Major Depressive Disorder
Conditions
Keywords
Geriatrics, Depression, Elderly, Cognition, Memory
Brief summary
Late-life depression is characterized by both affective (mood) symptoms and cognitive deficits. There is currently no intervention that may provide consistent benefits to both mood and cognitive performance. Agonist activity at the nicotinic acetylcholine receptors via transdermal nicotine patches may provide benefit to both mood and cognition, working through nicotine's effects on brain neural networks, specifically the cognitive control network and default mode network. In this initial pilot project, the investigators will test this hypotheses in 15 nonsmoking depressed elders with subjective cognitive impairment. Following baseline neuroimaging and cognitive testing, participants will receive 12 weeks of open-label transdermal nicotine. Afterwards, participants will repeat neuroimaging and cognitive assessments.
Detailed description
Late-life depression (LLD) is characterized both by affective symptoms and cognitive deficits. The co-occurrence of cognitive deficits in LLD is a clinically relevant phenotype characterized by significant disability and poor antidepressant response. Cognitive deficits can persist even with successful antidepressant treatment and increase the risk of depression relapse. Despite the clinical importance of cognitive deficits in LLD, there are no established treatments that specifically target cognition in this population. The lack of treatments that improve cognitive deficits in depression is a deficiency in current therapeutics. Modulation of the cholinergic system by nicotinic receptor stimulation may improve both mood and cognition in depressed elders. Clinically, transdermal nicotine improves mood in smokers and a placebo-controlled pilot trial in nonsmoking adults found that transdermal nicotine significantly improved mood. In a previous trial examining Mild Cognitive Impairment, transdermal nicotine safely improved cognitive function on tests of attention, episodic memory, and processing speed. These same cognitive domains are impaired in LLD. The investigators hypothesize that these effects on mood and cognition are mediated through nicotine's effect to increase cognitive control network activity and reduce default mode network (DMN) activity. This pattern of network activity during tasks demanding external attention is associated with better task performance. Furthermore, as seen in smokers, nicotine's effect on these networks reduces depression's bias to negatively valenced stimuli and decreases rumination. The central hypothesis is that in LLD, transdermal nicotine will safely improve depression by increasing activity in cognitive control regions and decreasing activity in DMN regions. This will result in a decreased attentional bias to and reactivity to negative stimuli. A secondary hypothesis is that transdermal nicotine will also improve subjective and objective cognitive performance through these same network effects. Primary Aim 1: To determine whether administration of transdermal nicotine over 12 weeks improves clinical symptoms in patients with LLD with subjective cognitive impairment (SCI). Hypothesis 1: Transdermal nicotine administration will result in reductions in depression severity measured by the Montgomery-Asberg Depression Rating Scale (MADRS; primary mood outcome). It will also result in improvement in broader assessments of depressive symptomatology, including anhedonia, apathy, fatigue, sleep, and rumination (secondary outcomes). Hypothesis 2: Transdermal nicotine administration will result in improvements in attentional performance on the Conner's Continuous Performance Task (CPT; primary cognitive outcome). It will also result in improvement in subjective and objective cognitive performance on other tasks measuring attention, episodic memory, working memory, processing speed, and executive function (secondary outcomes). Secondary Aim 2: To determine whether administration of transdermal nicotine over 12 weeks modulates canonical intrinsic functional network activity in LLD with SCI. Hypothesis 3: On repeat administration of the Posner task of external attention, transdermal nicotine administration will result in increased activity within the cognitive control network and decreased activity within the default mode network. Hypothesis 4: Transdermal nicotine administration will result in increased functional connectivity within the cognitive control network and decreased connectivity within the default mode network at rest. Hypothesis 5: Changes in intrinsic network activity / connectivity with transdermal nicotine administration will be associated with changes in mood symptoms and subjective and objective cognitive performance.
Interventions
DRUGNicotine
Open-label transdermal nicotine patch
Sponsors
Vanderbilt University Medical Center
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age \> 60 years; * DSM-5 (Diagnostic and statistical manual-5) diagnosis of major depressive disorder, single or recurrent episode; * Subjective cognitive decline, defined as endorsing 20% of items on the Cognitive Complaint Index (CCI); * depression severity: MADRS (Montgomery-Asberg Depression Rating Scale) ≥ 15; * cognition: MOCA (Montreal Cognitive Assessment) ≥ 24; * fluent in English; * intact hearing / vision allowing completion of study procedures; * for individuals on antidepressants at study entry, they must be on a stable dose for at least 6 weeks.
