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Jensen KHR, Urdanibia-Centelles O, Dam VH, Köhler-Forsberg K, Frokjaer VG, Knudsen GM, Jørgensen MB, Ip CT. EEG abnormalities are not associated with poor antidepressant treatment outcome - A NeuroPharm study. Eur Neuropsychopharmacol 2024; 79:59-65. [PMID: 38128462 DOI: 10.1016/j.euroneuro.2023.11.004] [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] [Received: 06/06/2023] [Revised: 11/24/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
EEG brain abnormalities, such as slowing and isolated epileptiform discharges (IEDs), has previously been associated with non-response to antidepressant treatment with escitalopram and venlafaxine, suggesting a potential need for treatment with anticonvulsant property in some patients. The current study aims to replicate the reported association of EEG abnormality and treatment outcomes in an open-label trial of escitalopram for major depressive disorder (MDD) and explore its relationship to mood and cognition. Pretreatment, 6 min eyes-closed resting-state 256-channel EEG was recorded in 91 patients with MDD (age 18-57) who were treated with 10-20 mg escitalopram for 12 weeks; patients could switch to duloxetine after four weeks. A certified clinical neurophysiologist rated the EEGs. IED and EEG slowing was seen in 13.2%, and in 6.6% there were findings with unclear significance (i.e., Wicket spikes and theta activity). We saw no group-difference in remission or response rates after 8 and 12 weeks of treatment or switching to duloxetine. Patients with EEG abnormalities had higher pretreatment mood disturbances driven by greater anger (p=.039) and poorer verbal memory (p=.012). However, EEG abnormality was not associated with improved mood or verbal memory after treatment. Our findings should be interpreted in light of the rarity of EEG abnormalities and the sample size. While we cannot confirm that EEG abnormalities are associated with non-response to treatment, including escitalopram, abnormal EEG activity is associated with poor mood and verbal memory. The clinical utility of EEG abnormality in antidepressant treatment selection needs careful evaluation before deciding if useful for clinical implementation.
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Affiliation(s)
- Kristian H Reveles Jensen
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Olalla Urdanibia-Centelles
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke H Dam
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gitte M Knudsen
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Center for Cognitive and Brain Sciences, University of Macau, Taipa, Macau SAR, China
| | - Martin B Jørgensen
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cheng T Ip
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark; Center for Cognitive and Brain Sciences, University of Macau, Taipa, Macau SAR, China
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2
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Vulpius GM, Köhler-Forsberg K, Ozenne B, Larsen SV, Nasser A, Svarer C, Gillings N, Keller SH, Jørgensen MB, Knudsen GM, Frokjaer VG. Stress Hormone Dynamics Are Coupled to Brain Serotonin 4 Receptor Availability in Unmedicated Patients With Major Depressive Disorder: A NeuroPharm Study. Int J Neuropsychopharmacol 2023; 26:639-648. [PMID: 37542733 PMCID: PMC10519814 DOI: 10.1093/ijnp/pyad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND A prominent finding in major depressive disorder (MDD) is distorted stress hormone dynamics, which is regulated by serotonergic brain signaling. An interesting feature of the cerebral serotonin system is the serotonin 4 receptor (5-HT4R), which is lower in depressed relative to healthy individuals and also has been highlighted as a promising novel antidepressant target. Here, we test the novel hypothesis that brain 5-HT4R availability in untreated patients with MDD is correlated with cortisol dynamics, indexed by the cortisol awakening response (CAR). Further, we evaluate if CAR changes with antidepressant treatment, including a selective serotonin reuptake inhibitor, and if pretreatment CAR can predict treatment outcome. METHODS Sixty-six patients (76% women) with a moderate to severe depressive episode underwent positron emission tomography imaging with [11C]SB207145 for quantification of brain 5-HT4R binding using BPND as outcome. Serial home sampling of saliva in the first hour from awakening was performed to assess CAR before and after 8 weeks of antidepressant treatment. Treatment outcome was measured by change in Hamilton Depression Rating Scale 6 items. RESULTS In the unmedicated depressed state, prefrontal and anterior cingulate cortices 5-HT4R binding was positively associated with CAR. CAR remained unaltered after 8 weeks of antidepressant treatment, and pretreatment CAR did not significantly predict treatment outcome. CONCLUSIONS Our findings highlight a link between serotonergic disturbances in MDD and cortisol dynamics, which likely is involved in disease and treatment mechanisms. Further, our data support 5-HT4R agonism as a promising precision target in patients with MDD and disturbed stress hormone dynamics.
