Depression induced by treatment with interferon-alpha in patients affected by hepatitis C virus

Asymmetric dimethylarginine responses during interferon-α-induced depression in patients with chronic hepatitis C infection

OBJECTIVE

The aim of this study was to examine the association of depressive symptoms with asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA). Patients with chronic hepatitis C infection were examined during interferon-α (IFN-α) treatment, which is often associated with treatment-induced depression. The associations between IFN-α-induced depressive symptoms with ADMA and SDMA levels were prospectively investigated until 3 months after treatment.

METHODS

Psychiatric and biological assessments were obtained at six different time points: before, during (at 1, 3, 6, and 9 months), and after the end of IFN-α treatment.

RESULTS

During IFN-α treatment, 22 (53.7%) patients fulfilled the criteria for a treatment-related depressive disorder at least once during treatment. The increase in ADMA levels from baseline (depression group: 0.63 [0.08] μM, no depression group: 0.69 [0.08] μM) in response to IFN-α treatment was considerably higher in patients with IFN-α treatment-induced depressive episodes compared with patients without treatment-induced depressive episodes (3 months after the start of treatment: depression group: 0.72 [0.08] μM, no depression group: 0.72 [0.11] μM; ADMA: repeated-measure design analysis of variance [time × depression]: F(5,151) = 2.446, p = .036). The increase in SDMA was not associated with treatment-induced depression.

CONCLUSIONS

Depression in response to IFN-α treatment is associated with elevated ADMA levels. These findings are relevant to nitric oxide-related biological pathways linking depression to increased cardiovascular disease risk. Future studies are needed to clarify the role of serotonin in these pathways and may lead to preventative treatment strategies.

A biopsychosocial model of interferon-alpha-induced depression in patients with chronic hepatitis C infection

BACKGROUND

The aim of this prospective study was to gain a more comprehensive picture of the biopsychosocial effects of interferon-α (IFN-α) treatment of patients with chronic hepatitis C (HCV). The predictors of depressive development and changes in health-related quality of life, life satisfaction and cognitive ability were measured with the inclusion of the social context. Furthermore, the effects of IFN-α treatment on indoleamine 2,3-dioxygenase, the level of tryptophan supply in the brain, the development of neurotoxic kynurenine metabolites and the thyroid glands were investigated. Therefore, for the first time the conditions for the development of depressive episodes in HCV patients treated with IFN-α were examined over the entire period of treatment as well as 3 months later, applying a holistic biopsychosocial model.

METHOD

Psychiatric and biological assessments were carried out at 6 different times: before, during (at 1, 3, 6 and 9 months) and after the end of IFN-α treatment.

RESULTS

During IFN-α treatment 22 (53.7%) of 41 patients fulfilled the criteria for a treatment-related depressive disorder at least once during treatment. Contributing factors are tryptophan depletion (tryptophan to competing amino acids quotient), increased neurotoxic challenge (kynurenine to kynurenic acid quotient), less social support, female gender, preexisting psychiatric vulnerability, means of transmission, low financial security, impaired sexual satisfaction, small circle of friends, impaired physical role, strong body pain, low general health and vitality, reduced social functioning, impaired mental health and impaired emotional role.

CONCLUSIONS

The awareness of relevant risk factors of IFN-α treatment-induced depression is essential to develop preventative treatment strategies.

Kynurenines in CNS disease: regulation by inflammatory cytokines

The kynurenine pathway (KP) metabolizes the essential amino acid tryptophan and generates a number of neuroactive metabolites collectively called the kynurenines. Segregated into at least two distinct branches, often termed the “neurotoxic” and “neuroprotective” arms of the KP, they are regulated by the two enzymes kynurenine 3-monooxygenase and kynurenine aminotransferase, respectively. Interestingly, several enzymes in the pathway are under tight control of inflammatory mediators. Recent years have seen a tremendous increase in our understanding of neuroinflammation in CNS disease. This review will focus on the regulation of the KP by inflammatory mediators as it pertains to neurodegenerative and psychiatric disorders.

Baseline Comorbidities Enhance the Risk of Treatment-Induced Depression in HCV-Infected Men: A Pilot Study

BACKGROUND

Hepatitis C virus (HCV) infection is associated with clinical depression,a condition that is aggravated on interferon-based therapy. In HCV infection, men often appear more resilient to depression than women. However, men are subject to depression in diseases that tend to be comorbid in HCV-infected.

