drug in viloxazine ER (viloxazine) and methylphenidate was measured using chromatographic tandem mass spectrometry. Safety assessments included adverse events (AEs), vital signs, echocardiograms, and clinical laboratory evaluations. RESULTS Of 36 healthy adults who were enrolled, 34 completed the trial. The geometric least squares mean ratios are reported as [combination/single drug (90% confidence intervals)]. For viloxazine ER, maximum measured plasma concentration (Cmax) = 100.98% (96.21-105.99), area under the concentration-time curve from time zero to the last measurable time (AUCt) = 98.62% (96.21-101.08), and area under the concentration-time curve from time zero to infinity (AUC∞) = 98.96% (96.55-101.44). For methylphenidate, Cmax = 103.55% (97.42-110.07), AUCt = 106.67% (101.01-112.64), and AUC∞ = 106.61% (100.99-112.54). All reported AEs were mild in severity. CONCLUSIONS Coadministration of viloxazine ER and methylphenidate did not impact the pharmacokinetics of viloxazine or methylphenidate relative to administration of either drug alone. The combination appeared to be safe and well tolerated.
Collapse
Affiliation(s)
- Shamia L Faison
- Supernus Pharmaceuticals, Inc., 9715 Key West Avenue, Rockville, MD, 20850, USA
| | - Nicholas Fry
- Supernus Pharmaceuticals, Inc., 9715 Key West Avenue, Rockville, MD, 20850, USA
| | - Toyin Adewole
- Supernus Pharmaceuticals, Inc., 9715 Key West Avenue, Rockville, MD, 20850, USA
| | - Oyinkansola Odebo
- Supernus Pharmaceuticals, Inc., 9715 Key West Avenue, Rockville, MD, 20850, USA
| | - Stefan Schwabe
- Supernus Pharmaceuticals, Inc., 9715 Key West Avenue, Rockville, MD, 20850, USA
| | - Zhao Wang
- Supernus Pharmaceuticals, Inc., 9715 Key West Avenue, Rockville, MD, 20850, USA
| | - Vladimir Maletic
- Department of Psychiatry/Behavioral Science, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Azmi Nasser
- Supernus Pharmaceuticals, Inc., 9715 Key West Avenue, Rockville, MD, 20850, USA.
| |
Collapse
|
12
|
Yu C, Garcia-Olivares J, Candler S, Schwabe S, Maletic V. New Insights into the Mechanism of Action of Viloxazine: Serotonin and Norepinephrine Modulating Properties. J Exp Pharmacol 2020; 12:285-300. [PMID: 32943948 PMCID: PMC7473988 DOI: 10.2147/jep.s256586] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/25/2020] [Indexed: 12/14/2022] Open
Abstract
Background Viloxazine was historically described as a norepinephrine reuptake inhibitor (NRI). Since NRIs have previously demonstrated efficacy in attention deficit/hyperactivity disorder (ADHD), viloxazine underwent contemporary investigation in the treatment of ADHD. Its clinical and safety profile, however, was found to be distinct from other ADHD medications targeting norepinephrine reuptake. Considering the complexity of neuropsychiatric disorders, understanding the mechanism of action (MoA) is an important differentiating point between viloxazine and other ADHD medications and provides pharmacology-based rationale for physicians prescribing appropriate therapy. Methods Viloxazine was evaluated in a series of in vitro binding and functional assays. Its effect on neurotransmitter levels in the brain was evaluated using microdialysis in freely moving rats. Results We report the effects of viloxazine on serotoninergic (5-HT) system. In vitro, viloxazine demonstrated antagonistic activity at 5-HT2B and agonistic activity at 5-HT2C receptors, along with predicted high receptor occupancy at clinical doses. In vivo, viloxazine increased extracellular 5-HT levels in the prefrontal cortex (PFC), a brain area implicated in ADHD. Viloxazine also exhibited moderate inhibitory effects on the norepinephrine transporter (NET) in vitro and in vivo, and elicited moderate activity at noradrenergic and dopaminergic systems. Conclusion Viloxazine’s ability to increase 5-HT levels in the PFC and its agonistic and antagonistic effects on certain 5-HT receptor subtypes, which were previously shown to suppress hyperlocomotion in animals, indicate that 5-HT modulating activity of viloxazine is an important (if not the predominant) component of its MoA, complemented by moderate NET inhibition. Supported by clinical data, these findings suggest the updated psychopharmacological profile of viloxazine can be best explained by its action as a serotonin norepinephrine modulating agent (SNMA).
