Advances in depression treatment

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Via Christi Women's Connection presentation on advance in depression treatment by Matthew Macaluso, DO, medical director of Via Christi Psychiatric Clinic.

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  • KEY POINTS
    Chance for recovery decreases with increasing length of depressive illness.
    The first six months of an episode of major depression are an important period in terms of treatment and chance for recovery.
    The cumulative impact of extended morbidity suggests a progressive course.
    BACKGROUND
    431 subjects with major depression participating in the NIMH Collaborative Depression Study were prospectively observed for five years.
    These subjects had no history of mania, hypomania, or schizoaffective disorder, as well as no underlying minor depression (at least two years’ duration) and no chronic intermittent depressive disorder.
    Cumulative recovery probabilities were calculated for intervals ranging from one week to five years.
    Recovery was defined as remission (Psychiatric Status Rating [PSR] score 1 or 2, equivalent of minimal to absent symptoms, with no significant functional impairment) sustained for at least eight weeks.
    REFERENCE
    Keller MB, Lavori PW, Mueller TI, et al. Time to recovery, chronicity, and levels of
    psychopathology in major depression. A 5-year prospective follow-up of 431 subjects. Arch Gen
    Psychiatry. 1992;49(10):809-816.
  • KEY POINTS
    The hippocampus, a region of the brain involved in conscious memory, may begin to atrophy in depression.
    The hippocampus is at a “vulnerable intersection” of cognitive, emotional, and neuroendocrine regulation. It is rich in glucocorticoid receptors and is a recipient of significant excitatory glutaminergic innervation. A combined “toxic” impact may precipitate trophic changes.
    BACKGROUND
    The MRI scans above were obtained from a healthy control (L) and a person with severe depression (R).
    Indications of hippocampal atrophy are apparent in the diminished size of the area outlined in red in the enlargement of the scan obtained from the patient with depression.
    Investigators have found that about half of persons with severe depression exhibit high levels of the stress hormone, cortisol, which is thought to be toxic to neurons. (Source: J. Douglas Bremner, MD, Yale University).
    REFERENCE
    Bremner JD, Narayan M, Anderson ER, et al. Hippocampal volume reduction in major depression. Am J
    Psychiatry. 2000;157(1):115-118.
  • KEY POINT
    Patients with depression have abnormalities in cerebral blood flow in specific areas of the brain, implicating them in the cortical circuitry that may play a role in the pathophysiology of depressive symptoms.
  • KEY POINT
    There is a reciprocal polysynaptic connection between the ventromedial prefrontal cortex (VMPFC) and the dorsolateral prefrontal cortex (DLPFC) that leads through the cingulate and hippocampus. Increased activity in the DLPFC is often associated with diminished activity of the VMPFC. It is postulated that excessive excitatory (glutaminergic) input from the VMPFC, combined with elevated glucocorticoids, results in hippocampal injury.
    BACKGROUND
    Ventromedial PFC: receives integrated sensory information from the orbital PFC as well as fear- and reward-related input from the amygdala, medial temporal lobe, and ventral striatum (nucleus accumbens). It projects to the hippocampus, diencephalon, and brainstem, where it regulates autonomic and neuroendocrine response, pain modulation, aggression, and sexual and eating behaviors.1
    Lateral orbital PFC (lateral and posterior): receives highly processed and integrated sensory information from the parietal cortex. It is also connected to the amygdala, ventral striatum, and lateral hypothalamus. Activity is increased in depression, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and panic disorder. Orbital PFC plays a role in correcting and inhibiting maladaptive, perseverative, and emotional responses (in part, generated by the amygdala).2
    Dorsolateral PFC: has been implicated in cognitive control, solving complex tasks, maintenance, and manipulation of information in working memory. Hypoactivity of the DLPFC in depression has been associated with psychomotor retardation and anhedonia.2,3
    REFERENCES
    1. Öngür D, Price JL. The organization of networks within the orbital and medial prefrontal cortex of rats, monkeys and humans. Cereb Cortex. 2000;10(3):206-219.
