Antidepressant activity of anti-cytokine treatment: a systematic review and meta-analysis of clinical trials of chronic inflammatory conditions

N Kappelmann, G Lewis, R Dantzer, P B Jones, G M Khandaker, N Kappelmann, G Lewis, R Dantzer, P B Jones, G M Khandaker

Abstract

Inflammatory cytokines are commonly elevated in acute depression and are associated with resistance to monoaminergic treatment. To examine the potential role of cytokines in the pathogenesis and treatment of depression, we carried out a systematic review and meta-analysis of antidepressant activity of anti-cytokine treatment using clinical trials of chronic inflammatory conditions where depressive symptoms were measured as a secondary outcome. Systematic search of the PubMed, EMBASE, PsycINFO and Cochrane databases, search of reference lists and conference abstracts, followed by study selection process yielded 20 clinical trials. Random effect meta-analysis of seven randomised controlled trials (RCTs) involving 2370 participants showed a significant antidepressant effect of anti-cytokine treatment compared with placebo (standardised mean difference (SMD)=0.40, 95% confidence interval (CI), 0.22-0.59). Anti-tumour necrosis factor drugs were most commonly studied (five RCTs); SMD=0.33 (95% CI; 0.06-0.60). Separate meta-analyses of two RCTs of adjunctive treatment with anti-cytokine therapy and eight non-randomised and/or non-placebo studies yielded similar small-to-medium effect estimates favouring anti-cytokine therapy; SMD=0.19 (95% CI, 0.00-0.37) and 0.51 (95% CI, 0.34-0.67), respectively. Adalimumab, etanercept, infliximab and tocilizumab all showed statistically significant improvements in depressive symptoms. Meta-regression exploring predictors of response found that the antidepressant effect was associated with baseline symptom severity (P=0.018) but not with improvement in primary physical illness, sex, age or study duration. The findings indicate a potentially causal role for cytokines in depression and that cytokine modulators may be novel drugs for depression in chronically inflamed subjects. The field now requires RCTs of cytokine modulators using depression as the primary outcome in subjects with high inflammation who are free of other physical illnesses.

Conflict of interest statement

The authors have no competing financial interests in relation to the work described. PBJ received an honorarium that he donated to his department, from Roche (UK) for taking part in an advisory board to advise on education about schizophrenia for psychiatrists. RD received consulting fee and honorarium from Ironwood Pharma (USA) and Pfizer (France).

Figures

Figure 1
Figure 1
PRISMA Flow diagram of study selection for systematic review.
Figure 2
Figure 2
Meta-analysis of antidepressant activity of anti-cytokine treatment. (a) Meta-analysis of RCTs of anti-cytokine drug vs. placebo. (b) Meta-analysis of RCTs of anti-cytokine drug plus DMARD vs. DMARD. (c) Meta-analysis of other trials (non-randomised and/or non-placebo). CI, confidence interval; DMARD, Disease Modifying Anti-rheumatoid Drug; RCT, randomised controlled trial.
Figure 3
Figure 3
Antidepressant activity of anti-TNF treatment: meta-analysis of RCTs. CI, confidence interval; RCT, randomised controlled trial; TNF, tumor necrosis factor.
Figure 4
Figure 4
Meta-regression of the association between antidepressant effects and improvements in physical illness. P-value for meta-regression slope indicates no statistically significant association between antidepressant effect of anti-cytokine treatment and improvement in physical illness. The Figure shows that the antidepressant effect does not change significantly (that is, increase or decrease) across the range of effect estimates for physical illness. SMD, standardised mean difference.