Collapse
Affiliation(s)
- Chungping Yu
- Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | | | | | | | - Vladimir Maletic
- Department of Psychiatry/Behavioral Science, University of South Carolina School of Medicine, Greenville, SC, USA
| |
Collapse
|
13
|
Abstract
Many patients with mood disorders do not experience pure episodes of depression or mania. Rather, these individuals experience mixed presentations. In the past, individuals experiencing mixed mood episodes were often misdiagnosed due to overly strict diagnostic criteria, leading to poor outcomes and treatment response. The addition of the mixed features specifier to the DSM-5 holds promise for improving recognition in patients who may be experiencing mixed symptoms. Furthermore, awareness has grown important warning signs that should be considered risk factors for progression to bipolar disorder and should warrant special clinical attention. Finally, guidelines for patients experiencing depression with mixed features have recently become available to help provide evidence-based treatment to this patient population. .
Collapse
Affiliation(s)
- Rakesh Jain
- Department of Psychiatry, Texas Tech University Health Sciences Center Medical School, Midland, Texas, USA
| | - Vladimir Maletic
- Department of Neuropsychiatry and Behavioral Sciences, University of South Carolina School of Medicine, Greer, South Carolina, USA
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University of Toronto, Ontario, Canada
| |
Collapse
|
14
|
Maletic V, Eramo A, Gwin K, Offord SJ, Duffy RA. The Role of Norepinephrine and Its α-Adrenergic Receptors in the Pathophysiology and Treatment of Major Depressive Disorder and Schizophrenia: A Systematic Review. Front Psychiatry 2017; 8:42. [PMID: 28367128 PMCID: PMC5355451 DOI: 10.3389/fpsyt.2017.00042] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [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] [Received: 12/20/2016] [Accepted: 03/01/2017] [Indexed: 12/11/2022] Open
Abstract
Norepinephrine (NE) is recognized as having a key role in the pathophysiology of major depressive disorder (MDD) and schizophrenia, although its distinct actions via α-adrenergic receptors (α-ARs) are not well defined. We performed a systematic review examining the roles of NE and α-ARs in MDD and schizophrenia. PubMed and ProQuest database searches were performed to identify English language papers published between 2008 and 2015. In total, 2,427 publications (PubMed, n = 669; ProQuest, n = 1,758) were identified. Duplicates, articles deemed not relevant, case studies, reviews, meta-analyses, preclinical reports, or articles on non-target indications were excluded. To limit the review to the most recent data representative of the literature, the review further focused on publications from 2010 to 2015, which were screened independently by all authors. A total of 16 research reports were identified: six clinical trial reports, six genetic studies, two biomarker studies, and two receptor studies. Overall, the studies provided indirect evidence that α-AR activity may play an important role in aberrant regulation of cognition, arousal, and valence systems associated with MDD and schizophrenia. Characterization of the NE pathway in patients may provide clinicians with information for more personalized therapy of these heterogeneous diseases. Current clinical studies do not provide direct evidence to support the role of NE α-ARs in the pathophysiology of MDD and schizophrenia and in the treatment response of patients with these diseases, in particular with relation to specific valence systems. Clinical studies that attempt to define associations between specific receptor binding profiles of psychotropics and particular clinical outcomes are needed.
Collapse
Affiliation(s)
- Vladimir Maletic
- Department of Neuropsychiatry and Behavioral Science, University of South Carolina , Columbia, SC , USA
| | - Anna Eramo
- Medical Affairs - Psychiatry, Lundbeck LLC , Deerfield, IL , USA
| | - Keva Gwin
- Medical Affairs - Psychiatry, Lundbeck LLC , Deerfield, IL , USA
| | - Steve J Offord
- Medical Affairs, Otsuka Pharmaceutical Development and Commercialization, Inc. , Princeton, NJ , USA
| | - Ruth A Duffy
- Medical Affairs, Otsuka Pharmaceutical Development and Commercialization, Inc. , Princeton, NJ , USA
| |
Collapse
|
15
|
Abstract
From a neurobiological perspective there is no such thing as bipolar disorder. Rather, it is almost certainly the case that many somewhat similar, but subtly different, pathological conditions produce a disease state that we currently diagnose as bipolarity. This heterogeneity - reflected in the lack of synergy between our current diagnostic schema and our rapidly advancing scientific understanding of the condition - limits attempts to articulate an integrated perspective on bipolar disorder. However, despite these challenges, scientific findings in recent years are beginning to offer a provisional "unified field theory" of the disease. This theory sees bipolar disorder as a suite of related neurodevelopmental conditions with interconnected functional abnormalities that often appear early in life and worsen over time. In addition to accelerated loss of volume in brain areas known to be essential for mood regulation and cognitive function, consistent findings have emerged at a cellular level, providing evidence that bipolar disorder is reliably associated with dysregulation of glial-neuronal interactions. Among these glial elements are microglia - the brain's primary immune elements, which appear to be overactive in the context of bipolarity. Multiple studies now indicate that inflammation is also increased in the periphery of the body in both the depressive and manic phases of the illness, with at least some return to normality in the euthymic state. These findings are consistent with changes in the hypothalamic-pituitary-adrenal axis, which are known to drive inflammatory activation. In summary, the very fact that no single gene, pathway, or brain abnormality is likely to ever account for the condition is itself an extremely important first step in better articulating an integrated perspective on both its ontological status and pathogenesis. Whether this perspective will translate into the discovery of innumerable more homogeneous forms of bipolarity is one of the great questions facing the field and one that is likely to have profound treatment implications, given that fact that such a discovery would greatly increase our ability to individualize - and by extension, enhance - treatment.
