Giacomo Salvadore

Common and distinct patterns of grey-matter volume alteration in major depression and bipolar disorder: evidence from voxel-based meta-analysis

Finding robust brain substrates of mood disorders is an important target for research. The degree to which major depression (MDD) and bipolar disorder (BD) are associated with common and/or distinct patterns of volumetric changes is nevertheless unclear. Furthermore, the extant literature is heterogeneous with respect to the nature of these changes. We report a meta-analysis of voxel-based morphometry (VBM) studies in MDD and BD. We identified studies published up to January 2015 that compared grey matter in MDD (50 data sets including 4101 individuals) and BD (36 data sets including 2407 individuals) using whole-brain VBM. We used statistical maps from the studies included where available and reported peak coordinates otherwise. Group comparisons and conjunction analyses identified regions in which the disorders showed common and distinct patterns of volumetric alteration. Both disorders were associated with lower grey-matter volume relative to healthy individuals in a number of areas. Conjunction analysis showed smaller volumes in both disorders in clusters in the dorsomedial and ventromedial prefrontal cortex, including the anterior cingulate cortex and bilateral insula. Group comparisons indicated that findings of smaller grey-matter volumes relative to controls in the right dorsolateral prefrontal cortex and left hippocampus, along with cerebellar, temporal and parietal regions were more substantial in major depression. These results suggest that MDD and BD are characterised by both common and distinct patterns of grey-matter volume changes. This combination of differences and similarities has the potential to inform the development of diagnostic biomarkers for these conditions.

Ketamine as a Fast Acting Antidepressant: Current Knowledge and Open Questions

Several recent studies have shown that a single intravenous subanesthetic dose of ketamine, a NMDA receptor antagonist, exerts rapid antidepressant effects in patients with treatment refractory mood disorders and reduces suicidal ideation. Those insights have fueled tremendous excitement in the efforts to elucidate the mechanism underlying ketamines antidepressant properties in animal models of depression, as well as in humans through the use of brain imaging as well as peripheral blood measurements. For example, there is emerging evidence that ketamines antidepressant properties rely on increasing AMPA signaling and rapidly inducing synaptogenesis. While pilot clinical studies are promising, a number of critical questions still remain unanswered. They relate to the safe and effective use of ketamine in patients with mood disorders regarding the optimal dose range, modality and method of administration for acute and long‐term maintenance of effect, and the biomarkers associated with response/nonresponse. In this review article, we first summarize the clinical evidence about the use of ketamine in mood disorders, as well as preclinical and humans studies which investigated the mechanisms of action of ketamine, and predictors of antidepressant response in clinical populations. We then provide a critical overview of the knowledge gaps about the use of ketamine in depression and suggest some future research directions for the investigation of ketamine as a promising tool to develop novel more effective and fast acting antidepressants.

Computational META-analysis of statistical parametric maps in major depression

Several neuroimaging meta‐analyses have summarized structural brain changes in major depression using coordinate‐based methods. These methods might be biased toward brain regions where significant differences were found in the original studies. In this study, a novel voxel‐based technique is implemented that estimates and meta‐analyses between‐group differences in grey matter from individual MRI studies, which are then applied to the study of major depression.

SAT0182 Improvement in Measures of Depressed Mood and Anhedonia, and Fatigue, In a Randomized, Placebo-Controlled, Phase 2 Study of Sirukumab, A Human Anti-Interleukin-6 Antibody, In Patients with Rheumatoid Arthritis