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Affiliation(s)
- Gunild M Vulpius
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
- Psychiatric Center Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
- Psychiatric Center Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Denmark
| | - Søren V Larsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Arafat Nasser
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Claus Svarer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Nic Gillings
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Sune H Keller
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Martin B Jørgensen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
- Psychiatric Center Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Gitte M Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark
- Psychiatric Center Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
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3
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Rasmussen AL, Larsen SV, Ozenne B, Köhler-Forsberg K, Stenbæk DS, Jørgensen MB, Giraldi A, Frokjaer VG. Sexual health and serotonin 4 receptor brain binding in unmedicated patients with depression-a NeuroPharm study. Transl Psychiatry 2023; 13:247. [PMID: 37414758 DOI: 10.1038/s41398-023-02551-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/24/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023] Open
Abstract
Sexual dysfunction is prominent in Major Depressive Disorder (MDD) and affects women with depression more than men. Patients with MDD relative to healthy controls have lower brain levels of the serotonin 4 receptor (5-HT4R), which is expressed with high density in the striatum, i.e. a key hub of the reward system. Reduced sexual desire is putatively related to disturbed reward processing and may index anhedonia in MDD. Here, we aim to illuminate plausible underlying neurobiology of sexual dysfunction in unmedicated patients with MDD. We map associations between 5-HT4R binding, as imaged with [11C]SB207145 PET, in the striatum, and self-reported sexual function. We also evaluate if pre-treatment sexual desire score predicts 8-week treatment outcome in women. From the NeuroPharm study, we include 85 untreated MDD patients (71% women) who underwent eight weeks of antidepressant drug treatment. In the mixed sex group, we find no difference in 5-HT4R binding between patients with sexual dysfunction vs normal sexual function. However, in women we find lower 5-HT4R binding in the sexual dysfunctional group compared to women with normal sexual function (β = -0.36, 95%CI[-0.62:-0.09], p = 0.009) as well as a positive association between sexual desire and 5-HT4R binding (β = 0.07, 95%CI [0.02:0.13], p = 0.012). Sexual desire at baseline do not predict treatment outcome (ROC curve AUC = 52%[36%:67%]) in women. Taken together, we find evidence for a positive association between sexual desire and striatal 5-HT4R availability in women with depression. Interestingly, this raises the question if direct 5-HT4R agonism can target reduced sexual desire or anhedonia in MDD.
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Affiliation(s)
| | - Søren Vinther Larsen
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
- Psychiatric Centre Copenhagen, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark
| | - Dea Siggaard Stenbæk
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Martin Balslev Jørgensen
- Psychiatric Centre Copenhagen, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark
| | - Annamaria Giraldi
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Sexological Clinic, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit, Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Psychiatric Centre Copenhagen, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark.
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Köhler-Forsberg K, Dam VH, Ozenne B, Sankar A, Beliveau V, Landman EB, Larsen SV, Poulsen AS, Ip CT, Jørgensen A, Meyer M, Stenbæk DS, Eiberg HRL, Madsen J, Svarer C, Jørgensen MB, Frokjaer VG, Knudsen GM. Serotonin 4 Receptor Brain Binding in Major Depressive Disorder and Association With Memory Dysfunction. JAMA Psychiatry 2023; 80:296-304. [PMID: 36753296 PMCID: PMC9909578 DOI: 10.1001/jamapsychiatry.2022.4539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/05/2022] [Indexed: 02/09/2023]
Abstract
Importance The cerebral serotonin 4 (5-HT4) receptor is a promising novel target for treatment of major depressive disorder (MDD), and pharmacological stimulation of the 5-HT4 receptor has been associated with improved learning and memory in healthy individuals. Objective To map the neurobiological signatures of patients with untreated MDD compared with healthy controls and to examine the association between cerebral 5-HT4 receptor binding and cognitive functions in the depressed state. Design, Setting, and Participants This case-control study used baseline data from the NeuroPharm clinical depression trial in Denmark. Adult participants included antidepressant-free outpatients with a current moderate to severe depressive episode and healthy controls. All participants completed positron emission tomography (PET) scanning with [11C]SB207145 for quantification of brain 5-HT4 receptor binding, but only the patients underwent cognitive testing. Data analyses were performed from January 21, 2020, to April 22, 2022. Main Outcomes and Measures The main study outcome was the group difference in cerebral 5-HT4 receptor binding between patients with MDD and healthy controls. In addition, the association between 5-HT4 receptor binding and verbal memory performance in the patient group was tested. Other cognitive domains (working memory, reaction time, emotion recognition bias, and negative social emotions) were assessed as secondary outcomes. Results A total of 90 patients with untreated MDD (mean [SD] age, 27.1 [8.2] years; 64 women [71.1%]) and 91 healthy controls (mean [SD] age, 27.1 [8.0] years; 55 women [60.4%]) were included in the analysis. Patients with current MDD had significantly lower cerebral 5-HT4 receptor binding than healthy controls (-7.0%; 95% CI, -11.2 to -2.7; P = .002). In patients with MDD, there was a correlation between cerebral 5-HT4 receptor binding and verbal memory (r = 0.29; P = .02). Conclusions and Relevance Results of this study show that cerebral 5-HT4 receptor binding was lower in patients with MDD than in healthy controls and that the memory dysfunction in patients with MDD was associated with lower cerebral 5-HT4 receptor binding. The cerebral 5-HT4 receptor is a promising treatment target for memory dysfunction in patients with MDD.