Exclusion criteria
* Other Axis I psychiatric disorders, except for anxiety symptoms occurring in a depressive episode; * History of alcohol or drug dependence or abuse in the last 3 years; * Tobacco or nicotine use in last year; * History of a developmental disorder or IQ score \< 70; * Acute suicidality; * Acute grief (\<1 month); * Current or past psychosis; * Primary neurological disorder, including dementia, stroke, brain tumors, etc.; * Any MRI contraindication; * Unstable medical illness; * Allergy or hypersensitivity to nicotine patches; * Regular use of drugs with centrally acting cholinergic or anticholinergic properties in last 4 weeks, including acetylcholinesterase inhibitors; * Current or planned psychotherapy; * Electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS) in last two months.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Total MADRS (Montgomery Asberg Depression Rating Scale) Score | Baseline to week 12 | Primary mood outcome measured by the total score of the clinician-rated MADRS. MADRS was measured every 3 weeks (baseline, week 3, week 6, week 9, and week 12). MADRS total score range is 0-60, where higher scores indicate greater depression severity. |
| Change in Continuous Performance Task (CPT) Performance | Baseline to week 12 | Primary cognitive outcome, the CPT is a neuropsychological test that measures attention. In this 14-minute test, participants are asked to respond when any letter appears, except the non-target letter X. This test is conducted at baseline and at week 12. The specific primary outcome metric is standard error of change in the inter-stimulus hit reaction time, or variability between different trials. There is no absolute range, but lower scores indicate decreased variability across trials and overall better performance. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Ruminative Response Scale Total Score | Baseline to week 12 | Secondary mood outcome: Change in rumination measured by the Ruminative Response Scale total score measured at baseline and week 12. This is a self-report scale with a range of 0-66, where higher scores indicate higher levels of rumination. |
| Change in Apathy Evaluation Scale (AES) | Baseline to 12 weeks | Secondary Mood Outcomes: Change in apathy as measured by the self-report AES, a questionnaire with a range of 0-54, where lower scores indicate greater apathy. |
| Change in MFQ (Memory Frequency Questionnaire) Score | Baseline to week 12 | Secondary cognitive outcome: Change in subjective cognitive performance as measured by MFQ, a self-report scale ranging from 64-448. Higher scores indicate better subjective memory function, while lower scores indicate poorer subjective memory function. |
| Change in Snaith-Hamilton Pleasure Scale (SHAPS) Score | Baseline to week 12 | Secondary mood outcome: Change in anhedonia measured by SHAPS, a self-report questionnaire that ranges from 0-42, where higher scores indicate greater anhedonia. |
| Change in One-back Test Performance | Baseline to week 12 | Secondary cognitive outcome examining change in speed of responses ton the one-back test, no absolute range. In this variant of the N-back task, participants view a series of cards, and indicate whether the card they are currently viewing is identical to the previously viewed card. Lower scores indicate better performance. |
| Change in NYU (New York University) Paragraph Recall Performance | Baseline to week 12 | Secondary cognitive outcome of a neuropsychological test examining episodic memory performance using the NYU Paragraph Recall test. No absolute range. Higher scores indicate better performance. |
| Change in Choice Reaction Time (CRT) Performance | Baseline to week 12 | Secondary cognitive outcome, a neuropsychological test measure of attention. We examined the total response time for the CRT. Lower scores indicate better performance. |
| Change in Penn State Worry Questionnaire (PSWQ) | Baseline to week 12 | Secondary mood outcome: Change in anxiety and worry measured by PSWQ, a self-report questionnaire with a range of 16-80, where higher scores indicate greater anxiety and worry. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Transdermal Nicotine Patch Transdermal nicotine patch, administered on awakening and removed at bedtime (16h/d). Dosing began at 3.5mg patch/daily, titrated over study to maximum dose of 21mg patch/daily. Dose could be reduced to the prior level or an intermediate level for tolerability.
Titration schedule: 3.5mg patch x 1 week, 7mg patch x 2 weeks, 14mg patch x 3 weeks, 21mg patch x 6 weeks.
Nicotine: Open-label transdermal nicotine patch | 15 |
| Total | 15 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Adverse Event | 1 |
Baseline characteristics
| Characteristic | Transdermal Nicotine Patch |
|---|---|
| Age, Categorical <=18 years | 0 Participants |
| Age, Categorical >=65 years | 7 Participants |
| Age, Categorical Between 18 and 65 years | 8 Participants |
| Age, Continuous | 64.9 years STANDARD_DEVIATION 4.6 |
| Depression severity (measured by Montgomery Asberg Depression Rating Scale total score) | 27.7 units on a scale STANDARD_DEVIATION 4 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 15 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Past smoker (defined as smoking at least 1 cigarette daily for at least 6 months over the lifetime) | 5 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants |
| Race (NIH/OMB) Black or African American | 1 Participants |
| Race (NIH/OMB) More than one race | 1 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants |
| Race (NIH/OMB) White | 13 Participants |
| Region of Enrollment United States | 15 participants |
| Sex: Female, Male Female | 10 Participants |
| Sex: Female, Male Male | 5 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 0 / 15 |
| other Total, other adverse events | 14 / 15 |
| serious Total, serious adverse events | 0 / 15 |
Outcome results
Primary
Change in Continuous Performance Task (CPT) Performance
Primary cognitive outcome, the CPT is a neuropsychological test that measures attention. In this 14-minute test, participants are asked to respond when any letter appears, except the non-target letter X. This test is conducted at baseline and at week 12. The specific primary outcome metric is standard error of change in the inter-stimulus hit reaction time, or variability between different trials. There is no absolute range, but lower scores indicate decreased variability across trials and overall better performance.