AIM

This study examined whether HCV-infected men with baseline comorbidities were more or less susceptible to depression prior to and on treatment.

METHODS

Patients with chronic HCV infection preparing to begin treatment participated (n = 37). The presence of baseline comorbidities was determined by pretreatment medication regimes. Depression was measured by the Beck Depression Inventory prior to and following 2, 4, 8, and 12 weeks of interferon therapy.

RESULTS

At baseline, cohorts with (n = 16) and without (n = 21) comorbidities had equivocal demographics and infection characteristics. Comorbidities did not associate with baseline depression. However, on treatment, men with baseline comorbidities demonstrated an elevated risk for the onset of de novo depression (odds ratio = 19.25; confidence interval = 1.41, 582.14; p = .008). This was not observed for women. Baseline comorbidities did not alter the need for treatment discontinuations or the ability to achieve a sustained viral response.

CONCLUSION

The results of this study suggest that baseline comorbidities render men more susceptible to interferon treatment-induced depression.

Efficacy of adjunctive celecoxib treatment for patients with major depressive disorder: a meta-analysis

BACKGROUND

Numerous studies have reported that inflammation is closely associated with depression, and adjunctive non-steroidal anti-inflammatory drug (NSAID) treatment has been suggested as a novel therapeutic approach for depression.

METHODS

We searched electronic databases including Medline, Embase, and the Cochrane Central Register of Controlled Trials. We only included randomized controlled trials comparing adjunctive NSAIDs with placebos for treating depressive episodes.

RESULTS

Of the 654 retrieved entries, we identified four relevant studies with a total of 150 patients (75 NSAID patients and 75 placebo patients) with depressive episodes. All four studies used celecoxib as the NSAID. The patients receiving adjunctive celecoxib had significantly higher mean changes in the Hamilton Rating Scale for Depression scores between baseline and endpoint measurements compared with those receiving placebo (weighted mean difference=3.26, 95% confidence interval; CI=1.81 to 4.71). The adjunctive celecoxib group also showed better remission (odds ratio; OR=6.58, 95% CI=2.55 to 17.00) and response rates (OR=6.49, 95% CI=2.89 to 14.55) than the placebo group. The all-cause drop-out rate was more favorable for the celecoxib group than for the placebo group (OR=0.45, 95% CI=0.18 to 1.13), although the statistical significance was not statistically significant (p=0.09).

CONCLUSION

Adjunctive treatment with NSAIDs, particularly celecoxib, can be a promising strategy for patients with depressive disorder. Future studies with a larger sample size and longer study duration are needed to confirm the efficacy and tolerability of NSAIDs for depression.

Depression Correlates with Increased Plasma Levels of Inflammatory Cytokines and a Dysregulated Oxidant/Antioxidant Balance in HIV-1-Infected Subjects Undergoing Antiretroviral Therapy

OBJECTIVE

Depression is the most common psychiatric diagnosis in the HIV/AIDS population and represents a risk factor for disease progression. Since HIV-1 infection is characterized by immunologic and metabolic disturbances, we want to study the effects of depression on different components related to pro-inflammatory and oxidative stress markers. We hypothesize that depression will lead to increased pro-inflammatory cytokine levels and altered antioxidant/oxidant balance.

METHODS

We included males and females who were ≥21 years of age, whose HIV-1 sero-status was confirmed by Western Blot, and who were currently undergoing antiretroviral treatment. Patients completed the participation consent form, a socio-demographic survey, and the Patient Health Questionnaire-9 (PHQ-9) for depression assessment. We isolated the plasma from participants' blood samples for viral load analysis (RT-PCR), T-cell counts (flow cytometry), and hematological parameters. A cytokine magnetic bead panel was used to measure interleukin-15 (IL-15), interferon gamma-induced protein 10 (IP-10), IL-12 and granulocyte colony-stimulating factor (G-CSF) levels. We also performed assays to determine the antioxidant activity of superoxide dismutase (SOD) and catalase and to measure the lipid peroxidation levels using malondialdehyde (MDA) and 8-isoprostane assays. Statistical comparisons and correlations at 5% level of significance were determined.