Collapse
Affiliation(s)
- Vladimir Maletic
- Department of Neuropsychiatry and Behavioral Sciences, University of South Carolina School of Medicine , Columbia, SC , USA
| | - Charles Raison
- Department of Psychiatry, University of Arizona , Tucson, AZ , USA ; Norton School of Family and Consumer Sciences, College of Agriculture and Life Sciences, University of Arizona , Tucson, AZ , USA
| |
Collapse
|
16
|
|
17
|
Jain R, Jain S, Raison CL, Maletic V. Painful diabetic neuropathy is more than pain alone: examining the role of anxiety and depression as mediators and complicators. Curr Diab Rep 2011; 11:275-84. [PMID: 21611765 DOI: 10.1007/s11892-011-0202-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [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] [Indexed: 12/14/2022]
Abstract
A wealth of information exists regarding the plight of patients suffering with diabetic peripheral neuropathic pain (DPNP). Although physical pain is certainly a primary challenge in the management of this condition, disorders associated with emotional pain-especially depression and anxiety-also greatly complicate the clinician's efforts to attain optimal outcomes for DPNP patients. This article reviews the high rate of comorbidity between DPNP and depression/anxiety with a focus on why this pattern of comorbidity exists and what can be done about it. To accomplish this, the many physiologic similarities between neuropathic pain and depression/anxiety are reviewed as a basis for better understanding how, and why, optimal treatment strategies use behavioral and pharmacologic modalities known to improve both physical pain and symptoms of depression and anxiety. We conclude by highlighting that screening, diagnosing, and optimally treating comorbid depression/anxiety not only improves quality of life, these but also positively impacts DPNP pain.
Collapse
Affiliation(s)
- Rakesh Jain
- Department of Psychiatry, Texas Tech Health Sciences Center Medical School at Permian Basin, Midland, TX, USA.
| | | | | | | |
Collapse
|
18
|
Miller AH, Maletic V, Raison CL. La inflamación y sus desencantos: papel de las citocinas en la fisiopatología de la depresión mayor. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.psiq.2010.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
19
|
Abstract
Somatic symptoms are the foremost reason that individuals seek medical care, and most patients present with these symptoms in the primary care setting. Thus, clinicians must be able to recognize the manifestations of chronic pain as well as devise and implement an individualized treatment strategy that will relieve pain, manage any psychiatric comorbidities, and improve functioning and quality of life. This video includes 3 example patient cases and expert recommendations on accurately identifying, diagnosing, and treating the illnesses related to chronic pain, including comorbid depression and anxiety.
Collapse
Affiliation(s)
- Rakesh Jain
- Department of Psychiatric Drug Research, R/D Clinical Research, Inc, Lake Jackson, Texas, USA
| | | | | |
Collapse
|
20
|
Miller AH, Maletic V, Raison CL. Inflammation and its discontents: the role of cytokines in the pathophysiology of major depression. Biol Psychiatry 2009; 65:732-41. [PMID: 19150053 PMCID: PMC2680424 DOI: 10.1016/j.biopsych.2008.11.029] [Citation(s) in RCA: 2537] [Impact Index Per Article: 169.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 11/26/2008] [Accepted: 11/26/2008] [Indexed: 02/06/2023]
Abstract
Recognition that inflammation may represent a common mechanism of disease has been extended to include neuropsychiatric disorders including major depression. Patients with major depression have been found to exhibit increased peripheral blood inflammatory biomarkers, including inflammatory cytokines, which have been shown to access the brain and interact with virtually every pathophysiologic domain known to be involved in depression, including neurotransmitter metabolism, neuroendocrine function, and neural plasticity. Indeed, activation of inflammatory pathways within the brain is believed to contribute to a confluence of decreased neurotrophic support and altered glutamate release/reuptake, as well as oxidative stress, leading to excitotoxicity and loss of glial elements, consistent with neuropathologic findings that characterize depressive disorders. Further instantiating the link between inflammation and depression are data demonstrating that psychosocial stress, a well-known precipitant of mood disorders, is capable of stimulating inflammatory signaling molecules, including nuclear factor kappa B, in part, through activation of sympathetic nervous system outflow pathways. Interestingly, depressed patients with increased inflammatory biomarkers have been found to be more likely to exhibit treatment resistance, and in several studies, antidepressant therapy has been associated with decreased inflammatory responses. Finally, preliminary data from patients with inflammatory disorders, as well as medically healthy depressed patients, suggest that inhibiting proinflammatory cytokines or their signaling pathways may improve depressed mood and increase treatment response to conventional antidepressant medication. Translational implications of these findings include the unique opportunity to identify relevant patient populations, apply immune-targeted therapies, and monitor therapeutic efficacy at the level of the immune system in addition to behavior.