Background Interleukin-6 (IL-6) is among the known neuroactive cytokines involved in stress coping and neuronal plasticity. Clinical and preclinical studies suggest a role for IL-6 in the pathophysiology of depression; it is unclear whether peripheral anti-IL-6 treatment can directly alleviate depressive symptoms. Depressive symptoms and fatigue commonly affect RA patients, particularly those with high disease activity. Objectives To assess the effects of sirukumab, a human IL6 antibody, on measures of depressed mood and anhedonia, and fatigue from a Ph2 trial in patients with active RA. Methods This was a post-hoc analysis of the SF-36 Mental Health and Vitality domain items from a Ph2, multicenter, randomized, double-blind, placebo-controlled study evaluating efficacy and safety of 4 dose regimens of sirukumab (25mg q4wks up to 100mg q2wks) administered SC in patients with active RA despite MTX. Serum CRP ≥10mg/L was required for enrollment, and history of an uncontrolled psychiatric or emotional disorder that was of sufficient severity to interfere with study participation was excluded. Patients using anti-depressants were excluded from analysis. Patients were grouped by presence or absence of prevalent depressed mood and anhedonia (PDMA) at entry, defined as self-reported depressed mood and anhedonia on the SF-36 with >1 item designated “most of the time” and the other at least “some of the time” for 4wks. Sirukumab treatment was defined as receiving any sirukumab regimen. Change from baseline in PDMA and fatigue at wk12 were analyzed unadjusted and adjusted for baseline and wk12 DAS28-CRP score; to investigate the relationship between depressive symptoms improvement and RA clinical response, change in PDMA symptoms was also investigated separately in ACR50 responders and non-responders Results At entry, about 26% of patients were classified as having PDMA. This group also experienced significantly more fatigue and nervousness than those without PDMA. The severity of PDMA symptoms in this group was not significantly correlated with RA chronicity or severity, or with baseline serum levels of inflammatory biomarkers. Clinical efficacy of sirukumab on RA disease symptoms as measured with the DAS28-CRP occurred in patients with and without PDMA at entry. Patients in the PDMA group receiving sirukumab but not PBO achieved significant improvements at wk12 in PDMA symptoms (p=0.0006), and fatigue (p=0.0157). In patients with PDMA, significant improvements on PDMA symptoms upon sirukumab treatment, but not PBO, were observed in both ACR50 responders (p=0.0024) and non-responders (p=0.0014). In patients with PDMA treated with sirukumab, baseline soluble IL-6 receptor (sIL-6R) level significantly correlated with improvement at wk12 in PDMA symptoms (Spearman r=0.44, p=0.015). Conclusions These novel findings link IL-6 signaling pathway dysregulation to depressive symptoms and fatigue, and suggest that peripheral anti-IL-6 treatment can improve depressive symptoms in RA patients independently of clinical response. References Hodes GE et al,PNAS 2014;111(45):16136-16141. Smolen JS et al,ARD 2014;73:1616-1625. Disclosure of Interest B. Hsu Employee of: Janssen, D. Wang Employee of: Janssen, Y. Sun Employee of: Janssen, G. Salvadore Employee of: Janssen, J. Singh Employee of: Janssen, M. Curran Employee of: Janssen, I. Caers Employee of: Janssen, W. Drevets Employee of: Janssen, G. Wittenberg Employee of: Janssen, G. Chen Employee of: Janssen

Sparse factors for the positive and negative syndrome scale: which symptoms and stage of illness?

The Positive and Negative Syndrome Scale (PANSS) is frequently described with five latent factors, yet published factor models consistently fail to replicate across samples and related disorders. We hypothesize that (1) a subset of the PANSS, instead of the entire PANSS scale, would produce the most replicable five-factor models across samples, and that (2) the PANSS factor structure may be different depending on the treatment phase, influenced by the responsiveness of the positive symptoms to treatment. Using exploratory factor analysis, confirmatory factor analysis and cross validation on baseline and post-treatment observations from 3647 schizophrenia patients, we show that five-factor models fit best across samples when substantial subsets of the PANSS items are removed. The optimal model at baseline (five factors) omits 12 items: Motor Retardation, Grandiosity, Somatic Concern, Lack of Judgment and Insight, Difficulty in Abstract Thinking, Mannerisms and Posturing, Disturbance of Volition, Preoccupation, Disorientation, Excitement, Guilt Feelings and Depression. The PANSS factor models fit differently before and after patients have been treated. Patients with larger treatment response in positive symptoms have larger variations in factor structure across treatment stage than the less responsive patients. Negative symptom scores better predict the positive symptoms scores after treatment than before treatment. We conclude that sparse factor models replicate better on new samples, and the underlying disease structure of Schizophrenia changes upon treatment.

Sirukumab: A Potential Treatment for Mood Disorders?