RESULTS

Our results show that subjects with mild/moderate to severe depression as assessed by PHQ-9 had a significantly decreased adherence to anti-retroviral treatment. Subjects with depression also had significantly lower levels of white blood cells (WBC) and platelets (PLT) than did the non-depressed group. The HIV⁺ subjects with depression had increased levels of IL-15, IP-10, IL-12 p40/p70 and G-CSF compared to their non-depressed counterparts. The latter had increased MDA and 8-isoprostane levels.

CONCLUSIONS

Our results suggest that HIV⁺ subjects with depressive symptoms have higher levels of inflammation and altered oxidant/antioxidant balance. Although the groups were small, this study strengthens the hypothesis that alterations in cytokines are associated with the mechanisms underlying depression symptoms.

CRP, IL-6 and depression: a systematic review and meta-analysis of longitudinal studies

BACKGROUND

Inflammatory markers are raised in cross-sectional studies of depressed patients and may represent an important mediating factor for behaviour, neural plasticity and brain structure.

METHODS

We undertook a systematic review of longitudinal studies, investigating whether raised inflammatory markers indicate an increased risk of subsequent depressive symptoms. We searched three databases (1970-2012) for longitudinal studies with repeat data on CRP or IL-6 levels and subsequent depressive symptoms. We calculated effect sizes using a mixed-effects model, with separate meta-analyses for inflammatory markers and age groups.

RESULTS

We identified eight papers for CRP (14,832 participants) and three for IL-6 (3695 participants). There was a significant association between increased CRP and depressive symptoms (weighted-mean effect size 'unadjusted r'=0.069, p<0.0005; 'adjusted r'=0.046, p<0.0005), with moderate heterogeneity between studies (Q=11.21, p=0.08, I(2)=46.5). For IL-6 the weighted-mean effect size was smaller ('unadjusted r'=0.045, p-value=0.007; 'adjusted r'=0.097, p-value=0.06).

LIMITATIONS

The meta-analysis was based on a relatively small number of studies (particularly for IL-6) and only two inflammatory markers. There was moderate heterogeneity between studies and some evidence of publication bias.

CONCLUSIONS

Raised inflammatory markers have a small but significant association with the subsequent development of depressive symptoms. This is a robust effect which remains significant after adjustment for age and a wide range of factors associated with risk for depression. Our results support the hypothesis that there is a causal pathway from inflammation to depression.

Depression and fatigue in chronic hepatitis C patients with and without HIV co-infection

BACKGROUND

Depression and fatigue are common in chronic hepatitis C (CHC).

OBJECTIVE

We report clinical predictors of these conditions in patients seen in a university clinic.

METHODS

A total of 167 CHC patients completed the Patient Health Questionnaire-9 (PHQ-9) and Fatigue Severity Scale (FSS). Major depressive disorder (MDD) suggested by PHQ-9 was confirmed by clinical interview. FSS scores ≥41 were considered clinically significant fatigue. Logistic and multiple regression models were employed for analysis.

RESULTS

Thirty-three percent of patients had MDD and 52% had clinically significant fatigue. Sixty-one percent were HIV-infected, among whom both MDD and clinically significant fatigue were significantly less prevalent (OR = 0.47 and 0.46, respectively). MDD was least common in patients without a history of IV drug use (OR = 0.28), and highest in methadone users (OR = 3.57). Compared with methadone users, patients with no history of IV drug use and former IV drug users had less severe fatigue (coefficients = -31.0, -34.0, respectively). Lack of a history of hepatitis treatment was also associated with less severe fatigue (coefficient= -7.6).

CONCLUSION

Our study confirms high prevalence of fatigue and depression in CHC. HIV-positivity was associated with lower rates of MDD and clinically significant fatigue, arguably due to support systems for people living with HIV. Higher rates of depression in methadone users might be due to intrinsically higher rates of psychopathology in this group. Being on hepatitis treatment was associated with higher rates of fatigue, probably due to the adverse effects of interferon. Our findings emphasize the importance of routine screening and evaluation of depression and fatigue in CHC populations.