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Affiliation(s)
- Kristin Köhler-Forsberg
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke H. Dam
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Anjali Sankar
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Vincent Beliveau
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elizabeth B. Landman
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Søren V. Larsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Asbjørn S. Poulsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Cheng-Teng Ip
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Pharmacology, H. Lundbeck A/S, Valby, Denmark
| | - Anders Jørgensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Michal Meyer
- Center for Referral and Diagnostics, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Dea S. Stenbæk
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Hans R. L. Eiberg
- Department of Cellular and Molecular Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Madsen
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Claus Svarer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Martin B. Jørgensen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Vibe G. Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Gitte M. Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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5
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Ip CT, Ganz M, Ozenne B, Olbrich S, Beliveau V, Dam VH, Köhler-Forsberg K, Jørgensen MB, Frøkjær VG, Knudsen GM. Association between the loudness dependence of auditory evoked potential, serotonergic neurotransmission and treatment outcome in patients with depression. Eur Neuropsychopharmacol 2023; 70:32-44. [PMID: 36863106 DOI: 10.1016/j.euroneuro.2023.02.008] [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: 08/08/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/04/2023]
Abstract
Previous studies have suggested that the loudness dependence of auditory evoked potential (LDAEP) is associated with the effectiveness of antidepressant treatment in patients with major depressive disorders (MDD). Furthermore, both LDAEP and the cerebral serotonin 4 receptor (5-HT4R) density is inversely related to brain serotonin levels. We included 84 patients with MDD and 22 healthy controls to examined the association between LDAEP and treatment response and its association with cerebral 5-HT4R density. Participants underwent both EEG and 5-HT4R neuroimaging with [11C]SB207145 PET. Thirty-nine patients with MDD were re-examined after 8 weeks of treatment with selective serotonin reuptake inhibitors/serotonin noradrenaline reuptake inhibitor (SSRI/SNRI). We found that the cortical source of LDAEP was higher in untreated patients with MDD compared to healthy controls (p=0.03). Prior to SSRI/SNRI treatment, subsequent treatment responders had a negative association between LDAEP and depressive symptoms and a positive association between scalp LDAEP and symptom improvement at week 8. This was not found in source LDAEP. In healthy controls, we found a positive correlation between both scalp and source LDAEP and cerebral 5-HT4R binding but that was not observed in patients with MDD. We did not see any changes in scalp and source LDAEP in response to SSRI/SNRI treatment. These results support a theoretical framework where both LDAEP and cerebral 5-HT4R are indices of cerebral 5-HT levels in healthy individuals while this association seems to be disrupted in MDD. The combination of the two biomarkers may be useful for stratifying patients with MDD. Clinical Trials Registration:https://clinicaltrials.gov/ct2/show/NCT02869035?draw=1Registration number: NCT0286903.
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Affiliation(s)
- Cheng-Teng Ip
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark; Center for Cognitive and Brain Sciences, University of Macau, Taipa, Macau SAR, China
| | - Melanie Ganz
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Public Health, Section of Biostatistics, University of Copenhagen, Denmark
| | - Sebastian Olbrich
- Department for Psychiatry, Psychotherapy and Psychosomatic, University Zurich, Switzerland
| | - Vincent Beliveau
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Vibeke H Dam
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Martin B Jørgensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Vibe G Frøkjær
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Gitte M Knudsen
- Neurobiology Research Unit and NeuroPharm, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Dam VH, Stenbæk DS, Köhler-Forsberg K, Cheng Ip, Ozenne B, Sahakian BJ, Knudsen GM, Jørgensen MB, Frokjaer VG. Evaluating cognitive disturbances as treatment target and predictor of antidepressant action in major depressive disorder: A NeuroPharm study. Transl Psychiatry 2022; 12:468. [PMID: 36347845 PMCID: PMC9643376 DOI: 10.1038/s41398-022-02240-1] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Cognitive disturbances in major depressive disorder (MDD) constitute a critical treatment target and hold promise as an early predictor of antidepressant treatment response; yet their clinical relevance is not fully established. Therefore, we here investigate if (1) cognitive performance improves over the course of antidepressant treatment and (2) cognitive performance at baseline is predictive of antidepressant treatment response. In the NeuroPharm study (clinical trial id: NCT02869035), 92 antidepressant-free patients with a moderate to severe depressive episode were assessed with a comprehensive cognitive test battery including both cold (emotion-independent) and hot (emotion-dependent) tasks. Patients were tested before and after 12 weeks of standard antidepressant treatment with escitalopram in flexible doses of 10-20 mg. Performance improved across most cognitive domains over the course of antidepressant treatment. Notably, these improvements were independent of improvement in mood symptoms, emphasizing that cognitive disturbances are a distinct symptom and therefore treatment target in MDD. Results did not suggest that performance on any single cognitive measure at baseline was associated with later clinical response to antidepressant treatment. However, a small cluster of patients (N = 28) with globally disturbed cognition at baseline exhibited poorer clinical response after 8 but not 12 weeks of antidepressant treatment, suggesting that severe cognitive disturbances may delay treatment response. Thus, while pretreatment cognitive performance on individual tests may not be useful as clinical markers of treatment response, profiles capturing performance across different cognitive domains may be useful for stratification of patients with MDD and could be helpful in future intervention trials.
