Bupropion Versus Escitalopram on Reward Circuitry and Motivational Deficits
Study Details
Study Description
Brief Summary
This study is designed to determine whether bupropion (vs escitalopram) increases functional connectivity (FC) within reward-related neurocircuits and decreases motivational deficits in depressed patients with increased inflammation and anhedonia. Participants will be randomized to take bupropion extended release (XL) or escitalopram for 8 weeks.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Phase 4 |
Detailed Description
The goal of the proposed research is to determine the mechanism of action of an antidepressant of known efficacy (bupropion) and to tie this mechanism of action to a biomarker of inflammation in support of precision medicine for the treatment of major depression (MD). MD is a devastating disease affecting approximately 10% of US adults and being the leading cause of disability worldwide. Despite availability of several classes of antidepressant medications, initial treatment response is low (around 30%), and approximately 1/3 of depressed patients are non-responsive to conventional antidepressant therapies. Although extensive reviews of the literature suggest that available antidepressant medications are equally effective, recent studies suggest that there may be differential responsiveness to conventional antidepressants among subgroups of depressed patients. One subgroup of depressed patients who may exhibit differential antidepressant responsiveness are those with increased markers of inflammation. Data from previous studies support the notion that differential responsiveness to conventional antidepressants exists and may be revealed by pretreatment levels of inflammation as indexed by the inflammatory biomarker C-reactive protein (CRP).
This study proposes to use a mechanistic clinical trial design with drugs of known efficacy to take the first step toward establishing whether antidepressants that target dopamine (e.g. bupropion) might be a better choice for depressed patients with increased inflammation and anhedonia than an selective serotonin reuptake inhibitor (SSRI). Accordingly, 50 depressed patients with a CRP>2mg/L and increased anhedonia will be randomized to 8 weeks of bupropion or escitalopram in order to analyze data from 40 patients (accounting for drop outs). All depressed patients will undergo functional magnetic resonance imaging (fMRI) to examine functional connectivity in reward-related circuits at baseline and 4 and 8 weeks along with objective and clinical assessments of Research Domain Criteria (RDoC) positive (motivational) valence constructs at baseline and 2, 4, 6 and 8 weeks.
The researchers hypothesize that patients who receive bupropion versus escitalopram will exhibit increased functional connectivity between ventral striatum and ventromedial prefrontal cortex in association with decreased motivational deficits and anhedonia.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Experimental: Bupropion Participants randomized to take bupropion for 8 weeks. |
Drug: Bupropion XL
Participants will take 150 milligrams per day (mg/d) of bupropion XL for two weeks, then the dose will be increased to 300mg/d, as tolerated, for the remaining 6 weeks of the study.
Other Names:
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| Active Comparator: Escitalopram Participants randomized to take escitalopram for 8 weeks. |
Drug: Escitalopram
Participants will take 10mg/d of escitalopram for two weeks, then the dose will be increased to 20mg/d, as tolerated, for the remaining 6 weeks of the study.
Other Names:
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Outcome Measures
Primary Outcome Measures
- Change in Targeted Ventromedial Prefrontal Cortex-Ventral Striatal (vmPFC-VS) Functional Connectivity (FC) [Baseline, Week 4, Week 8]
Targeted FC will be calculated as the degree of correlation in activity between a 3mm3 radius sphere in VS and the vmPFC cluster identified as being reward-sensitive in neuroimaging meta-analyses and as used to define vmPFC in previous work. Z-scores will be extracted and the change in mean FC values compared to baseline will be calculated.
Secondary Outcome Measures
- Change in Effort-Expenditure for Rewards Task (EEfRT) Score [Baseline, Week 2, Week 4, Week 6, Week 8]
The EEfRT task is a multi-trial game in which participants are given an opportunity to choose different task difficulty levels to obtain monetary rewards (easy tasks have low rewards while hard tasks have higher rewards). The task is 20 min, and first 50 trials are analyzed. Each trial has a high, medium, or low probability of success, and this information is given to the participant when they are deciding between easy and hard tasks. The proportion of hard-task choices across each level of probability is calculated. Lower proportions of hard task choices indicate decreased motivation.