References

    1. Dantzer R, O'Connor JC, Freund GG, Johnson RW, Kelley KW. From inflammation to sickness and depression: when the immune system subjugates the brain. Nat Rev Neurosci 2008; 9: 46–56.
    1. Raison CL, Capuron L, Miller AH. Cytokines sing the blues: inflammation and the pathogenesis of depression. Trends Immunol 2006; 27: 24–31.
    1. Maes M. Evidence for an immune response in major depression: a review and hypothesis. Prog Neuro-Psychopharmacol Biol Psychiatry 1995; 19: 11–38.
    1. Udina M, Castellvi P, Moreno-Espana J, Navines R, Valdes M, Forns X et al. Interferon-induced depression in chronic hepatitis C: a systematic review and meta-analysis. J Clin Psychiatry 2012; 73: 1128–1138.
    1. Reichenberg A, Yirmiya R, Schuld A, Kraus T, Haack M, Morag A et al. Cytokine-associated emotional and cognitive disturbances in humans. Arch Gen Psychiatry 2001; 58: 445–452.
    1. Harrison NA, Brydon L, Walker C, Gray MA, Steptoe A, Critchley HD. Inflammation causes mood changes through alterations in subgenual cingulate activity and mesolimbic connectivity. Biol Psychiatry 2009; 66: 407–414.
    1. Goldsmith DR, Rapaport MH, Miller BJ. A meta-analysis of blood cytokine network alterations in psychiatric patients: comparisons between schizophrenia, bipolar disorder and depression. Mol Psychiatry 2016; doi: 10.1038/mp.2016.3.
    1. Howren MB, Lamkin DM, Suls J. Associations of depression with C-reactive protein, IL-1, and IL-6: a meta-analysis. Psychosom Med 2009; 71: 171–186.
    1. Dowlati Y, Herrmann N, Swardfager W, Liu H, Sham L, Reim EK et al. A meta-analysis of cytokines in major depression. Biol Psychiatry 2010; 67: 446–457.
    1. Haapakoski R, Mathieu J, Ebmeier KP, Alenius H, Kivimaki M. Cumulative meta-analysis of interleukins 6 and 1beta, tumour necrosis factor alpha and C-reactive protein in patients with major depressive disorder. Brain Behav Immunity 2015; 49: 206–215.
    1. Khandaker GM, Pearson RM, Zammit S, Lewis G, Jones PB. Association of serum interleukin 6 and C-reactive protein in childhood with depression and psychosis in young adult life: a population-based longitudinal study. JAMA Psychiatry 2014; 71: 1121–1128.
    1. Gimeno D, Kivimaki M, Brunner EJ, Elovainio M, De Vogli R, Steptoe A et al. Associations of C-reactive protein and interleukin-6 with cognitive symptoms of depression: 12-year follow-up of the Whitehall II study. Psychol Med 2009; 39: 413–423.
    1. Carvalho LA, Torre JP, Papadopoulos AS, Poon L, Juruena MF, Markopoulou K et al. Lack of clinical therapeutic benefit of antidepressants is associated overall activation of the inflammatory system. J Affect Disord 2013; 148: 136–140.
    1. Yoshimura R, Hori H, Ikenouchi-Sugita A, Umene-Nakano W, Ueda N, Nakamura J. Higher plasma interleukin-6 (IL-6) level is associated with SSRI- or SNRI-refractory depression. Prog Neuro-Psychopharmacol Biol Psychiatry 2009; 33: 722–726.
    1. Muller N, Schwarz MJ, Dehning S, Douhe A, Cerovecki A, Goldstein-Muller B et al. The cyclooxygenase-2 inhibitor celecoxib has therapeutic effects in major depression: results of a double-blind, randomized, placebo controlled, add-on pilot study to reboxetine. Mol Psychiatry 2006; 11: 680–684.
    1. Kohler O, Benros ME, Nordentoft M, Farkouh ME, Iyengar RL, Mors O et al. Effect of anti-inflammatory treatment on depression, depressive symptoms, and adverse effects: a systematic review and meta-analysis of randomized clinical trials. JAMA Psychiatry 2014; 71: 1381–1391.
    1. Hu F, Wang X, Pace TW, Wu H, Miller AH. Inhibition of COX-2 by celecoxib enhances glucocorticoid receptor function. Mol Psychiatry 2005; 10: 426–428.
    1. Pariante CM, Miller AH. Glucocorticoid receptors in major depression: relevance to pathophysiology and treatment. Biol Psychiatry 2001; 49: 391–404.