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Affiliation(s)
- Vibeke Høyrup Dam
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. .,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Dea Siggaard Stenbæk
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cheng Ip
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark ,Department of Clinical Pharmacology, Lundbeck Pharma A/S, Valby, Denmark
| | - Brice Ozenne
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Barbara Jacquelyn Sahakian
- grid.5335.00000000121885934Department of Psychiatry, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Behavioral and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
| | - Gitte Moos Knudsen
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin Balslev Jørgensen
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark ,grid.466916.a0000 0004 0631 4836Psychiatric Center Copenhagen, Copenhagen, Denmark
| | - Vibe Gedsoe Frokjaer
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Psychology, University of Copenhagen, Copenhagen, Denmark ,grid.466916.a0000 0004 0631 4836Psychiatric Center Copenhagen, Copenhagen, Denmark
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7
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Köhler-Forsberg K, Ozenne B, Larsen SV, Poulsen AS, Landman EB, Dam VH, Ip CT, Jørgensen A, Svarer C, Knudsen GM, Frokjaer VG, Jørgensen MB. Concurrent anxiety in patients with major depression and cerebral serotonin 4 receptor binding. A NeuroPharm-1 study. Transl Psychiatry 2022; 12:273. [PMID: 35821015 PMCID: PMC9276803 DOI: 10.1038/s41398-022-02034-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/13/2022] [Accepted: 06/23/2022] [Indexed: 11/09/2022] Open
Abstract
Concurrent anxiety is frequent in major depressive disorder and a shared pathophysiological mechanism between anxiety and other depressive symptoms is plausible. The serotonin 4 receptor (5-HT4R) has been implicated in both depression and anxiety. This is the first study to investigate the association between the cerebral 5-HT4R binding and anxiety in patients with depression before and after antidepressant treatment and the association to treatment response. Ninety-one drug-free patients with depression were positron emission tomography scanned with the 5-HT4R ligand [11C]-SB207145. Depression severity and concurrent anxiety was measured at baseline and throughout 8 weeks of antidepressant treatment. Anxiety measures included four domains: anxiety/somatization factor score; Generalized Anxiety Disorder 10-items (GAD-10) score; anxiety/somatization factor score ≥7 (anxious depression) and syndromal anxious depression. Forty patients were rescanned at week 8. At baseline, we found a negative association between global 5-HT4R binding and both GAD-10 score (p < 0.01) and anxiety/somatization factor score (p = 0.06). Further, remitters had a higher baseline anxiety/somatization factor score compared with non-responders (p = 0.04). At rescan, patients with syndromal anxious depression had a greater change in binding relative to patients with non-syndromal depression (p = 0.04). Concurrent anxiety in patients with depression measured by GAD-10 score and anxiety/somatization factor score is negatively associated with cerebral 5-HT4R binding. A lower binding may represent a subtype with reduced natural resilience against anxiety in a depressed state, and concurrent anxiety may influence the effect on the 5-HT4R from serotonergic antidepressants. The 5-HT4R is a promising neuroreceptor for further understanding the underpinnings of concurrent anxiety in patients with depression.
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Affiliation(s)
- Kristin Köhler-Forsberg
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.475435.4Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Brice Ozenne
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Søren V. Larsen
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Asbjørn S. Poulsen
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Elizabeth B. Landman
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Vibeke H. Dam
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Cheng-Teng Ip
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.424580.f0000 0004 0476 7612Department of Clinical Pharmacology, H. Lundbeck A/S, Valby, Denmark
| | - Anders Jørgensen
- grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.475435.4Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Claus Svarer
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gitte M. Knudsen
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Vibe G. Frokjaer
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.475435.4Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Martin B. Jørgensen
- grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.475435.4Psychiatric Centre Copenhagen, Rigshospitalet, Copenhagen, Denmark
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8
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Jorgensen A, Köhler-Forsberg K, Henriksen T, Weimann A, Brandslund I, Ellervik C, Poulsen HE, Knudsen GM, Frokjaer VG, Jorgensen MB. Systemic DNA and RNA damage from oxidation after serotonergic treatment of unipolar depression. Transl Psychiatry 2022; 12:204. [PMID: 35577781 PMCID: PMC9110351 DOI: 10.1038/s41398-022-01969-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/27/2022] [Accepted: 05/04/2022] [Indexed: 11/09/2022] Open
Abstract
Previous studies have indicated that antidepressants that inhibit the serotonin transporter reduces oxidative stress. DNA and RNA damage from oxidation is involved in aging and a range of age-related pathophysiological processes. Here, we studied the urinary excretion of markers of DNA and RNA damage from oxidation, 8-oxodG and 8-oxoGuo, respectively, in the NeuroPharm cohort of 100 drug-free patients with unipolar depression and in 856 non-psychiatric community controls. Patients were subsequently treated for 8 weeks with escitalopram in flexible doses of 5-20 mg; seven of these switched to duloxetine by week 4, as allowed by the protocol. At week 8, 82 patients were followed up clinically and with measurements of 8-oxodG/8-oxoGuo. Contextual data were collected in patients, including markers of cortisol excretion and low-grade inflammation. The intervention was associated with a substantial reduction in both 8-oxodG/8-oxoGuo excretion (25% and 10%, respectively). The change was not significantly correlated to measures of clinical improvement. Both markers were strongly and negatively correlated to cortisol, as measured by the area under the curve for the full-day salivary cortisol excretion. Surprisingly, patients had similar levels of 8-oxodG excretion and lower levels of 8-oxoGuo excretion at baseline compared to the controls. We conclude that intervention with serotonin reuptake inhibitors in unipolar depression is associated with a reduction in systemic DNA and RNA damage from oxidation. To our knowledge, this to date the largest intervention study to characterize this phenomenon, and the first to include a marker of RNA oxidation.
