A systematic review and network meta-analysis of carbon dioxide provocation in psychiatric disorders
BACKGROUND:False suffocation alarm hypothesis has been widely used to explain carbon dioxide hypersensitivity in panic disorder (PD). However, hypersensitivity to carbon dioxide has been observed in other psychiatric disorders. We explored the specificity of carbon dioxide inhalation as a panic provocation test among psychiatric disorders via network meta-analysis. METHODS:A systematic literature search on PubMed, EMBASE, and PsycNET was performed to acquire the studies using the carbon dioxide provocation test in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklists. Odds ratios (OR) for a panic attack (PA) induced by the carbon dioxide inhalation tests were extracted from each of the original studies and were pooled using the random-effects model. RESULTS:Network meta-analysis on a pool of 2181 participants from 41 studies was used to compare the efficacy of carbon dioxide provocation tests among psychiatric disorders. The network meta-analysis showed that the odds for PA in response to carbon dioxide inhalation are higher in patients with PD, premenstrual dysphoric syndrome (PMDD), and social anxiety disorder (SAD) than healthy controls (HC). The odds for PA were not significantly different among patients with generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), major depressive disorder (MDD), and healthy controls (HC). CONCLUSIONS:The vulnerability to the carbon dioxide provocation test is not limited to PD. The specificity of the test for PD is questionable, as individuals suffering from PMDD and SAD are also significantly more responsive to carbon dioxide inhalation compared to HC, OCD, MDD, and GAD. There may be shared underpinning biological mechanisms between PD, PMDD, and SAD.
P.327 Efficacy and safety of AXS-05, an oral, NMDA receptor antagonist with multimodal activity in major depressive disorder [Meeting Abstract]
Background: Major depressive disorder (MDD) is a debilitating and prevalent condition. Nearly two-thirds of treated patients with MDD do not experience an adequate response to first-line therapy, and most of these inadequate responders also fail second-line treatment. Time to clinically meaningful response with currently available antidepressants (up to 6-8 weeks) is also suboptimal. There is an urgent need for new, more effective, mechanistically novel, and faster-acting MDD treatments. AXS-05 (dextromethorphan/bupropion modulated delivery tablet) is a novel, oral, investigational NMDA receptor antagonist with multimodal activity, including sigma-1 receptor agonism. AXS-05 is being developed for the treatment of MDD.
Objective(s): To evaluate the efficacy and safety of AXS-05 versus placebo in MDD.
Method(s): The GEMINI study is a Phase 3, randomized, double-blind, placebo-controlled, multi-center, which enrolled subjects with a confirmed diagnosis of moderate to severe MDD. Three hundred twenty-seven (327) subjects were randomised (1:1) to receive AXS-05 (45 mg DM/105 mg bupropion) or placebo, twice daily for 6 weeks. The primary efficacy endpoint was the change in the Montgomery-Asberg Depression Rating Scale (MADRS) total score from baseline to week 6.
Result(s): On the primary endpoint, AXS-05 demonstrated a statistically significant mean reduction from baseline in the MADRS total score of 16.6 points versus 11.9 for placebo (p=0.002) after 6 weeks of treatment. AXS-05 rapidly, substantially and durably reduced depressive symptoms, demonstrating a statistically significant improvement compared to placebo on the key secondary endpoint of change from baseline in the MADRS total score at Week 1, the earliest time point measured (p=0.007), and at all timepoints thereafter. Rates of response (>= 50% MADRS improvement) were statistically significantly greater for AXS-05 compared to placebo at Week 1 (p=0.035) and at every time point thereafter, being achieved by 54% of AXS-05 patients versus 34% of placebo patients at Week 6 (p<0.001). Rates of remission (MADRS <=10) were statistically significantly greater for AXS-05 compared to placebo at Week 2 (p=0.013) and at every time point thereafter, being achieved by 40% of AXS-05 patients versus 17% of placebo patients at Week 6 (p<0.001). The observed rapid and durable antidepressant effects translated into early and statistically significant improvements in daily functioning as measured by the Sheehan Disability Scale, and in quality of life as measured by the Quality of Life Enjoyment and Satisfaction Questionnaire. AXS-05 was safe and well tolerated with the most commonly reported adverse events being dizziness, nausea, headache, diarrhea, somnolence and dry mouth. Treatment with AXS-05 was not associated with psychotomimetic effects. Rates of discontinuation due to adverse events in the trial were low (6.2% for AXS-05 and 0.6% for placebo).