    1. Mukherjee D, Nissen SE, Topol EJ. Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA 2001; 286: 954–959.
    1. Raison CL, Rutherford RE, Woolwine BJ, Shuo C, Schettler P, Drake DF et al. A randomized controlled trial of the tumor necrosis factor antagonist infliximab for treatment-resistant depression: the role of baseline inflammatory biomarkers. JAMA Psychiatry 2013; 70: 31–41.
    1. Aaltonen KJ, Virkki LM, Malmivaara A, Konttinen YT, Nordstrom DC, Blom M. Systematic review and meta-analysis of the efficacy and safety of existing TNF blocking agents in treatment of rheumatoid arthritis. PloS One 2012; 7: e30275.
    1. Reich K, Burden AD, Eaton JN, Hawkins NS. Efficacy of biologics in the treatment of moderate to severe psoriasis: a network meta-analysis of randomized controlled trials. Br J Dermatol 2012; 166: 179–188.
    1. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008; 5: e45.
    1. Kessler D, Lewis G, Kaur S, Wiles N, King M, Weich S et al. Therapist-delivered Internet psychotherapy for depression in primary care: a randomised controlled trial. Lancet 2009; 374: 628–634.
    1. Svenningsson A, Falk E, Celius EG, Fuchs S, Schreiber K, Berko S et al. Natalizumab treatment reduces fatigue in multiple sclerosis. Results from the TYNERGY trial; a study in the real life setting. PloS One 2013; 8: e58643.
    1. Tyring S, Bagel J, Lynde C, Klekotka P, Thompson EH, Gandra SR et al. Patient-reported outcomes in moderate-to-severe plaque psoriasis with scalp involvement: results from a randomized, double-blind, placebo-controlled study of etanercept. J Eur Acad Dermatol Venereol 2013; 27: 125–128.
    1. Tyring S, Gottlieb A, Papp K, Gordon K, Leonardi C, Wang A et al. Etanercept and clinical outcomes, fatigue, and depression in psoriasis: double-blind placebo-controlled randomised phase III trial. Lancet 2006; 367: 29–35.
    1. Jelicic Kadic A, Vucic K, Dosenovic S, Sapunar D, Puljak L. Extracting data from figures with software was faster, with higher interrater reliability than manual extraction. J Clin Epidemiol 2016; 74: 119–123.
    1. Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ 2010; 340: c869.
    1. Chinn S. A simple method for converting an odds ratio to effect size for use in meta-analysis. Stat Med 2000; 19: 3127–3131.
    1. Egger M, Smith DG, Altman DG. Systematic Reviews in Health Care: Meta-Analysis in Context. BMJ: London, UK, 2001.
    1. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539–1558.
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–634.
    1. Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–463.
    1. Loftus EV, Feagan BG, Colombel JF, Rubin DT, Wu EQ, Yu AP et al. Effects of adalimumab maintenance therapy on health-related quality of life of patients with Crohn's disease: patient-reported outcomes of the CHARM trial. Am J Gastroenterol 2008; 103: 3132–3141.
    1. Gniadecki R, Robertson D, Molta CT, Freundlich B, Pedersen R, Li W et al. Self-reported health outcomes in patients with psoriasis and psoriatic arthritis randomized to two etanercept regimens. J Eur Acad Dermatol Venereol 2012; 26: 1436–1443.
    1. Dauden E, Griffiths CE, Ortonne JP, Kragballe K, Molta CT, Robertson D et al. Improvements in patient-reported outcomes in moderate-to-severe psoriasis patients receiving continuous or paused etanercept treatment over 54 weeks: the CRYSTEL study. J Eur Acad Dermatol Venereol 2009; 23: 1374–1382.
    1. Minderhoud IM, Samsom M, Oldenburg B. Crohn's disease, fatigue, and infliximab: is there a role for cytokines in the pathogenesis of fatigue? World J Gastroenterol 2007; 13: 2089–2093.
    1. Hinz A, Brahler E. Normative values for the hospital anxiety and depression scale (HADS) in the general German population. J Psychosom Res 2011; 71: 74–78.