Time frame: Baseline to week 12
Population: Subject who withdrew early not included due to no 12-week data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in Continuous Performance Task (CPT) Performance | -0.003 milliseconds | Standard Deviation 0.135 |
p-value: 0.761Wilcoxon (Mann-Whitney)
Primary
Change in Total MADRS (Montgomery Asberg Depression Rating Scale) Score
Primary mood outcome measured by the total score of the clinician-rated MADRS. MADRS was measured every 3 weeks (baseline, week 3, week 6, week 9, and week 12). MADRS total score range is 0-60, where higher scores indicate greater depression severity.
Time frame: Baseline to week 12
Population: Analyses included all participants, including the one subject who withdrew early. Missing values were imputed using the mean value of the sample at that time point.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in Total MADRS (Montgomery Asberg Depression Rating Scale) Score | -18.45 units on a scale | Standard Deviation 7.98 |
p-value: <0.001Regression, Linear
Secondary
Change in Apathy Evaluation Scale (AES)
Secondary Mood Outcomes: Change in apathy as measured by the self-report AES, a questionnaire with a range of 0-54, where lower scores indicate greater apathy.
Time frame: Baseline to 12 weeks
Population: Subject who withdrew early not included due to no 12-week data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in Apathy Evaluation Scale (AES) | 7.7 units on a scale | Standard Deviation 5.4 |
p-value: <0.001Wilcoxon (Mann-Whitney)
Secondary
Change in Choice Reaction Time (CRT) Performance
Secondary cognitive outcome, a neuropsychological test measure of attention. We examined the total response time for the CRT. Lower scores indicate better performance.
Time frame: Baseline to week 12
Population: Subject who withdrew early not included due to no 12-week data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in Choice Reaction Time (CRT) Performance | -16.0 milliseconds | Standard Error 85.9 |
p-value: 0.502Wilcoxon (Mann-Whitney)
Secondary
Change in MFQ (Memory Frequency Questionnaire) Score
Secondary cognitive outcome: Change in subjective cognitive performance as measured by MFQ, a self-report scale ranging from 64-448. Higher scores indicate better subjective memory function, while lower scores indicate poorer subjective memory function.
Time frame: Baseline to week 12
Population: Subject who withdrew early not included due to no 12-week data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in MFQ (Memory Frequency Questionnaire) Score | 23.64 units on a scale | Standard Deviation 40.96 |
p-value: 0.049Wilcoxon (Mann-Whitney)
Secondary
Change in NYU (New York University) Paragraph Recall Performance
Secondary cognitive outcome of a neuropsychological test examining episodic memory performance using the NYU Paragraph Recall test. No absolute range. Higher scores indicate better performance.
Time frame: Baseline to week 12
Population: Subject who withdrew early not included due to no 12-week data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in NYU (New York University) Paragraph Recall Performance | 3.4 Items correct | Standard Error 5.8 |
p-value: 0.068Wilcoxon (Mann-Whitney)
Secondary
Change in One-back Test Performance
Secondary cognitive outcome examining change in speed of responses ton the one-back test, no absolute range. In this variant of the N-back task, participants view a series of cards, and indicate whether the card they are currently viewing is identical to the previously viewed card. Lower scores indicate better performance.
Time frame: Baseline to week 12
Population: Subject who withdrew early not included due to no 12-week data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in One-back Test Performance | -0.040 milliseconds | Standard Deviation 0.065 |
p-value: 0.049Wilcoxon (Mann-Whitney)
Secondary
Change in Penn State Worry Questionnaire (PSWQ)
Secondary mood outcome: Change in anxiety and worry measured by PSWQ, a self-report questionnaire with a range of 16-80, where higher scores indicate greater anxiety and worry.
Time frame: Baseline to week 12
Population: One participant not included due to early withdrawal.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in Penn State Worry Questionnaire (PSWQ) | -5.1 units on a scale | Standard Deviation 13.4 |
Comparison: Wilcoxon signed-rank test assessing for change from baseline to 12-weeksp-value: 0.073Wilcoxon (Mann-Whitney)
Secondary
Change in Ruminative Response Scale Total Score
Secondary mood outcome: Change in rumination measured by the Ruminative Response Scale total score measured at baseline and week 12. This is a self-report scale with a range of 0-66, where higher scores indicate higher levels of rumination.
Time frame: Baseline to week 12
Population: Subject who withdrew early not included due to no 12-week data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in Ruminative Response Scale Total Score | -9.0 units on a scale | Standard Deviation 10 |
p-value: 0.002Wilcoxon (Mann-Whitney)
Secondary
Change in Snaith-Hamilton Pleasure Scale (SHAPS) Score
Secondary mood outcome: Change in anhedonia measured by SHAPS, a self-report questionnaire that ranges from 0-42, where higher scores indicate greater anhedonia.
Time frame: Baseline to week 12
Population: One subject not included due to early withdrawal
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Transdermal Nicotine Patch | Change in Snaith-Hamilton Pleasure Scale (SHAPS) Score | -3.4 units on a scale | Standard Deviation 6.6 |
Comparison: Wilcoxon signed-rank test assessing for change from baseline to 12-weeksp-value: 0.084Wilcoxon (Mann-Whitney)