The neuroprogressive nature of major depressive disorder: pathways to disease evolution and resistance, and therapeutic implications

In some patients with major depressive disorder (MDD), individual illness characteristics appear consistent with those of a neuroprogressive illness. Features of neuroprogression include poorer symptomatic, treatment and functional outcomes in patients with earlier disease onset and increased number and length of depressive episodes. In such patients, longer and more frequent depressive episodes appear to increase vulnerability for further episodes, precipitating an accelerating and progressive illness course leading to functional decline. Evidence from clinical, biochemical and neuroimaging studies appear to support this model and are informing novel therapeutic approaches. This paper reviews current knowledge of the neuroprogressive processes that may occur in MDD, including structural brain consequences and potential molecular mechanisms including the role of neurotransmitter systems, inflammatory, oxidative and nitrosative stress pathways, neurotrophins and regulation of neurogenesis, cortisol and the hypothalamic-pituitary-adrenal axis modulation, mitochondrial dysfunction and epigenetic and dietary influences. Evidence-based novel treatments informed by this knowledge are discussed.

The neurobiology of suicide - A Review of post-mortem studies

The neurobiology of suicidal behaviour, which constitutes one of the most serious problems both in psychiatry and general medical practice, still remains to a large degree unclear. As a result, scientists constantly look for new opportunities of explaining the causes underlying suicidality. In order to elucidate the biological changes occurring in the brains of the suicide victims, studies based on post-mortem brain tissue samples are increasingly being used. These studies employ different research methods to provide an insight into abnormalities in brain functioning on various levels, including gene and protein expression, neuroplasticity and neurotransmission, as well as many other areas. The aim of this paper to summarize the available data on the post-mortem studies, to provide an overview of main research directions and the most up-to-date findings, and to indicate the possibilities of further research in this field.

[Interferon α therapy in patients with chronic hepatitis C infection: biopsychosocial consequences]

BACKGROUND

Interferon α (IFN-alpha) is widely used in the treatment of viral infections, including hepatitis C. Unfortunately depression is a common side effect of IFN-alpha therapy. The presence of depressive symptoms is important because they have an adverse effect on the course of the illness and reduce the quality of life and the treatment adherence. The current prospective study examines the effects of IFN-alpha on the development of depressive disorders, on cognitive functioning and on quality of life.

METHOD

A total of 25 patients with chronic hepatitis C infection were investigated. All patients were treated in the Department of Gastroenterology and Hepatology, University of Medicine of Graz, Austria. Psychometric observer rating and self-rating scales were administered 1 month and 3 months after the beginning of the antiviral treatment to evaluate depressive symptoms [Beck Depression Inventory (BDI); Hamilton Depression Scale]. The data on life satisfaction before therapy and health-related quality of life were obtained from the Fragebogen zur Lebenszufriedenheit (FLZ) and the SF-36 (Health Status Questionnaire). Cognitive function was based on the SKT (Syndrom Kurztest). All patients completed the Social Support Questionnaire (SSS), a multidimensional self-report measure of social support.

RESULTS

Three months after the initial IFN-alpha administration in the whole sample significant impairments in health-related quality of life were found in the health-related domains "physical functioning", "role physical", "role emotional", "social functioning" and "vitality". The whole sample showed cognitive impairments. No changes in social support were recorded. Three months after the first INF-alpha administration, 48% (n=12) of the sample suffered from moderate clinical depression. In comparison to patients without pathological affective findings, patients with INF-alpha-induced clinical depression showed decreased life satisfaction before the initial antiviral therapy. Impairments in health-related quality of life (SF-36) were found in the sample with clinical depression in the health-related domains "general health", "social functioning", "role emotional", "vitality" and "mental health".

CONCLUSION

Hepatitis C is associated with an increased prevalence of psychiatric disorders, particularly depression. INF-alpha patients having low levels of life satisfaction in the domains "self-concept" (skills, appearance, self-confidence, vitality …), "employment" and "physical health and constitution" seem to face a major risk of depression.

Psychiatric side effects of medications prescribed in internal medicine

Several pharmacological treatments used in internal medicine can induce psychiatric side effects (PSEs) that mimic diagnoses seen in psychiatry. PSEs may occur upon withdrawal or intoxication, and also at usual therapeutic doses. Drugs that may lead to depressive, anxious, or psychotic syndromes include corticosteroids, isotretinoin, levo-dopar mefloquine, interferon-a, and anabolic steroids, as well as some over-the-counter medications. PSEs are often difficult to diagnose and can be very harmful to patients. PSEs are discussed in this review, as well as diagnostic clues to facilitate their identification.