Conclusion(s): Treatment with AXS-05 resulted in rapid, substantial, durable and statistically significant improvements in depressive symptomatology across multiple efficacy endpoints as compared to placebo in patients with MDD. Symptomatic benefits translated into statistically significant improvements on validated measures of daily functioning and quality of life. AXS-05 was safe and well tolerated in this trial and was not associated with psychotomimetic effects. Disclosure statement: Employee and shareholder of Axsome Therapeutics Inc.
Dimensions of interoception in obsessive-compulsive disorder
Interoceptive sensibility (IS) refers to the subjective experience of perceiving and being aware of one's internal body sensations, and is typically evaluated using self-report questionnaires or confidence ratings. Here we evaluated IS in 81 patients with OCD and 76 controls using the Multidimensional Scale of Interoceptive Awareness (MAIA), which contains 8 subscales assessing adaptive and maladaptive responses to sensation. Compared to controls, OCD patients showed hyperawareness of body sensations. Patients also demonstrated a more maladaptive profile of IS characterized by greater distraction from and worry about unpleasant sensations, and reduced tendency to experience the body as safe and trustworthy. These findings were independent of medication status and comorbidities in the patient group. Correlational analyses showed that subscales of the MAIA were differentially associated with OCD symptom dimensions. These findings indicate that patients with OCD show abnormality of IS that is independent of confounding factors related to medication and comorbidities and associated with different OCD symptom dimensions. Future work would benefit from examining neural correlates of these effects and evaluating whether dimensions of IS are impacted by treatments for the disorder.
Selective kappa-opioid antagonism ameliorates anhedonic behavior: evidence from the Fast-fail Trial in Mood and Anxiety Spectrum Disorders (FAST-MAS)
Anhedonia remains a major clinical issue for which there is few effective interventions. Untreated or poorly controlled anhedonia has been linked to worse disease course and increased suicidal behavior across disorders. Taking a proof-of-mechanism approach under the auspices of the National Institute of Mental Health FAST-FAIL initiative, we were the first to show that, in a transdiagnostic sample screened for elevated self-reported anhedonia, 8 weeks of treatment with a kappa-opioid receptor (KOR) antagonist resulted in significantly higher reward-related activation in one of the core hubs of the brain reward system (the ventral striatum), better reward learning in the Probabilistic Reward Task (PRT), and lower anhedonic symptoms, relative to 8 weeks of placebo. Here, we performed secondary analyses of the PRT data to investigate the putative effects of KOR antagonism on anhedonic behavior with more precision by using trial-level model-based Bayesian computational modeling and probability analyses. We found that, relative to placebo, KOR antagonism resulted in significantly higher learning rate (i.e., ability to learn from reward feedback) and a more sustained preference toward the more frequently rewarded stimulus, but unaltered reward sensitivity (i.e., the hedonic response to reward feedback). Collectively, these findings provide novel evidence that in a transdiagnostic sample characterized by elevated anhedonia, KOR antagonism improved the ability to modulate behavior as a function of prior rewards. Together with confirmation of target engagement in the primary report (Krystal et al., Nat Med, 2020), the current findings suggest that further transdiagnostic investigation of KOR antagonism for anhedonia is warranted.