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Affiliation(s)
- Anders Jorgensen
- Psychiatric Center Copenhagen, Mental Health Services, Copenhagen, Denmark. .,Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. .,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Kristin Köhler-Forsberg
- grid.466916.a0000 0004 0631 4836Psychiatric Center Copenhagen, Mental Health Services, Copenhagen, Denmark ,grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Trine Henriksen
- grid.4973.90000 0004 0646 7373Department of Clinical Pharmacology, University Hospital Copenhagen, Bispebjerg and Frederiksberg, Denmark
| | - Allan Weimann
- grid.4973.90000 0004 0646 7373Department of Clinical Pharmacology, University Hospital Copenhagen, Bispebjerg and Frederiksberg, Denmark
| | - Ivan Brandslund
- grid.459623.f0000 0004 0587 0347Department of Clinical Immunology and Biochemistry, Lillebælt Hospital, Vejle, Denmark ,grid.10825.3e0000 0001 0728 0170Faculty of Health Science, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Christina Ellervik
- grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.38142.3c000000041936754XHarvard Medical School, Boston, USA
| | - Henrik E. Poulsen
- grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.4973.90000 0004 0646 7373Department of Clinical Pharmacology, University Hospital Copenhagen, Bispebjerg and Frederiksberg, Denmark ,grid.4973.90000 0004 0646 7373Department of Cardiology, Copenhagen University Hospital Hillerød, Copenhagen, Denmark ,grid.4973.90000 0004 0646 7373Department of Endocrinology, Copenhagen University Hospital Hillerød, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Vibe G. Frokjaer
- grid.466916.a0000 0004 0631 4836Psychiatric Center Copenhagen, Mental Health Services, Copenhagen, Denmark ,grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin B. Jorgensen
- grid.466916.a0000 0004 0631 4836Psychiatric Center Copenhagen, Mental Health Services, Copenhagen, Denmark ,grid.475435.4Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XInstitute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Larsen SV, Ozenne B, Köhler-Forsberg K, Poulsen AS, Dam VH, Svarer C, Knudsen GM, Jørgensen MB, Frokjaer VG. The Impact of Hormonal Contraceptive Use on Serotonergic Neurotransmission and Antidepressant Treatment Response: Results From the NeuroPharm 1 Study. Front Endocrinol (Lausanne) 2022; 13:799675. [PMID: 35360055 PMCID: PMC8962375 DOI: 10.3389/fendo.2022.799675] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Hormonal contraceptive (HC) use has been associated with an increased risk of developing a depressive episode. This might be related to HC's effect on the serotonergic brain system as suggested by recent cross-sectional data from our group, which show that healthy oral contraceptive (OC) users relative to non-users have lower cerebral serotonin 4 receptor (5-HT4R) levels. Here, we determine if cerebral 5-HT4R binding differs between HC non-users, OC users, and hormonal intrauterine device (HIUD) users among women with an untreated depressive episode. Also, we test if antidepressant drug treatment response and its association with pre-treatment 5-HT4R binding depends on HC status. METHODS [11C]-SB207145 Positron Emission Tomography imaging data from the NeuroPharm-NP1 Study (NCT02869035) were available from 59 depressed premenopausal women, of which 26 used OCs and 10 used HIUDs. The participants were treated with escitalopram. Treatment response was measured as the relative change in the Hamilton Depression Rating Scale 6 items (rΔHAMD6) from baseline to week eight. Latent variable models were used to evaluate the association between global 5-HT4R binding and OC and HIUD use as well as rΔHAMD6. RESULTS We found no evidence of a difference in global 5-HT4R binding between depressed HC users and non-users (p≥0.51). A significant crossover interaction (p=0.02) was observed between non-users and OC users in the association between baseline global 5-HT4R binding and week eight rΔHAMD6; OC users had 3-4% lower binding compared to non-users for every 10% percent less improvement in HAMD6. Within the groups, we observed a trend towards a positive association in non-users (padj=0.10) and a negative association in OC users (padj=0.07). We found no strong evidence of a difference in treatment response between the groups (p=0.13). CONCLUSIONS We found no difference in 5-HT4R binding between HC users vs. non-users in depressed women, however, it seemed that 5-HT4R settings differed qualitatively in their relation to antidepressant drug treatment response between OC users and non-users. From this we speculate that depressed OC users constitutes a special serotonin subtype of depression, which might have implications for antidepressant drug treatment response.
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Affiliation(s)
- Søren Vinther Larsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Center Copenhagen, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark
| | | | - Vibeke Høyrup Dam
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Claus Svarer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin Balslev Jørgensen
- Psychiatric Center Copenhagen, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark
| | - Vibe Gedso Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Center Copenhagen, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark
- *Correspondence: Vibe Gedso Frokjaer,
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10
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Dam VH, Stenbæk DS, Köhler-Forsberg K, Ip C, Ozenne B, Sahakian BJ, Knudsen GM, Jørgensen MB, Frokjaer VG. Hot and cold cognitive disturbances in antidepressant-free patients with major depressive disorder: a NeuroPharm study. Psychol Med 2021; 51:2347-2356. [PMID: 32317043 PMCID: PMC8506354 DOI: 10.1017/s0033291720000938] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 09/17/2019] [Revised: 02/05/2020] [Accepted: 03/24/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cognitive disturbances are common and disabling features of major depressive disorder (MDD). Previous studies provide limited insight into the co-occurrence of hot (emotion-dependent) and cold (emotion-independent) cognitive disturbances in MDD. Therefore, we here map both hot and cold cognition in depressed patients compared to healthy individuals. METHODS We collected neuropsychological data from 92 antidepressant-free MDD patients and 103 healthy controls. All participants completed a comprehensive neuropsychological test battery assessing hot cognition including emotion processing, affective verbal memory and social cognition as well as cold cognition including verbal and working memory and reaction time. RESULTS The depressed patients showed small to moderate negative affective biases on emotion processing outcomes, moderate increases in ratings of guilt and shame and moderate deficits in verbal and working memory as well as moderately slowed reaction time compared to healthy controls. We observed no correlations between individual cognitive tasks and depression severity in the depressed patients. Lastly, an exploratory cluster analysis suggested the presence of three cognitive profiles in MDD: one characterised predominantly by disturbed hot cognitive functions, one characterised predominantly by disturbed cold cognitive functions and one characterised by global impairment across all cognitive domains. Notably, the three cognitive profiles differed in depression severity. CONCLUSION We identified a pattern of small to moderate disturbances in both hot and cold cognition in MDD. While none of the individual cognitive outcomes mapped onto depression severity, cognitive profile clusters did. Overall cognition-based stratification tools may be useful in precision medicine approaches to MDD.