- Change in Snaith-Hamilton Pleasure Scale (SHAPS-C) Score [Baseline, Week 2, Week 4, Week 6, Week 8]
The SHAPS-C is a 14-item clinician-administered scale assessing the amount of pleasure during common daily activities that the participant has experienced in the past week. Responses are given on a scale of 1 to 4 where 1 = lots of pleasure and 4 = no pleasure. Total scores range from 14 to 56 with lower scores indicating greater enjoyment of activities.
- Change in Motivation and Pleasure Scale-Self-Report (MAP-SR) Score [Baseline, Week 2, Week 4, Week 6, Week 8]
The MAP-SR is an 18-item self-report inventory that has been validated in psychiatric populations and is designed to disentangle motivational and consummatory components of everyday activities over a 24-hr period. Responses are given on a 5-point scale where 0 = no pleasure or motivation and 4 = extreme pleasure or motivation. Total scores range from 0 to 72 and higher scores indicate greater motivation and pleasure during everyday activities.
- Change in Inventory of Depressive Symptomatology - Self-Report (IDS-SR) [Baseline, Week 2, Week 4, Week 6, Week 8]
The IDS-SR is a 30-item self-reported measurement of depression severity. Responses are given on a 4-point scale where 0 = no problems and 3 = severe problems. Total scores are based on 28 items and range from 0 to 84 with higher scores indicating more severe symptoms of depression.
Eligibility Criteria
Criteria
Inclusion Criteria:
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willing and able to give written informed consent
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a primary diagnosis of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) MD, current as diagnosed by the Structured Clinical Interview for DSM-V Axis I Disorders (SCID-V)
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score of ≥16 on the 16-item Quick Inventory of Depressive Symptomatology (QIDS)-SR
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off all antidepressant or other psychotropic therapy (e.g. mood stabilizers, antipsychotics, and sedative hypnotics) for at least 4 weeks prior to baseline visit (8 weeks for fluoxetine); concomitant administration of up to 2 mg of clonazepam or its equivalent per day will be allowed, but not within 12 hours of study assessments
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CRP>2mg/L
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IDS-SR anhedonia subscale score ≥5
Exclusion Criteria:
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history of any autoimmune disorder
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history of hepatitis B or C infection or human immunodeficiency virus infection
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history of any type of cancer requiring treatment with more than minor surgery
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unstable cardiovascular, endocrinologic, hematologic, hepatic, renal, or neurologic disease (as determined by physical examination and laboratory testing)
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history of any (non-mood-related) psychotic disorder; active psychotic symptoms of any type; substance abuse/dependence within 6 months of study entry (as determined by SCID)
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an active eating disorder or antisocial personality disorder
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a history of a cognitive disorder or ≤28 on the Mini-Mental State Exam unless otherwise approved by the PI
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pregnancy or lactation
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chronic use of non-steroidal anti-inflammatory agents (NSAIDS) (excluding 81mg of aspirin), glucocorticoid containing medications
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use of NSAIDS or oral glucocorticoids at any time during the study
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any contraindication for MRI scanning
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failure of more than 2 antidepressant trials in the current episode
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Intolerance of bupropion or escitalopram
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BMI >40 (to exclude severe obesity)
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due to the high co-morbidity between anxiety disorders and depression, the study team plans to include patients with anxiety-related disorders excluding obsessive-compulsive disorder (OCD) if depression is the primary diagnosis. Patients with stable medical conditions and on medications for those conditions will not be excluded. Concomitant administration of up to 2 mg of clonazepam or its equivalent per day will be allowed, but not within 12 hours of study assessments.
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sexually active participants are required to use medically approved birth control methods as defined in the Birth Control Method Form for the duration of the study
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Emory Clinic | Atlanta | Georgia | United States | 30322 |
Sponsors and Collaborators
- Emory University
- National Institute of Mental Health (NIMH)
Investigators
- Principal Investigator: Andrew Miller, MD, Emory University
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- IRB00117673
- 1R21MH121891