Convergent evidence indicates that abnormalities in the innate immune system may be pertinent to the pathogenesis, phenomenology, and possible treatment of several mental disorders. In keeping with this view, the targeting of interleukin-6 with the human monoclonal antibody sirukumab may represent a possible treatment and disease modification approach, for adults with brain-based disorders (e.g., major depressive disorder). A PubMed/Medline database search was performed using the following search terms: sirukumab; anti-IL-6; IL-6; major depressive disorder; inflammation. A systematic review was conducted of both preclinical and clinical trials reporting on the pharmacology of sirukumab or investigating the efficacy of targeting IL-6 signaling. Overall, sirukumab has been reported to be a safe and well-tolerated agent, capable of modulating the immune response in healthy populations as well as in subjects with inflammatory disorders (e.g., rheumatoid arthritis). Sirukumab’s effects on cytokine networks as part of the innate immune system provide a coherent rationale for possible application in neuropsychiatric disorders with possible benefits across several domains of the biobehavioral Research Domain Criteria matrix (e.g., general cognitive processes, positive valence systems). Amongst individuals with complex brain-based disorders (e.g., mood disorders), the dimensions/domains most likely to benefit with sirukumab are negative valence disturbances (e.g., anxiety, depression, rumination), positive valence disturbances (e.g., anhedonia) as well as general cognitive processes. We suggest that sirukumab represents a prototype and possibly a proof-of-concept that agents that engage IL-6 targets have salutary effects in psychiatry.

Evaluating Potential QT Effects of JNJ‐54861911, a BACE Inhibitor in Single‐ and Multiple‐Ascending Dose Studies, and a Thorough QT Trial With Additional Retrospective Confirmation, Using Concentration‐QTc Analysis

Nonclinical assays with JNJ‐54861911, a β‐secretase 1 inhibitor have indicated that at high concentrations, it may delay cardiac repolarization. A 4‐way crossover thorough QT (TQT) study was performed in 64 healthy subjects with 50 and 150 mg JNJ‐54861911 once daily for 7 days, placebo, and 400 mg moxifloxacin. Retrospective high‐precision QT (HPQT) analysis was performed on serial elecrocardiograms extracted from first‐in‐human single‐ascending dose (SAD) and multiple‐ascending dose (MAD) studies to evaluate if early studies could detect and predict QT effect. In the TQT study, a high therapeutic 50 mg dose did not cause QT prolongation, and an effect >10 milliseconds could be excluded at all postdose timepoints. QT prolongation with peak effect on placebo‐corrected change from baseline QTcF of 15.5 milliseconds (90%CI, 12.9‐18.1 milliseconds) was observed following a supratherapeutic dose (150 mg). No clinically relevant QT changes were observed in earlier studies. However, with SAD/MAD findings by HPQT, the slope of the exposure–response (ER) relationship in the SAD study (doses up to 150 mg) was similar to the TQT study slope, and the estimated QT effect was comparable at high plasma levels. In the MAD study, doses up to 90 mg once daily for 7 days resulted in JNJ‐54861911 peak plasma concentrations (Cmax) comparable to those in the SAD study (∼750 ng/mL), but ER by HPQT failed to detect a QT effect and resulted in negative estimations. Adding a higher dose cohort (150 mg; Cmax, 1125 ng/mL) demonstrated a QT effect, with a slightly lower ER slope than the TQT study. JNJ‐54861911 (up to 50 mg) did not cause QT prolongation at clinically relevant plasma concentrations in any studies. Provided sufficiently high plasma concentrations were captured, mild QT prolongation observed postdose with a supratherapeutic dose could be detected (TQT study) and estimated in SAD/MAD studies. Based on population pharmacokinetic modeling and simulation, 5 and 25 mg doses are currently considered for further phase 3 studies and are expected not to cause any relevant QT prolongation.