    1. Zimmerman M, Chelminski I, Posternak M. A review of studies of the Hamilton depression rating scale in healthy controls: implications for the definition of remission in treatment studies of depression. J Nerv Ment Dis 2004; 192: 595–601.
    1. Knight RG, Waal-Manning HJ, Spears GF. Some norms and reliability data for the State—Trait Anxiety Inventory and the Zung Self-Rating Depression scale. Br J Clin Psychol 1983; 22: 245–249.
    1. Jylha P, Isometsa E. Temperament, character and symptoms of anxiety and depression in the general population. Eur Psychiatry 2006; 21: 389–395.
    1. Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S et al. The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008. J Clin Epidemiol 2010; 63: 1179–1194.
    1. Viechtbauer W. Conducting meta-analysis in R with the metafor package. J Stat Softw 2010; 36: 1–48.
    1. Simpson E, Worm M, Soong W, Blauvelt A, Eckert L, Wu R et al. Dupilumab improves patient-reported outcomes (PROs) in a phase 2 study in adults with moderate-to-severe atopic dermatitis. J Allergy Clin Immunol 2015; 135: AB167.
    1. Menter A, Augustin M, Signorovitch J, Yu AP, Wu EQ, Gupta SR et al. The effect of adalimumab on reducing depression symptoms in patients with moderate to severe psoriasis: a randomized clinical trial. J Am Acad Dermatol 2010; 62: 812–818.
    1. Langley RG, Feldman SR, Han C, Schenkel B, Szapary P, Hsu MC et al. Ustekinumab significantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-to-severe psoriasis: Results from a randomized, double-blind, placebo-controlled phase III trial. J Am Acad Dermatol 2010; 63: 457–465.
    1. Bae SC, Gun SC, Mok CC, Khandker R, Nab HW, Koenig AS et al. Improved health outcomes with etanercept versus usual DMARD therapy in an Asian population with established rheumatoid arthritis. BMC Musculoskelet Disord 2013; 14: 13.
    1. Machado DA, Guzman RM, Xavier RM, Simon JA, Mele L, Pedersen R et al. Open-label observation of addition of etanercept versus a conventional disease-modifying antirheumatic drug in subjects with active rheumatoid arthritis despite methotrexate therapy in the Latin American region. J Clin Rheumatol 2014; 20: 25–33.
    1. Kekow J, Moots RJ, Emery P, Durez P, Koenig A, Singh A et al. Patient-reported outcomes improve with etanercept plus methotrexate in active early rheumatoid arthritis and the improvement is strongly associated with remission: the COMET trial. Ann Rheum Dis 2010; 69: 222–225.
    1. Guh D, Papp K, Lynde C, Bansback N, Zhang W, Qian H et al. Impact of adalimumab on quality of life and depression in psoriasis patients: results from PRIDE. Value Health 2010; 132010: A148.
    1. Bhutani T, Patel T, Koo B, Nguyen T, Hong J, Koo J. A prospective, interventional assessment of psoriasis quality of life using a nonskin-specific validated instrument that allows comparison with other major medical conditions. J Am Acad Dermatol 2013; 69: e79–e88.
    1. Ertenli I, Ozer S, Kiraz S, Apras SB, Akdogan A, Karadag O et al. Infliximab, a TNF-alpha antagonist treatment in patients with ankylosing spondylitis: the impact on depression, anxiety and quality of life level. Rheumatol Int 2012; 32: 323–330.
    1. Traki L, Rostom S, Tahiri L, Bahiri R, Harzy T, Abouqal R et al. Responsiveness of the euroQol EQ-5D and hospital anxiety and depression scale (HADS) in rheumatoid arthritis patients receiving tocilizumab. Clin Rheumatol 2014; 33: 1055–1060.
    1. Gossec L, Steinberg G, Rouanet S, Combe B. Fatigue in rheumatoid arthritis: quantitative findings on the efficacy of tocilizumab and on factors associated with fatigue. The French multicentre prospective PEPS Study. Clin Exp Rheumatol 2015; 33: 664–670.