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Affiliation(s)
- V. H. Dam
- Neurobiology Research Unit, the Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - D. S. Stenbæk
- Neurobiology Research Unit, the Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - K. Köhler-Forsberg
- Neurobiology Research Unit, the Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- Psychiatric Center Copenhagen, Copenhagen University Hospital Rigshospitalet, Denmark
| | - C. Ip
- Neurobiology Research Unit, the Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- Department of Clinical Pharmacology, H. Lundbeck A/S, Valby, Denmark
| | - B. Ozenne
- Neurobiology Research Unit, the Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Denmark
| | - B. J. Sahakian
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Behavioral and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
| | - G. M. Knudsen
- Neurobiology Research Unit, the Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - M. B. Jørgensen
- Psychiatric Center Copenhagen, Copenhagen University Hospital Rigshospitalet, Denmark
| | - V. G. Frokjaer
- Neurobiology Research Unit, the Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Denmark
- Psychiatric Center Copenhagen, Copenhagen University Hospital Rigshospitalet, Denmark
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11
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Ip CT, Ganz M, Dam VH, Ozenne B, Rüesch A, Köhler-Forsberg K, Jørgensen MB, Frokjaer VG, Søgaard B, Christensen SR, Knudsen GM, Olbrich S. NeuroPharm study: EEG wakefulness regulation as a biomarker in MDD. J Psychiatr Res 2021; 141:57-65. [PMID: 34175743 DOI: 10.1016/j.jpsychires.2021.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 05/19/2021] [Accepted: 06/13/2021] [Indexed: 01/08/2023]
Abstract
While several electroencephalogram (EEG)-based biomarkers have been proposed as diagnostic or predictive tools in major depressive disorder (MDD), there is a clear lack of replication studies in this field. Markers that link clinical features such as disturbed wakefulness regulation in MDD with neurophysiological patterns are particularly promising candidates for e.g., EEG-informed choices of antidepressive treatment. We investigate if we in an independent MDD sample can replicate abnormal findings of EEG-vigilance regulation during rest and as a predictor for antidepressive treatment response. EEG-resting state was recorded in 91 patients and 35 healthy controls from the NeuroPharm trial. EEG-vigilance was assessed using the Vigilance Algorithm Leipzig (VIGALL). We compared the vigilance regulation during rest between patients and healthy controls and between remitters/responders and non-remitters/non-responders after eight weeks of SSRI/SNRI treatment using two different sets of response criteria (NeuroPharm and iSPOT-D). We replicated previous findings showing hyperstable EEG-wakefulness regulation in patients in comparison to healthy subjects. Responders defined by the iSPOT-D criteria showed a higher propensity toward low vigilance stages in comparison to patients with no response at pretreatment, however, this did not apply when using the NeuroPharm criteria. EEG-wakefulness regulation patterns normalized toward patterns of healthy controls after 8 weeks of treatment. This replication study supports the diagnostic value of EEG-vigilance regulation and its usefulness as a biomarker for the choice of treatment in MDD.
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Affiliation(s)
- Cheng-Teng Ip
- Department of Experimental Medicine, H. Lundbeck A/S, Valby, Denmark; Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melanie Ganz
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke H Dam
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Public Health, Section of Biostatistics, University of Copenhagen, Denmark
| | - Annia Rüesch
- Department for Psychiatry, Psychotherapy and Psychosomatic, University Zurich, Switzerland
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin B Jørgensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Birgitte Søgaard
- Department of Experimental Medicine, H. Lundbeck A/S, Valby, Denmark
| | | | - Gitte M Knudsen
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Olbrich
- Department for Psychiatry, Psychotherapy and Psychosomatic, University Zurich, Switzerland.