    2. Drevets WC. Functional neuroimaging studies of depression: the anatomy of melancholia. Annu Rev Med. 1998;49:341-361.
    3. MacDonald AW III, Cohen JD, Stenger VA, Carter CS. Dissociating the role of the dorsolateral prefrontal and anterior cingulate cortex in cognitive control. Science. 2000;288(5472):1835-1838.
  • KEY POINT
    The prefrontal cortex and limbic system are organized in intricate networks involved in processing emotional and cognitive information. These areas predominantly utilize GABA and glutamate for neurotransmission. Information processing and mutual relationships are significantly influenced by monoaminergic (5-HT, NE, and DA) projections.
    BACKGROUND
    Amygdala: is involved in recruiting and coordinating cortical arousal and neuroendocrine response to underdetermined (surprising and ambiguous) stimuli. The amygdala is also involved in emotional learning and memory. Abnormal activation of the amygdala correlates with degree of depression. (It has also been noted in bipolar depression and anxiety.) The amygdala may be implicated in a tendency to ruminate on emotionally negative memories.1
    Hippocampus: has a critical role in episodic, contextual learning, and memory. It is rich in corticosteroid receptors and provides inhibitory feedback to hypothalamic-pituitary-adrenal axis. Hippocampal dysfunction may be responsible for inappropriate context-dependent emotional responses.2
    REFERENCES
    1. Davidson RJ. Affective neuroscience and psychophysiology: toward a synthesis. Psychophysiology. 2003;40(5):655-665.
    2. Davidson RJ, Pizzagalli D, Nitschke JB, Putnam K. Depression: perspectives from affective neuroscience. Annu Rev Psychol. 2002;53:545-574.
  • KEY POINTS
    Not only do 5-HT and NE influence the balance between excitatory (Glu) and inhibitory (GABA) transmission in key areas involved in processing of emotional/cognitive information, prefrontal Glu neurons have a regulatory (mostly inhibitory) impact on monoaminergic nuclei.1
    A combination of excessive excitatory input, elevated glucocorticoids, and compromised monoaminergic function may result in prefrontal and hippocampal atrophy and disrupt adaptive emotional processing.2 Hippocampal dysfunction may also contribute to neuroendocrine imbalance and perpetuate this vicious cycle.
    REFERENCES
    1. Paul IA, Skolnick P. Glutamate and depression: clinical and preclinical studies. Ann NY Acad Sci. 2003;1003:250-272.
    2. Sheline YI. 3D MRI studies of neuroanatomic changes in unipolar major depression: the role of stress and medical comorbidity. Biol Psychiatry. 2000;48(8):791-800.
  • The opening of NMDA glutamate receptors requires the presence of both glutamate and glycine, each of which bind to a different site on the receptor.
    Magnesium is a negative allosteric modulator (NAM) at NMDA glutamate receptors. When magnesium is also bound and the membrane is not depolarized, it prevents the effects of glutamate and glycine and thus does not allow the ion channel to open. In order for the channel to open, depolarization must remove magnesium while both glutamate and glycine are bound to their sites on the ligand-gated ion channel complex.
  • AMPA and/or kainate may affect the functioning of NMDA receptors in gating the calcium channel.
    When glutamate arrives, it binds to the AMPA or kainate receptor, causing the sodium channel to open. This increases the flow of sodium into the neuron and the flow of potassium out of it. This causes the membrane to depolarize; it also triggers a postsynaptic nerve impulse.
    Depolarization of the membrane removes magnesium from the calcium channel. Coupled with glutamate binding to the NMDA receptor in the presence of glycine, this causes the NMDA receptor to open and allow calcium influx. Calcium influx through NMDA receptors contributes to long-term potentiation, a phenomenon that may be involved in long-term learning, synaptogenesis, and other neuronal functions.