    1. Gelfand JM, Kimball AB, Mostow EN, Chiou CF, Patel V, Xia HA et al. Patient-reported outcomes and health-care resource utilization in patients with psoriasis treated with etanercept: continuous versus interrupted treatment. Value Health 2008; 11: 400–407.
    1. Eisenberg E, Sandler I, Treister R, Suzan E, Haddad M. Anti tumor necrosis factor - alpha adalimumab for complex regional pain syndrome type 1 (CRPS-I): a case series. Pain Pract 2013; 13: 649–656.
    1. Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L. Performance of the trim and fill method in the presence of publication bias and between‐study heterogeneity. Stat Med 2007; 26: 4544–4562.
    1. Abbott R, Whear R, Nikolaou V, Bethel A, Coon JT, Stein K et al. Tumour necrosis factor-alpha inhibitor therapy in chronic physical illness: A systematic review and meta-analysis of the effect on depression and anxiety. J Psychosom Res 2015; 79: 175–184.
    1. Capuron L, Fornwalt FB, Knight BT, Harvey PD, Ninan PT, Miller AH. Does cytokine-induced depression differ from idiopathic major depression in medically healthy individuals? J Affect Disord 2009; 119: 181–185.
    1. Capuron L, Gumnick JF, Musselman DL, Lawson DH, Reemsnyder A, Nemeroff CB et al. Neurobehavioral effects of interferon-alpha in cancer patients: phenomenology and paroxetine responsiveness of symptom dimensions. Neuropsychopharmacology 2002; 26: 643–652.
    1. Nemeroff CB. Prevalence and management of treatment-resistant depression. J Clin Psychiatry 2007; 68: 17–25.
    1. Wium-Andersen MK, Orsted DD, Nielsen SF, Nordestgaard BG. Elevated C-reactive protein levels, psychological distress, and depression in 73, 131 individuals. JAMA Psychiatry 2013; 70: 176–184.
    1. Maes M, Bosmans E, De Jongh R, Kenis G, Vandoolaeghe E, Neels H. Increased serum IL-6 and IL-1 receptor antagonist concentrations in major depression and treatment resistant depression. Cytokine 1997; 9: 853–858.
    1. O'Brien SM, Scully P, Fitzgerald P, Scott LV, Dinan TG. Plasma cytokine profiles in depressed patients who fail to respond to selective serotonin reuptake inhibitor therapy. J Psychiatr Res 2007; 41: 326–331.
    1. Christmas DM, Potokar J, Davies SJ. A biological pathway linking inflammation and depression: activation of indoleamine 2,3-dioxygenase. Neuropsychiatr Dis Treat 2011; 7: 431–439.
    1. O'Connor JC, Andre C, Wang Y, Lawson MA, Szegedi SS, Lestage J et al. Interferon-gamma and tumor necrosis factor-alpha mediate the upregulation of indoleamine 2,3-dioxygenase and the induction of depressive-like behavior in mice in response to bacillus Calmette-Guerin. J Neuroscience 2009; 29: 4200–4209.
    1. Litzenburger UM, Opitz CA, Sahm F, Rauschenbach KJ, Trump S, Winter M et al. Constitutive IDO expression in human cancer is sustained by an autocrine signaling loop involving IL-6, STAT3 and the AHR. Oncotarget 2014; 5: 1038–1051.
    1. Hodes GE, Pfau ML, Leboeuf M, Golden SA, Christoffel DJ, Bregman D et al. Individual differences in the peripheral immune system promote resilience versus susceptibility to social stress. Proc Natl Acad Sci USA 2014; 111: 16136–16141.
    1. Fairweather D, Frisancho-Kiss S, Rose NR. Sex differences in autoimmune disease from a pathological perspective. Am J Pathol 2008; 173: 600–609.
    1. Kristensen LE, Kapetanovic MC, Gulfe A, Soderlin M, Saxne T, Geborek P. Predictors of response to anti-TNF therapy according to ACR and EULAR criteria in patients with established RA: results from the South Swedish Arthritis Treatment Group Register. Rheumatology 2008; 47: 495–499.
    1. Hansel TT, Kropshofer H, Singer T, Mitchell JA, George AJ. The safety and side effects of monoclonal antibodies. Nat Rev Drug discov 2010; 9: 325–338.

Source: PubMed

3
Se inscrever