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12
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Ip CT, Olbrich S, Ganz M, Ozenne B, Köhler-Forsberg K, Dam VH, Beniczky S, Jørgensen MB, Frokjaer VG, Søgaard B, Christensen SR, Knudsen GM. Pretreatment qEEG biomarkers for predicting pharmacological treatment outcome in major depressive disorder: Independent validation from the NeuroPharm study. Eur Neuropsychopharmacol 2021; 49:101-112. [PMID: 33910154 DOI: 10.1016/j.euroneuro.2021.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/24/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
Several electroencephalogram (EEG) biomarkers for prediction of drug response in major depressive disorder (MDD) have been proposed, but validations in larger independent datasets are missing. In the current study, we investigated the prognostic value of previously suggested EEG biomarkers. We gathered data that matched prior studies in terms of EEG methodology, clinical criteria for MDD, and statistical approach as closely as possible. The NeuroPharm study is a non-randomized and open label prospective clinical trial. One hundred antidepressant free patients with MDD were enrolled in the study and 79 (57 female) were included in the per-protocol analysis. The biomarkers candidates for cross-validation were derived from prior studies such as iSPOT-D and EMBARC and include frontal and occipital alpha power and asymmetry and delta and theta activity at anterior cingulate cortex (ACC). The alpha asymmetry, reported in two out of six prior studies, could be partially validated. We found that in female patients, larger right than left frontal alpha power prior to drug treatment was associated with better clinical outcome 8 weeks later. Moreover, female non-responder had higher central left alpha power relative to the right. In contrast to prior reports, we found that lower theta activity at ACC was present in remitters and was associated with greater improvement at week 8. We provide evidence that in women with MDD, alpha asymmetry seems to be the most promising EEG biomarker for prediction of treatment response. Registration number: NCT02869035.
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Affiliation(s)
- Cheng-Teng Ip
- Department of Clinical Pharmacology, H. Lundbeck A/S, Valby, Denmark; Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Olbrich
- Department of Psychiatry, Psychotherapy and Psychosomatic, University Zürich, Switzerland
| | - Melanie Ganz
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Section of Biostatistics, Department of Public Health, University of Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke H Dam
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund, Denmark; Department of Clinical Medicine, University of Aarhus, Aarhus, Denmark; Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Martin B Jørgensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Birgitte Søgaard
- Department of Clinical Pharmacology, H. Lundbeck A/S, Valby, Denmark
| | | | - Gitte M Knudsen
- Neurobiology Research Unit, University Hospital Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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13
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Brandt IM, Köhler-Forsberg K, Ganz M, Ozenne B, Jorgensen MB, Poulsen A, Knudsen GM, Frokjaer VG, Fisher PM. Reward processing in major depressive disorder and prediction of treatment response - Neuropharm study. Eur Neuropsychopharmacol 2021; 44:23-33. [PMID: 33455816 DOI: 10.1016/j.euroneuro.2020.12.010] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/04/2020] [Accepted: 12/28/2020] [Indexed: 11/18/2022]
Abstract
Major depressive disorder (MDD) is a prevalent brain disorder for which anhedonia is a core symptom, indicating aberrations in the neural processing of reward. The striatum, medial prefrontal cortex (mPFC) and anterior insula (AI) are core reward processing regions. Here we used a reward-related, card-guessing functional magnetic resonance imaging (fMRI) paradigm to assay brain responses to reward in 90 MDD individuals and 58 healthy controls. We evaluated group differences in task-responsive, reward-related striatal, mPFC, and AI reactivity and whether baseline reactivity predicted an eight-week escitalopram antidepressant treatment response in MDD individuals. Thirty-eight MDD individuals also completed the reward paradigm after treatment and we evaluated antidepressant effects on reward reactivity estimates. Multivariate statistical analysis of task-responsive striatum, mPFC and AI brain responses did not reveal statistically significant differences between MDD and HC individuals (puncorrected>0.23). Logistic regression models (five-fold cross-validation, statistical significance assessed with permutation testing) also did not support that baseline reward-related brain responses significantly predicted antidepressant treatment response (puncorrected>0.39). Finally, reward-related brain responses were not statistically significantly changed over the course of treatment (puncorrected>0.27). Our findings in a comparatively large MDD cohort do not support that these reward-related fMRI brain responses are informative biomarkers of MDD or antidepressant treatment response to escitalopram.
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Affiliation(s)
- Ida Marie Brandt
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Faculty of Science, University of Copenhagen, Copenhagen, DK
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Psychiatric Center Copenhagen, Rigshospitalet, 2100 Copenhagen O, Denmark
| | - Melanie Ganz
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark; Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark; Department of Public Health, Section of Biostatistics, University of Copenhagen, 1014 Copenhagen K, Denmark
| | - Martin B Jorgensen
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Psychiatric Center Copenhagen, Rigshospitalet, 2100 Copenhagen O, Denmark
| | - Asbjorn Poulsen
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark
| | - Gitte M Knudsen
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vibe G Frokjaer
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Psychiatric Center Copenhagen, Rigshospitalet, 2100 Copenhagen O, Denmark
| | - Patrick M Fisher
- Neurobiology Research Unit and NeuroPharm, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen O, Denmark.