  • Advances in depression treatment

    1. 1. Matthew Macaluso, D.O. Assistant Professor and Director of Research University of Kansas School of Medicine Medical Director, Via Christi Psychiatric Clinic Treatment of Major Depression and Unmet Needs
    2. 2. Potential Conflicts of InterestPotential Conflicts of Interest  Dr. Macaluso has been principal investigator on clinical trials sponsoredDr. Macaluso has been principal investigator on clinical trials sponsored by the following entities over the last year:by the following entities over the last year:  AbbVie (schizophrenia)AbbVie (schizophrenia)  Eisai (Alzheimer disease)Eisai (Alzheimer disease)  Envivo (schizophrenia)Envivo (schizophrenia)  Janssen (treatment resistant depression)Janssen (treatment resistant depression)  Naurex (treatment resistant depression)Naurex (treatment resistant depression)  Pfizer (Alzheimer disease)Pfizer (Alzheimer disease)  All clinical trial and study contracts were with and payments made to theAll clinical trial and study contracts were with and payments made to the University of Kansas Medical Center Research Institute.University of Kansas Medical Center Research Institute. 2
    3. 3. Adequate Dosage Adequate Duration Poor Tolerability Nonadherence Safety Issues Lack of Efficacy Comorbidities 1. Nemeroff CB. Depress Anxiety. 1996/1997;4(4):169-181; 2. Oquendo MA et al. J Clin Psychiatry. 2003;64(7):825-833; 3. Oquendo MA et al. Am J Psychiatry. 1999;156(2):190-194. Factors contributing to inadequate treatment include: In MDD, “Adequate” Treatment Is Difficult to Achieve1-3
    4. 4. A Significant Percentage of Patients With MDD Remain Poorly Served Kessler RC et al. JAMA. 2003;289(23):3095-3105. 14 Million US Adults 7.2 Million Treated 6.8 Million Untreated 3.2 Million Adequately Treated 4 Million Poorly Served • Inadequate response • Intolerant to side effects
    5. 5. Current Treatment Practices in MDD Kessler RC et al. Arch Gen Psychiatry. 2005;62(6):617-627; Kessler RC et al. JAMA. 2003;289(23):3095-3105; Herrmann RC et al. Am J Psychiatry. 1995;152(6):869-875. SSRI SNRI NDRI Primary Care • Initial Diagnosis • Early Treatment Attempts Psychiatry • Improved Diagnosis • Improved Dosing • Psychotherapy • New Treatment Options Combination & Augmentation – Atypical Antipsychotics – Mood Stabilizers MAOI & TCA ECT 10M 8M 6M 4M 2M 0 1 2 3 4 5 6 7 8 Failed Treatment Attempts in Current Episode NumberofMDDPatients VNS Treatment-Resistance Continuum
    6. 6. STARSTARD http://www.edc.gsph.pitt.edu/stard National Institute of Mental Health Sequenced Treatment Alternatives To Relieve Depression
    7. 7. STAR D Regional Centers
    8. 8. STAR D: Patient Participants  N = 4,000  MDD, nonpsychotic  Specialty and primary care  Almost all co-morbidities
    9. 9. Treatment Duration:Treatment Duration: 12 weeks at each level at12 weeks at each level at highest recommended dosehighest recommended dose 1 year follow up after a1 year follow up after a satisfactory therapeuticsatisfactory therapeutic responseresponse
    10. 10. * Defined 17-itemHDRS < 7 Obtain Consent Level 2 Follow-up Remission* Nonremission Citalopram Level 1Level 1
    11. 11. STAR*D Study Design Overview Rush, 2006 SWITCH TO: Mirtazapine or Nortriptyline OR AUGMENT WITH: Lithium or Triiodothyronine SWITCH TO: Tranylcypromine or Mirtazapine combined with Venlafaxine XR SWITCH TO: Bupropion SR, Sertraline, Venlafaxine XR OR AUGMENT WITH: Bupropion SR, Buspirone INITIAL TREATMENT: CitalopramLEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
    12. 12. Remission Rates (RR)* in STAR*D by Treatment LevelRemission Rates (RR)* in STAR*D by Treatment Level Level RR Range % Average RR % Original Population Still Symptomatic** 1 28 28 72 2 18-30 25 54 3 12-25 18 44 4 7-14 11 39 * Remission = a score of <7 on a 17-item Hamilton Depression Rating Scale. ** Assumes every nonremitter went through the next treatment level rather than dropping out.