An Exploration of Depressive Symptoms in Hepatitis C Patients Taking Interferon-alpha: Increase in Sickness Behaviors but not Negative Cognitions

OBJECTIVE

The most investigated adverse event associated with interferon-alpha (IFN-α) treatment is depressed mood, with many studies finding a significant increase in depression scale scores from baseline to treatment. This paper is concerned with exploring discrete categories of depressive symptoms (somatic, behavioral, negative cognitions and depressed mood) in order to explore the behavioral syndrome associated with IFN-α.

METHODS

Thirty-five Hepatitis C patients due to commence IFN-α treatment were assessed using the Structured Clinical Interview (SCID), and the 24-item Hamilton Depression Inventory (HAM-D) at 0 and 8 weeks.

RESULTS

Somatic symptoms comprised the significant majority of scores across all weeks for patients taking IFN-α. Patients who developed a depression had significantly more somatic and mood symptoms at Week 8 than those patients who did not develop a depression.

CONCLUSIONS

These exploratory results indicate that the increase in raw depression scores is due to an increase in somatic and mood symptoms, rather than negative cognitions. However, this increase does not correspond to a proportional increase in a particular subscale. These results also indicate that development of an IFN-α-induced depression is due to mood symptoms rather than negative cognitions.

Symptomatic treatment of interferon-α-induced depression in hepatitis C: a systematic review

Despite its efficacy in treating hepatitis C, interferon-α (IFN-α) can cause depression. The purpose of this systematic review is to summarize and discuss the available and effective therapies in treating IFN-α-induced depression. Using PubMed, The Cochrane Library, Scopus, Embase, Ovid of Medline, PsycINFO, and ISI Web of Knowledge, we selected 64 articles concerning IFN-α-induced depression treatment in hepatitis C patients. Selective serotonin reuptake inhibitors can be considered the first choice for the treatment of IFN-α-induced depression, as demonstrated in open-label studies, case reports, and a randomized, double-blind, placebo-controlled trial. Also 5-hydroxytryptophan and tryptophan have been suggested to be effective as monotherapy or as augmentation of selective serotonin reuptake inhibitors. Clinical cases that show positive effects of tricyclic antidepressants, however, do not provide sufficient evidence for the use of these drugs. Two cohort studies have reported the effectiveness of amisulpride, but not of levosulpiride. Mirtazapine has been suggested to be a better choice of treatment in cases where insomnia or anorexia develop. Milnacipram can be useful in cases of concomitant medications, for the unlikely occurrence of drug-drug interactions. Psychostimulants represent an empirical treatment without controlled data to support their use. Two case reports have shown the favorable use of bupropion, particularly if sexual dysfunction or cravings for illicit drugs are present. A single case report suggests electroconvulsive therapy to be a possible choice when antidepressants are ineffective or poorly tolerated. The main limitation of our review is that the quality of the findings varied across the reviewed studies. Our observations may help clinicians with managing IFN-α-induced depression.

The supplementation of acetyl-L-carnitine decreases fatigue and increases quality of life in patients with hepatitis C treated with pegylated interferon-α 2b plus ribavirin

The aim of this study was to evaluate whether supplementation of acetyl-L-carnitine (ALC) to pegylated-interferon-α 2b (Peg-IFN-α 2b) and ribavirin (RBV) improves the health-related quality of life during the treatment for chronic hepatitis C, thereby decreasing the risk of treatment discontinuation. Sixty patients with chronic hepatitis C underwent treatment with Peg-IFN-α 2b + RBV (group A; n = 29) or Peg-IFN-α 2b + RBV + ALC (group B; n = 31) for 12 months. At the end of the study, the comparison between group A and group B showed significant differences in aspartate aminotransferase (AST) (-80.9 versus -110.3; P < 0.001), alanine aminotransferase (-111.6 versus -134.7; P < 0.001), Viremia (-3.26 versus -3.82; P < 0.05), mental health (0 versus 11; P < 0.001), physical functioning (-1 versus 8; P < 0.001), role-physical (1 versus 13; P < 0.001), bodily pain (1 versus 12; P < 0.001), general health (3 versus 12; P < 0.001), vitality (3 versus 13; P < 0.001), social functioning (3 versus 10; P < 0.001), physical fatigue (2.1 versus -5.4; P < 0.001), mental fatigue (-0.7 versus -2.7; P < 0.001), and fatigue severity scale (-3.4 versus -12; P < 0.001). ALC supplementation reduced both mental and physical fatigue, improved health-related quality of life, and, therefore, has the potential to increase patient adherence to the combination regimen. This, in turn, may increase the percentage of patients achieving a sustained virological response.