Double-blind, placebo-controlled, dose-ranging trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD)
Numerous placebo-controlled studies have demonstrated the ability of ketamine, an NMDA receptor antagonist, to induce rapid (within hours), transient antidepressant effects when administered intravenously (IV) at subanesthetic doses (0.5â€‰mg/kg over 40â€‰min). However, the optimal antidepressant dose remains unknown. We aimed to compare to active placebo the rapid acting antidepressant properties of a broad range of subanesthetic doses of IV ketamine among outpatients with treatment-resistant depression (TRD). A range of IV ketamine doses were compared to active placebo in the treatment of adult TRD over a 3-day period following a single infusion over 40â€‰min. This was an outpatient study conducted across six US academic sites. Outpatients were 18-70 years old with TRD, defined as failure to achieve a satisfactory response (e.g., less than 50% improvement of depression symptoms) to at least two adequate treatment courses during the current depressive episode. Following a washout period, 99 eligible subjects were randomly assigned to one of the five arms in a 1:1:1:1:1 fashion: a single intravenous dose of ketamine 0.1â€‰mg/kg (nâ€‰=â€‰18), a single dose of ketamine 0.2â€‰mg/kg (nâ€‰=â€‰20), a single dose of ketamine 0.5â€‰mg/kg (nâ€‰=â€‰22), a single dose of ketamine 1.0â€‰mg/kg (nâ€‰=â€‰20), and a single dose of midazolam 0.045â€‰mg/kg (active placebo) (nâ€‰=â€‰19). The study assessments (HAM-D-6, MADRS, SDQ, PAS, CGI-S, and CGI-I) were performed at days 0, 1, 3 (endpoint), 5, 7, 14, and 30 to assess the safety and efficacy. The overall groupâ€‰Ã—â€‰time interaction effect was significant for the primary outcome measure, the HAM-D-6. In post hoc pairwise comparisons controlling for multiple comparisons, standard dose (0.5â€‰mg/kg) and high dose (1â€‰mg/kg) of intravenous ketamine were superior to active placebo; a low dose (0.1â€‰mg/kg) was significant only prior to adjustment (pâ€‰=â€‰0.02, p-adjâ€‰=â€‰0.14, dâ€‰=â€‰-0.82 at day 1). Most of the interaction effect was due to differences at day 1, with no significant adjusted pairwise differences at day 3. This pattern generally held for secondary outcomes. The infusions of ketamine were relatively well tolerated compared to active placebo, except for greater dissociative symptoms and transient blood pressure elevations with the higher doses. Our results suggest that there is evidence for the efficacy of the 0.5â€‰mg/kg and 1.0â€‰mg/kg subanesthetic doses of IV ketamine and no clear or consistent evidence for clinically meaningful efficacy of lower doses of IV ketamine.
Correction: Double-blind, placebo-controlled, dose-ranging trial of intravenous ketamine as adjunctive therapy in treatment-resistant depression (TRD) [Correction]
Supplementary Figure 1 and Supplementary Tables 1-4 have been re-uploaded so as to reflect the versions supplied during proofs stage. The publisher apologizes for the error in versioning. The HTML version of the paper has been updated.
Are Electroencephalogram-Derived Predictors of Antidepressant Efficacy Closer to Clinical Usefulness?
Effects of the KCNQ channel opener ezogabine on functional connectivity of the ventral striatum and clinical symptoms in patients with major depressive disorder
Major depressive disorder (MDD) is a leading cause of disability worldwide, yet current treatment strategies remain limited in their mechanistic diversity. Recent evidence has highlighted a promising novel pharmaceutical target-the KCNQ-type potassium channel-for the treatment of depressive disorders, which may exert a therapeutic effect via functional changes within the brain reward system, including the ventral striatum. The current study assessed the effects of the KCNQ channel opener ezogabine (also known as retigabine) on reward circuitry and clinical symptoms in patients with MDD. Eighteen medication-free individuals with MDD currently in a major depressive episode were enrolled in an open-label study and received ezogabine up to 900â€‰mg/day orally over the course of 10 weeks. Resting-state functional magnetic resonance imaging data were collected at baseline and posttreatment to examine brain reward circuitry. Reward learning was measured using a computerized probabilistic reward task. After treatment with ezogabine, subjects exhibited a significant reduction of depressive symptoms (Montgomery-Asberg Depression Rating Scale score change: -13.7â€‰Â±â€‰9.7, pâ€‰<â€‰0.001, dâ€‰=â€‰2.08) and anhedonic symptoms (Snaith-Hamilton Pleasure Scale score change: -6.1â€‰Â±â€‰5.3, pâ€‰<â€‰0.001, dâ€‰=â€‰1.00), which remained significant even after controlling for overall depression severity. Improvement in depression was associated with decreased functional connectivity between the ventral caudate and clusters within the mid-cingulate cortex and posterior cingulate cortex (nâ€‰=â€‰14, voxel-wise pâ€‰<â€‰0.005). In addition, a subgroup of patients tested with a probabilistic reward task (nâ€‰=â€‰9) showed increased reward learning following treatment. These findings highlight the KCNQ-type potassium channel as a promising target for future drug discovery efforts in mood disorders.