    13. 13. Discontinuation due to AEs Accelerates with Increasing Treatment Resistance %DiscontinuingduetoAEs No or Limited Prior Rx One Prior Failure Two Prior Failures Three Prior Failures Sample Size (N): 2876 727 221 58 Trivedi et al. (Am J Psychiatry, 2006); Rush et al. (NEJM, 2006); Fava et al (Am J Psychiatry, 2006); McGrath et al (Am J Psychiatry, 2006)
    14. 14. Relapse During Long-Term Follow-Up STAR*D Study Results The higher the level of treatment resistance prior to remission, the faster the relapse in long term follow up Rush, (2006) Level 1 (non-resistant) Level 2 (1 prior Tx failure) Level 3 (2 prior Tx failures) Level 4 (3 prior Tx failures)
    15. 15. Unmet needsUnmet needs Limited and significant overlap in efficacy withLimited and significant overlap in efficacy with small gain to switching between existing biogenicsmall gain to switching between existing biogenic amine based antidepressants .amine based antidepressants . All Slow onset of action.All Slow onset of action. Newer drugs (SSRIs/SNRIs vs TCAs/MAOIs) haveNewer drugs (SSRIs/SNRIs vs TCAs/MAOIs) have better tolerability and safety but not better efficacy.better tolerability and safety but not better efficacy. Currently MarketedCurrently Marketed Antidepressant MedicationsAntidepressant Medications
    16. 16. Major excitatory neurotranmitter in the brain:Major excitatory neurotranmitter in the brain: ““The Ying to the Yang of GABA”The Ying to the Yang of GABA” Like GABA, found at 50% of all synapses in theLike GABA, found at 50% of all synapses in the brain.brain. Is circuits implicated in the pathophysiology ofIs circuits implicated in the pathophysiology of major depressionmajor depression Glutamate as aGlutamate as a target neurotransmitter systemtarget neurotransmitter system
    17. 17. employed a double-blind, parallel group design in a small number (n = 30) of patients with treatment resistant major depression, used an IV dose of CP-101,606 that did not produce dissociative symptoms, evaluated response at prespecified 96 hours after CP- 101,606 administration, found robust antidepressant response which was sustained up to 30 days after a single administration. Antidepressant Effects of the CP-101,606 (NR2B NMDA Antagonist) versus Placebo
    18. 18. 100 90 80 70 60 50 40 30 20 10 0 CP101,606 Placebo PercentageofResponders IIIIIIIII Antidepressant Effects of CP-101,606 versus Placebo Preskorn, S., et al. J Clin Psychopharmacol 28(6):1-7, 2008.
    19. 19. Percentage of CP-101,606 treated responders continuing to meet response criteria (i.e., > 50% reduction in HDRS score) at subsequent Period II visits. 100 90 80 70 60 50 40 30 20 10 0 Percentage Days after the Period II infusion 0 5 10 15 20 25 30 35 Preskorn, S., et al. J Clin Psychopharmacol 28(6):1-7, 2008.
    20. 20. Further replication is needed in a larger scale study. Development plan should address: Can an oral drug be developed capable of producing a comparable antidepressant response? Is the effect sustained with repeated administration? If so, how frequently must the drug be administered? Is efficacy limited to patients with treatment resistant depression? What is the risk:benefit ratio (i.e., where do such drugs fit within relative to existing antidepressants)? Antidepressant Effects of the NR2B NMDA Antagonist, CP-101,606 versus Placebo
    21. 21. NMDA ReceptorsNMDA Receptors Na+ Ca++ glutamate RESTINGRESTING Na+ Na+ Ca++Ca++ MgMg++++ glycine Stahl SM. Stahl’s Essential Psychopharmacology. 3rd ed. 2008. NMDA
    22. 22. NMDA ReceptorsNMDA Receptors Na+ Na+ Ca++ Ca++ NMDA glutamate DEPOLARIZED & OPENDEPOLARIZED & OPEN Na+ Na+ Na+ Na+ Ca++ Ca++ Ca++Ca++ glycine MgMg++++ AMPA or kainate Stahl SM. Stahl’s Essential Psychopharmacology. 3rd ed. 2008.

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