The lipid landscape shapes the immunomodulatory potential of fluoxetine in macrophages

Treatment-resistant depression (TRD) affects approximately one-third of depressed patients, yet the molecular mechanisms underlying this therapeutic non-responsiveness remain unclear. Pharmacological antidepressants, such as the selective serotonin reuptake inhibitor (SSRI) fluoxetine, exert immunomodulatory effects, partially by shifting macrophages towards an anti-inflammatory phenotype. Clinical aberrations in lipid metabolism have been associated with fluoxetine non-responsiveness in depressed populations. As macrophage polarization is highly sensitive to changes in lipid metabolism, pathological alterations in lipid metabolism may directly interfere with the therapeutic efficacy of SSRIs such as fluoxetine. However, how metabolic and immunomodulatory effects of antidepressants relate to each other in the context of TRD remains largely unexplored. We studied the interplay between immunomodulatory capacity of fluoxetine and the macrophage lipid landscape. Human monocyte-derived macrophages (MoDMs) and murine bone marrow-derived macrophages (BMDMs) were utilized as experimental models to evaluate these localized immunometabolic effects. Under baseline conditions in wild-type macrophages, the characteristic anti-inflammatory effect of fluoxetine coincided with distinct intracellular lipid accumulation. Conversely, disrupting this lipid environment yielded opposite immunological outcomes. BMDMs deficient in the low-density lipoprotein receptor (Ldlr-/-) or wild-type BMDMs exposed to inflammatory oxidized phosphocholine-containing phospholipids (OxPLs) failed to undergo anti-inflammatory polarization and exhibited a robust pro-inflammatory response upon fluoxetine treatment instead. Collectively, these data demonstrate a critical link between the macrophage lipid landscape and immunomodulatory efficacy of fluoxetine. These findings suggest that deficiencies in the endogenous LDLR pathway and exposure to circulating lipid peroxidation products can modulate the immunological response to fluoxetine. Our observations highlights microenvironmental lipid stress as a potential contributor to the underlying biology of antidepressant resistance in TRD.