Collapse
|
21
|
|
22
|
Abstract
Neuroimaging and pathohistologic research may show whether bipolar disorder is a degenerative and progressive condition, if detectable changes in the brain record past occurrences, and whether these changes are reversible. Interpreting neuroimaging studies has been complicated by a lack of identification of patient mood states and differences in patients' medication status, but several observations have been made. Pathohistologic research suggests that bipolar disorder is associated with significant cell pathology.
Collapse
Affiliation(s)
- Vladimir Maletic
- Department of Neuropsychiatry and Behavioral Sciences, University of South Carolina School of Medicine, Columbia, USA
| |
Collapse
|
23
|
Abstract
AIMS The objectives of the present review were to summarise the key findings from the clinical literature regarding the neurobiology of major depressive disorder (MDD) and their implications for maximising treatment outcomes. Several neuroanatomical structures in the prefrontal and limbic areas of the brain are involved in affective regulation. In patients with MDD, alterations in the dynamic patterns of activity among these structures have profound implications for the pathogenesis of this illness. DISCUSSION The present work reviews the evidence for the progressive nature of MDD along with associated changes in neuroanatomical structure and function, especially for the hippocampus. The role of glucocorticoids, inflammatory cytokines and brain-derived growth factors are discussed as mediators of these pathological alterations. From this integrated model, the role of antidepressant therapy in restoring normative processes is examined along with additional treatment guidelines. CONCLUSION Major depressive disorder is an illness with significant neurobiological consequences involving structural, functional and molecular alterations in several areas of the brain. Antidepressant pharmacotherapy is associated with restoration of the underlying physiology. Clinicians are advised to intervene with MDD using an early, comprehensive treatment approach that has remission as the goal.
Collapse
Affiliation(s)
- V Maletic
- School of Medicine, University of South Carolina, Greer, SC 29650, USA.
| | | | | | | | | | | |
Collapse
|
24
|
Maletic V. DSM-IV-TR Case Studies. Prim Care Companion J Clin Psychiatry 2003. [DOI: 10.4088/pcc.v05n0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
25
|
Stanojevicbakic N, Vuckovicdekic L, Maletic V, Borkovacki R. Mitogen-induced lymphoproliferative response and phagocytic-activity of monocytes in renal-cell carcinoma patients treated by interferon a alone or in combination with vinblastine. Oncol Rep 1995; 2:891-5. [PMID: 21597837 DOI: 10.3892/or.2.5.891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The functions of T cells and monocytes were studied in relation to the clinical stage and clinical course of renal cell carcinoma (RCC) patients, treated by interferon alpha (LFN-alpha). Lymphoproliferative response (LPR) to phytohemagglutinin and phagocytic activity of peripheral blood monocytes were estimated before, immediately after, and six months after completion of therapy with IFN-alpha alone (applied in stage II RCC) or in combination with vinblastine (in stages III and IV). The number of total T cells and their mitogen-induced proliferative response were diminished in all patient groups before therapy, the decrease of LPR being more pronounced in advanced (III and IV) stages of the disease. The pretreatment number of monocytes and their phagocytic activity were increased in RCC patients regardless of clinical stage. The initial level of the lymphocyte and monocyte functions did not correlate with the clinical course of the disease. The pretreatment levels of LPR and phagocytic activity were not changed immediately after IFN treatment, irrespective of the clinical response to therapy. Similar results were obtained six months after therapy; the only exception was the increased LPR in stage III patients, which was unrelated to clinical response to the therapy, since it was seen in patients with progression of the disease. These findings suggest that the pretreatment level of LPR and monocyte phagocytic activity in RCC patients in different clinical stages of RCC were not predictive of the clinical response to IFN therapy. IFN-alpha, as used in this study, had no major influence on LPR and phagocytic activity of monocytes irrespective of the clinical stage or clinical course of the disease.
Collapse
|
26
|
|