Proinflammatory cytokines in the prefrontal cortex of teenage suicide victims

Teenage suicide is a major public health concern, but its neurobiology is not well understood. Proinflammatory cytokines play an important role in stress and in the pathophysiology of depression-two major risk factors for suicide. Cytokines are increased in the serum of patients with depression and suicidal behavior; however, it is not clear if similar abnormality in cytokines occurs in brains of suicide victims. We therefore measured the gene and protein expression levels of proinflammatory cytokines interleukin (IL)-1β, IL-6, and tissue necrosis factor (TNF)-α in the prefrontal cortex (PFC) of 24 teenage suicide victims and 24 matched normal control subjects. Our results show that the mRNA and protein expression levels of IL-1β, IL-6, and TNF-α were significantly increased in Brodmann area 10 (BA-10) of suicide victims compared with normal control subjects. These results suggest an important role for IL-1β, IL-6, and TNF-α in the pathophysiology of suicidal behavior and that proinflammatory cytokines may be an appropriate target for developing therapeutic agents.

Advances in research of sleep disturbance in patients with hepatitis C virus infection

According to the WHO statistics, approximately 171 million people are infected by hepatitis C virus (HCV) worldwide. Chronic HCV infection is associated with physical and mental symptoms including fatigue, sleep disturbance, and depression that adversely affect quality of life. But sleep disturbance has received little attention in the literature, with the exception of sleep changes noted in patients with cirrhosis and end-stage liver disease. More studies focusing on the role of chronic hepatitis C (CHC) infection in the development of sleep disorders are needed. Increased knowledge about the mechanisms behind the pathogenesis of sleep disturbance in patients with CHC will help us develop appropriate treatments.

Functional biomarkers of depression: diagnosis, treatment, and pathophysiology

Major depressive disorder (MDD) is a heterogeneous illness for which there are currently no effective methods to objectively assess severity, endophenotypes, or response to treatment. Increasing evidence suggests that circulating levels of peripheral/serum growth factors and cytokines are altered in patients with MDD, and that antidepressant treatments reverse or normalize these effects. Furthermore, there is a large body of literature demonstrating that MDD is associated with changes in endocrine and metabolic factors. Here we provide a brief overview of the evidence that peripheral growth factors, pro-inflammatory cytokines, endocrine factors, and metabolic markers contribute to the pathophysiology of MDD and antidepressant response. Recent preclinical studies demonstrating that peripheral growth factors and cytokines influence brain function and behavior are also discussed along with their implications for diagnosing and treating patients with MDD. Together, these studies highlight the need to develop a biomarker panel for depression that aims to profile diverse peripheral factors that together provide a biological signature of MDD subtypes as well as treatment response.

The role of tumor necrosis factor-alpha and other cytokines in depression: what dermatologists should know

Recent studies have suggested that inflammatory responses may play an important role in the pathophysiology of depression. In fact, depressed individuals have been found to have higher levels of pro-inflammatory cytokines, especially tumor necrosis factor-alpha (TNF-α) and interleukin-6. This appears to be independent of any pre-existing chronic inflammatory disorders. In this article, various studies correlating increased levels of cytokines to depression are reviewed. As much as 60% of individuals with psoriasis also suffer from clinical depression. TNF-α antagonists, frequently used in the treatment of psoriasis, may be helpful in directly reducing depressive symptoms for patients with psoriasis and other chronic inflammatory conditions.

The kynurenine system and immunoregulation

There is developing interest in the role of the kynurenines in the immune function. A considerable amount of evidence has accumulated as concerns interactions between the kynurenine pathway, cytokines and the nervous system. Indoleamine 2,3-dioxygenase (IDO) occupies a key position connecting the immune system and the kynurenine pathway. There are evidences of the immunosuppressive effect of IDO. Following the interferon (IFN)-mediated activation of antigen presenting cells, the induction of IDO and the kynurenine system exerts a counter-regulating effect, maintaining the homeostasis. Inhibition of T cell functions, activation of the regulatory T cells, and the inhibition of Natural Killer cells are among the important factors in the immunosuppressive effects of IDO and kynurenines. There is a close connection between cytokines (IFN-α, IFN-γ, TNF-α, TGF-β, IL-4 and IL-23) and the kynurenine system, and an imbalance in the TH1/TH2 cytokine profile may possibly lead to neurologic or psychiatric disorders. As the tryptophan metabolic pathway is activated by pro-inflammatory stimuli, the anti-inflammatory effect of kynurenic acid provides a further feedback mechanism in modulating the immune responses.