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14
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Hjordt LV, Ozenne B, Armand S, Dam VH, Jensen CG, Köhler-Forsberg K, Knudsen GM, Stenbæk DS. Psychometric Properties of the Verbal Affective Memory Test-26 and Evaluation of Affective Biases in Major Depressive Disorder. Front Psychol 2020; 11:961. [PMID: 32581907 PMCID: PMC7289973 DOI: 10.3389/fpsyg.2020.00961] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/17/2020] [Indexed: 11/30/2022] Open
Abstract
We developed the Verbal Affective Memory Test-26 (VAMT-26), a computerized test to assess verbal memory, as an improvement of the Verbal Affective Memory Test-24 (VAMT-24). Here, we psychometrically evaluate the VAMT-26 in 182 healthy controls, examine 1-month test–retest stability in 48 healthy controls, and examine whether 87 antidepressant-free patients diagnosed with Major Depressive Disorder (MDD) tested with VAMT-26 differed in affective memory biases from 335 healthy controls tested with VAMT24/26. We also examine whether affective memory biases are associated with depressive symptoms across the patients and healthy controls. VAMT-26 showed good psychometric properties. Age, sex, and IQ, but not education, influenced VAMT-26 scores. VAMT-26 scores converged satisfactorily with scores on a test associated with non-affective verbal memory. Test–retest analyses showed a learning effect and a r ≥ 0.0.8, corresponding to a typical variation of 10% in recalled words from first to second test. Patients tended to remember more negative words relative to positive words compared to healthy controls at borderline significance (p = 0.06), and affective memory biases were negatively associated with depressive symptoms across the two groups at borderline significance (p = 0.07), however, the effect sizes were small. Future studies are needed to address whether VAMT-26 can be used to distinguish between depression subtypes in patients with MDD. As a verbal memory test, VAMT-26 is a well validated neuropsychological test and we recommend it to be used in Danish and international studies on affective memory.
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Affiliation(s)
- Liv V Hjordt
- Neurobiology Research Unit and Center for Integrated Molecular Brain Imaging, Rigshospitalet, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit and Center for Integrated Molecular Brain Imaging, Rigshospitalet, Copenhagen, Denmark.,Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Sophia Armand
- Neurobiology Research Unit and Center for Integrated Molecular Brain Imaging, Rigshospitalet, Copenhagen, Denmark
| | - Vibeke H Dam
- Neurobiology Research Unit and Center for Integrated Molecular Brain Imaging, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christian G Jensen
- Centre for Mental Health Promotion, Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Kristin Köhler-Forsberg
- Neurobiology Research Unit and Center for Integrated Molecular Brain Imaging, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Psychiatric Center Copenhagen, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gitte M Knudsen
- Neurobiology Research Unit and Center for Integrated Molecular Brain Imaging, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dea S Stenbæk
- Neurobiology Research Unit and Center for Integrated Molecular Brain Imaging, Rigshospitalet, Copenhagen, Denmark
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Köhler-Forsberg K, Jorgensen A, Dam VH, Stenbæk DS, Fisher PM, Ip CT, Ganz M, Poulsen HE, Giraldi A, Ozenne B, Jørgensen MB, Knudsen GM, Frokjaer VG. Predicting Treatment Outcome in Major Depressive Disorder Using Serotonin 4 Receptor PET Brain Imaging, Functional MRI, Cognitive-, EEG-Based, and Peripheral Biomarkers: A NeuroPharm Open Label Clinical Trial Protocol. Front Psychiatry 2020; 11:641. [PMID: 32792991 PMCID: PMC7391965 DOI: 10.3389/fpsyt.2020.00641] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 11/27/2019] [Accepted: 06/19/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Between 30 and 50% of patients with major depressive disorder (MDD) do not respond sufficiently to antidepressant regimens. The conventional pharmacological treatments predominantly target serotonergic brain signaling but better tools to predict treatment response and identify relevant subgroups of MDD are needed to support individualized and mechanistically targeted treatment strategies. The aim of this study is to investigate antidepressant-free patients with MDD using neuroimaging, electrophysiological, molecular, cognitive, and clinical examinations and evaluate their ability to predict clinical response to SSRI treatment as individual or combined predictors. METHODS We will include 100 untreated patients with moderate to severe depression (>17 on the Hamilton Depression Rating Scale 17) in a non-randomized open clinical trial. We will collect data from serotonin 4 receptor positron emission tomography (PET) brain scans, functional magnetic resonance imaging (fMRI), electroencephalogram (EEG), cognitive tests, psychometry, and peripheral biomarkers, before (at baseline), during, and after 12 weeks of standard antidepressant treatment. Patients will be treated with escitalopram, and in case of non-response at week 4 or intolerable side effects, offered to switch to a second line treatment with duloxetine. Our primary outcome (treatment response) is assessed using the Hamilton depression rating subscale 6-item scores at week 8, compared to baseline. In a subset of the patients (n = ~40), we will re-assess the neurobiological response (using PET, fMRI, and EEG) 8 weeks after initiated pharmacological antidepressant treatment, to map neurobiological signatures of treatment responses. Data from matched controls will either be collected or is already available from other cohorts. DISCUSSION The extensive investigational program with follow-up in this large cohort of participants provides a unique possibility to (a) uncover potential biomarkers for antidepressant treatment response, (b) apply the findings for future stratification of MDD, (c) advance the understanding of pathophysiological underpinnings of MDD, and (d) uncover how putative biomarkers change in response to 8 weeks of pharmacological antidepressant treatment. Our data can pave the way for a precision medicine approach for optimized treatment of MDD and also provides a resource for future research and data sharing. CLINICAL TRIAL REGISTRATION The study was registered at clinicaltrials.gov prior to initiation (NCT02869035; 08.16.2016, URL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02869035&cntry=&state=&city=&dist=).
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Affiliation(s)
- Kristin Köhler-Forsberg
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Anders Jorgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Vibeke H Dam
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Dea Siggaard Stenbæk
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Patrick M Fisher
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Cheng-Teng Ip
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Pharmacology, H. Lundbeck A/S, Valby, Denmark
| | - Melanie Ganz
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center Copenhagen, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Martin Balslev Jørgensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vibe Gedsoe Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Psychiatry, Psychiatric Centre Copenhagen, Copenhagen, Denmark
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