PHARMACODYNAMICS OF THE ORAL BACE INHIBITOR JNJ-54861911 IN EARLY ALZHEIMER'S DISEASE

cebo were studied. Comprehensive neuropathological assessments were performed ranging from 4 months to 14 years after the trial. Large coronal paraffin sections of cerebral hemisphere were immunostained for Ab, scanned, then (i) the entire neocortical ribbon was scored for plaques in a CERAD-like manner (frequent1⁄43, moderate1⁄42, sparse1⁄41, none1⁄40) and (ii) false coloured to permit visualisation of staining patterns at low power. Results: 16/21 had a distribution of tangles and at least some residual Ab pathology indicating the cause of dementia had been AD, whereas 5/21 had alternative causes for dementia (PSP1⁄41, DLB1⁄41, VaD1⁄41and FTDTDP431⁄42). 18/21 had received the active agent and 3/21 the placebo. Scanning and false colouration of large Ab immunostained sections generated images suitable for comparison with amyloid PET scans as used in current immunotherapy trials. 13/15 AD subjects receiving the active agent had evidence of plaque removal (almost complete removal1⁄45, extensive patches of removal1⁄44, small patches of removal1⁄44, no plaque removal1⁄42). In the immunised AD group the mean plaque score was 1.46 (range1⁄40.05-2.9) vs. 2.4 for the single placebo AD case. There was a significant inverse correlation between peripheral blood anti-Ab titres and plaque scores. Conclusions: AD patients actively immunised against Ab can remain virtually plaque–free for up to 14 years. Nearly a quarter of the patients examined in this study did not have neuropathologically verified AD. Neuropathology follow up of patients in therapeutic trials for AD provides valuable information on the cause of dementia and effects of treatment.

Validation of a novel Montreal Cognitive Assessment scoring algorithm in non-demented Parkinson’s disease patients

IntroductionThe early diagnosis of mild cognitive impairment (PD-MCI) in Parkinson’s disease (PD) is essential as it increases the future risk for PD dementia (PDD). Recently, a novel weighting algorithm for the Montreal Cognitive Assessment (MoCA) subtests has been reported, to best discriminate between those with and without cognitive impairment in PD. The aim of our study was to validate this scoring algorithm in a large sample of non-demented PD patients, hypothesizing that the weighted MoCA would have a higher diagnostic accuracy for PD-MCI than the original MoCA.MethodsIn 202 non-demented PD patients, we evaluated cognitive status, clinical and demographic data, as well as the MoCA with a weighted and unweighted score. Receiver operating characteristic (ROC) curve analysis was used to evaluate discriminative ability of the MoCA. Group comparisons and ROC analysis were performed for PD-MCI classifications with a cut-off ≤ 1, 1.5, and 2 standard deviation (SD) below appropriate norms.ResultsPD-MCI patients scored lower on the weighted than the original MoCA version (p < 0.001) compared to PD patients with normal cognitive function. Areas under the curve only differed significantly for the 2 SD cut-off, leading to an increased sensitivity of the weighted MoCA score (72.9% vs. 70.5%) and specificity compared to the original version (79.0% vs. 65.4%).ConclusionsOur results indicate better discriminant power for the weighted MoCA compared to the original for more advanced stages of PD-MCI (2 SD cut-off). Future studies are needed to evaluate the predictive value of the weighted MoCA for PDD.

Measuring pathology using the PANSS across diagnoses: Inconsistency of the positive symptom domain across schizophrenia, schizoaffective, and bipolar disorder

Although the Positive and Negative Syndrome Scale (PANSS) was developed for use in schizophrenia (SZ), antipsychotic drug trials use the PANSS to measure symptom change also for bipolar (BP) and schizoaffective (SA) disorder, extending beyond its original indications. If the dimensions measured by the PANSS are different across diagnoses, then the same score change for the same drug condition may have different meanings depending on which group is being studied. Here, we evaluated whether the factor structure in the PANSS was consistent across schizophrenia (n = 3647), bipolar disorder (n = 858), and schizoaffective disorder (n = 592). Along with congruency coefficients, Hancocks H, and Jaccard indices, we used target rotations and statistical tests of invariance based on confirmatory factor models. We found the five symptom dimensions measured by the 30-item PANSS did not generalize well to schizoaffective and bipolar disorders. A model based on an 18-item version of the PANSS generalized better across SZ and BP groups, but significant problems remained in generalizing some of the factors to the SA sample. Schizophrenia and bipolar disorder showed greater similarity in factor structure than did schizophrenia and schizoaffective disorder. The Anxiety/Depression factor was the most consistent across disorders, while the Positive factor was the least consistent.