Efficacy of Esketamine Augmentation in Major Depressive Disorder: A Meta-Analysis
OBJECTIVE:Esketamine, the S-enantiomer of ketamine, was recently approved as a rapid-acting intranasal therapy for depression and is currently under development for suicidality. The authors sought to determine the efficacy of adjunctive intranasal esketamine in major depressive disorder (MDD). DATA SOURCES/METHODS:A systematic search of PubMed/MEDLINE was conducted up to January 2019, in addition to abstracts of major psychiatric meetings held since 2010. Searches were conducted by cross-referencing the term intranasal with the term esketamine. Where necessary, authors and/or study sponsors were contacted in order to obtain a copy of the presentation as well as any pertinent study details. STUDY SELECTION/METHODS:241 study abstracts were initially identified and reviewed. Selected studies were randomized, double-blind clinical trials comparing adjunctive intranasal esketamine to adjunctive placebo for MDD. DATA EXTRACTION/METHODS:Data were extracted independently by two of the authors. A random effects model was used to calculate the standardized mean difference (SMD) between esketamine and placebo (intranasal saline) in the Montgomery-Asberg Depression Rating Scale (MADRS) score change from baseline to endpoint, serving as the primary outcome of the study. RESULTS:Five trials with 774 patients were pooled. Adjunctive esketamine was significantly more effective than placebo for MADRS score change, response, and remission (N = 774, SMD = 0.36, 95% CI = 0.24-0.49, P < .0001; response: risk ratio [RR] = 1.40, 95% CI = 1.22-1.61, P < .0001; remission: RR = 1.45, 95% CI = 1.20-1.75, P < .0001). Results remained statistically significant regardless of differences in the study sample, fixed vs new/optimized baseline antidepressants. CONCLUSIONS:Adjunctive intranasal esketamine for patients with MDD who are either treatment-resistant or acutely suicidal appears to be an effective treatment strategy.
A randomized proof-of-mechanism trial applying the 'fast-fail' approach to evaluating Îº-opioid antagonism as a treatment for anhedonia
The National Institute of Mental Health (NIMH) 'fast-fail' approach seeks to improve too-often-misleading early-phase drug development methods by incorporating biomarker-based proof-of-mechanism (POM) testing in phase 2a. This first comprehensive application of the fast-fail approach evaluated the potential of Îº-opioid receptor (KOR) antagonism for treating anhedonia with a POM study determining whether robust target engagement favorably impacts the brain circuitry hypothesized to mediate clinical effects. Here we report the results from a multicenter, 8-week, double-blind, placebo-controlled, randomized trial in patients with anhedonia and a mood or anxiety disorder (selective KOR antagonist (JNJ-67953964, 10â€‰mg; nâ€‰=â€‰45) and placebo (nâ€‰=â€‰44)). JNJ-67953964 significantly increased functional magnetic resonance imaging (fMRI) ventral striatum activation during reward anticipation (primary outcome) as compared to placebo (baseline-adjusted mean: JNJ-67953964, 0.72 (s.d.â€‰=â€‰0.67); placebo, 0.33 (s.d.â€‰=â€‰0.68); F(1,86)â€‰=â€‰5.58, Pâ€‰<â€‰0.01; effect sizeâ€‰=â€‰0.58 (95% confidence interval, 0.13-0.99)). JNJ-67953964, generally well tolerated, was not associated with any serious adverse events. This study supports proceeding with assessment of the clinical impact of target engagement and serves as a model for implementing the 'fast-fail' approach.