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Gamma-aminobutyric acid (GABA) is the key inhibitory neurotransmitter in the brain, working primarily via GABA<jats:sub>A<\/jats:sub>receptors, with an important role in virtually all physiologic functions in the brain. Some neuroactive steroids (NASs) are positive allosteric modulators (PAMs) of GABA<jats:sub>A<\/jats:sub>receptors and potentiate phasic and tonic inhibitory responses via activation of synaptic and extrasynaptic GABA<jats:sub>A<\/jats:sub>receptors, respectively. This review first discusses preclinical and clinical data that support the association of depression with diverse defects in the GABAergic system of neurotransmission. Decreased levels of GABA and NASs have been observed in adults with depression compared with healthy controls, while treatment with antidepressants normalized the altered levels of GABA and NASs. Second, as there has been intense interest in treatment approaches for depression that target dysregulated GABAergic neurotransmission, we discuss NASs approved or currently in clinical development for the treatment of depression. Brexanolone, an intravenous NAS and a GABA<jats:sub>A<\/jats:sub>receptor PAM, is approved by the U.S. Food and Drug Administration for the treatment of postpartum depression (PPD) in patients 15 years and older. Other NASs include zuranolone, an investigational oral GABA<jats:sub>A<\/jats:sub>receptor PAM, and PH10, which acts on nasal chemosensory receptors; clinical data to date have shown improvement in depressive symptoms with these investigational NASs in adults with MDD or PPD. Finally, the review discusses how NAS GABA<jats:sub>A<\/jats:sub>receptor PAMs may potentially address the unmet need for novel and effective treatments with rapid and sustained antidepressant effects in patients with MDD.<\/jats:p>","DOI":"10.1038\/s41398-023-02514-2","type":"journal-article","created":{"date-parts":[[2023,6,26]],"date-time":"2023-06-26T08:09:54Z","timestamp":1687766994000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":149,"title":["Understanding the mechanism of action and clinical effects of neuroactive steroids and GABAergic compounds in major depressive disorder"],"prefix":"10.1038","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5800-0378","authenticated-orcid":false,"given":"Andrew J.","family":"Cutler","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0234-6860","authenticated-orcid":false,"given":"Gregory W.","family":"Mattingly","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vladimir","family":"Maletic","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2023,6,26]]},"reference":[{"key":"2514_CR1","unstructured":"Depression. 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Dr. Cutler serves as a speaker for\/receives promotional honoraria from AbbVie, Acadia, Alfasigma, Alkermes, Axsome, Corium, Intra-Cellular Therapies, Janssen, Lundbeck, Neurocrine, Noven, Otsuka, Sunovion, Supernus, Takeda, and Teva. He has received research grants from Acadia, Alkermes, Allergan, Axsome, Biohaven, Intra-Cellular Therapies, Janssen, Lilly, Lundbeck, Novartis, Otsuka, Sage Therapeutics, Inc., Sunovion, and Takeda. Dr. Cutler is also an employee and board member of the Neuroscience Education Institute. GWM serves as a researcher for AbbVie, Akili, Alkermes, Axsome, Boehringer Ingelheim, Genentech, Janssen, Lundbeck, Medgenics, NLS Pharma, Otsuka, Reckitt Benckiser, Roche, Sage Therapeutics, Inc., Sunovion, Supernus, Takeda, Taisho, and Teva. Dr. Mattingly serves as a consultant for AbbVie, Alkermes, Alfasigma, Ironshore, Janssen, Lundbeck, Major League Baseball, Otsuka, National Football League, Neos, NLS Pharma, Purdue, Rhodes, Sage Therapeutics, Inc., Sunovion, Supernus, Takeda, Teva, and Vanda. Additionally, he serves as a speaker for AbbVie, Alkermes, Ironshore, Janssen, Lundbeck, Otsuka, Neos, Shire, Sunovion, Takeda, and Teva. VM serves as a consultant for AbbVie\/Allergan, Acadia Pharmaceuticals, Inc., Alfasigma, USA, Inc., Alkermes, Inc., Eisai, Intra-Cellular Therapies, Ironshore, Janssen, Lundbeck A\/S, Jazz Pharmaceuticals, Noven Pharmaceuticals Inc, Otsuka America Pharmaceutical, Inc., Sage Therapeutics, Inc., Sunovion, Supernus, and Takeda. Dr. Maletic also serves as a speaker for AbbVie, Acadia, Alfasigma, Alkermes, Allergan, Eisai, Ironshore, Intra-Cellular, Janssen, H. Lundbeck A\/S, Otsuka America Pharmaceutical, Inc., Sunovion, Supernus, and Takeda.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"228"}}