Vortioxetine found to significantly improve depression in early-stage dementia

23rd June 2023

Vortioxetine improves depressive symptoms, cognitive performance, functioning and health-related quality of life in patients with both major depressive disorder and early-stage dementia, according to a recent trial.

In a significant proportion of patients, depressive symptoms and dementia are related. However, there is insufficient evidence to support the use of antidepressants to treat depression in patients with dementia. Despite this, a recent meta-analysis suggested that the antidepressant, vortioxetine could help patients with major depressive disorder (MDD) recover cognitive function. Whether vortioxetine is able to provide similar benefits in patients with MDD and comorbid early stage dementia is unclear.

For the present study, published in the Journal of Affective Disorders, a team of Spanish and Danish researchers, investigated the effectiveness of vortioxetine at improving depressive symptoms, cognitive performance, functioning and health-related quality of life in patients with both MDD and early-onset dementia.

Eligible patients were aged 55-85 years and had a primary diagnosis of recurrent MDD, with onset before 55 years of age, and comorbid early-stage dementia diagnosed ≥6 months before screening and after onset of MDD.

Treatment with vortioxetine was started at a dose of 5 mg once daily and up-titrated to 10 mg daily in all patients. The dosage could then be either increased to 20 mg or reduced to 5 mg at the investigator’s discretion. The primary endpoint was change from baseline in Montgomery-Åsberg Depression Rating Scale (MADRS) total score at week 12.

Vortioxetine and depression symptoms

A total of 82 patients with a mean age of 70.3 years (66%) were included in the study and the most common dementia diagnosis was Alzheimer’s disease (43%).

There were statistically significant and clinically meaningful improvements in the severity of depressive symptoms, based on the MADRS total score, seen at all assessment timepoints up to 12 weeks (p < 0.0001). In fact, at week 12, the mean change from baseline was −12.4.

There were also significant improvements in cognitive performance, daily and global functioning and health-related quality of life. Vortioxetine was well tolerated, and from week four, more than half of patients received the 20 mg dose.

Psilocybin therapy effective for major depression among cancer patients

19th April 2023

Psilocybin therapy for patients with cancer and major depressive disorder appears to provide sustainable improvements in symptoms

Major depressive disorder affects around 14.3% of patients with cancer. Advances in psycho-oncology show that psychotropic drugs are effective for cancer patients. There is some data suggesting that psilocybin therapy for cancer patients improves depressed mood and anxiety. Whether this effect occurs in cancer patients with a diagnosis of major depressive disorder (MDD) is not clear.

In the current study, researchers gave adult cancer patients and a diagnosis of MDD, a single 25 mg dose of psilocybin. Individuals were divided into cohorts and had a single group preparation session and two group integration sessions. Therapeutic care was provided throughout the study using the 1:1 model of psychological support. Researchers assessed the safety of psilocybin therapy and the effect on depression with the Montgomery Asberg Depression Rating Scale (MADRS).

Psilocybin therapy outcomes

The study had 30 patients, all with MDD and assessments carried out after 8 weeks. The study observed a robust and significant decrease in MADRS score (p < 0.0001) at week 8 with a ≥ 50% decrease in the MADRS score in 24 patients at week 8. Half of the group had complete remission of depression symptoms (a MADRS score < 10) after 7 days which was still present at week 8.

Self-reported depressive symptom scores were 48% lower at week 8. The Maudsley visual analogue scale was 53% lower at week 8. There were no treated-related serious adverse effects reported.

Citation
Agrawal M et al. Assessment of Psilocybin Therapy for Patients With Cancer and Major Depression Disorder. JAMA Oncol 2023

First oral NMDA receptor antagonist approved by FDA for major depression

25th August 2022

The first-in-class NMDA receptor antagonist auvelity has been approved by the FDA for use in adults with major depressive disorder

According to the manufacturer Axsome Therapeutics, the oral N-methyl D-aspartate (NMDA) receptor antagonist, auvelity (dextromethorphan-bupropion) has been approved by the US Food and Drug Administration (FDA) for the treatment of patients with major depressive disorder.

The introduction of a NMDA receptor antagonist is an important development in the treatment of patients with major depressive disorder (MDD).

The condition is characterised by an individual who has a persistently low or depressed mood, anhedonia or decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or agitation, sleep disturbances, or suicidal thoughts.

It is a highly prevalent condition with a 2020 systemic review of 63 articles identifying a lifetime prevalence of MDD ranging from 2 to 21%, with the highest rates found in some European countries and the lowest in some Asian countries. 

Treatment of MDD relies on the use of antidepressants such as selective serotonin re-uptake inhibitors though response rates to some drugs within this class such as citalopram only approach 50%.

Recent neuroimaging studies have demonstrated abnormalities in glutamatergic transmission in major depression which is one of the major mediators of excitatory neurotransmission in the central nervous system.

Furthermore, post-mortem data suggests that the NMDA receptor represents a target for novel antidepressants. Dextromethorphan is an antagonist of the NMDA receptor and a σ₁ receptor agonist and it has been postulated that the drug exerts some of its antidepressant actions through σ1 receptors.

Thus, blockade of the NMDA receptor and agonism of the σ₁ receptor modulate glutamate signalling in the central nervous system. Inclusion of the bupropion component serves to increase plasma dextromethorphan concentrations by competitively inhibiting cytochrome P450 2D6, which is a major biotransformation pathway for dextromethorphan.

NMDA receptor antagonism and auvelity clinical efficacy

Two clinical studies have provided the necessary data to assess the clinical effectiveness of auvelity. The first, GEMINI, randomised patients to either dextromethorphan-bupropion (45 mg/105 mg tablet, i.e., auvelity) or bupropion (105 mg tablet), once daily for the first 3 days and twice daily thereafter, for a total of 6 weeks.

Both trials used the Montgomery-Åsberg Depression Rating Scale (MADRS) score to assess depression. The results from GEMINI showed that in patients with major depression, dextromethorphan-bupropion significantly improved depressive symptoms compared with bupropion after 6 weeks and was generally well tolerated.

The second trial found that after 6 weeks, response rates (defined as a ≥ 50% decrease in MADRS score from baseline) at week 6 were 60.5% with dextromethorphan-bupropion and 40.5% with bupropion.

Auvelity is a proprietary extended-release oral tablet and though currently the mode of action in depression remains unclear.

Commenting on the FDA approval, Maurizio Fava, Psychiatrist-In-Chief, Department of Psychiatry, Massachusetts General Hospital, said: ‘The approval of Auvelity represents a milestone in depression treatment based on its novel oral NMDA antagonist mechanism, its rapid antidepressant efficacy demonstrated in controlled trials, and a relatively favourable safety profile.’

They added: ‘Given the debilitating nature of depression, the efficacy of Auvelity observed at one week and sustained thereafter may have a significant impact on the current treatment paradigm for this condition.’

To date, there is no information on when the EMA might review Auvelity.