Persistent pro-inflammatory cytokines following the initiation of pegylated IFN therapy in hepatitis C infection is associated with treatment-induced depression

Pegylated interferon (IFN), the basis for chronic hepatitis C virus (HCV) treatment, causes depression in 30-40% of patients. The potential for cytokine mRNA patterns from baseline into early treatment to associate with the onset of treatment-induced depression (TID) was examined. Depression was measured by the Beck Depression Inventory at baseline and weeks 2, 4, 8 and 12 of treatment (n = 38). At baseline and weeks 2 and 4, peripheral blood mononuclear cell (PMBC, n = 28), isolated ex vivo, were examined for tumour neurosis factor (TNF)-alpha, interleukin (IL)-1beta and IL-10 mRNA expression. In patients that developed treatment-induced depression, pro-inflammatory TNF-alpha mRNA levels from baseline into week 4 of therapy remained constant (1.1-fold increase); whereas IL-1beta transcripts decreased 3.5 fold. However, corresponding TNF-alpha (3-fold, P < 0.05) and IL-1beta (7.5-fold) transcript expression diminished to a greater extent in the absence of TID. Changes in TNF-alpha mRNA values correlated to the average change in BDI scores over the 12 weeks (r = 0.56, P < 0.05). Concomitantly, anti-inflammatory IL-10 transcript levels decreased in (TID), relative to increased expression in the absence of TID (P < 0.05). The potential influence of IL-10 was observed upon calculation of individual pro- verses anti-inflammatory mRNA ratios. Stable in the presence of depression, TNF-alpha/IL-10 and IL-1beta/IL-10 mRNA ratios declined significantly over time in its absence (P < 0.05). This study suggests that in chronic HCV infection, upon pegylated IFN administration persistent pro-inflammatory cytokine MRNA expression associates with TID. In contrast, therapeutic activation of mechanisms that decrease pro-inflammatory immunity may protect against depression during therapy.

Proinflammatory activity and the sensitization of depressive-like behavior during maternal separation

When guinea pig pups are isolated for a few hours in a novel environment, they exhibit a distinctive passive behavioral response that appears to be mediated by proinflammatory activity. Recently, we observed that pups separated on two consecutive days show an enhanced (sensitized) passive response on the second day. In Experiment 1, pups receiving intracerebroventricular infusion of 50 ng of the anti-inflammatory cytokine interleukin-10 prior to a first separation failed to show a sensitized behavioral response to separation the next day. In Experiment 2, pups separated on Days 1 and 2, or just 2, showed an increase in passive responding during separation on Day 5. Pups injected with the bacterial antigen lipopolysacchride (LPS; 75 μg/kg body weight, intraperitoneal) prior to separation on Day 1 showed an increase in passive behavior several days later not shown by pups injected with saline prior to Day 1 separation. However, injection of LPS without separation on the first day did not enhance responding during an initial separation on the second day. These results suggest that immune activation is necessary, but not sufficient, to account for the sensitization of passive behavior of isolated guinea pig pups the following day, that boosting proinflammatory activity during an initial separation may promote sensitization several days later, and that the sensitized response persists for at least several days.

Effect of CBT on Depressive Symptoms in Methadone Maintenance Patients Undergoing Treatment for Hepatitis C

To examine the efficacy of a cognitive-behavioral intervention (CBT) to prevent depression among methadone maintenance patients undergoing antiviral treatment for hepatitis C (HCV), 29 patients beginning HCV treatment were randomized to CBT or standard care (SC). Study participants did not meet criteria for major depressive disorder at the time of study recruitment. CBT did not result in less depression-related antiviral treatment failure, better adherence to antiviral treatment, or better HCV RNA outcomes. There were no significant treatment group differences on depressive symptoms over time. The CBT group did display a greater and more consistent decline in both BDI-II and HAM-D scores over time (d=.85 on the BDI-II; d=.72 on the HAM-D).

The use of psychoeducation for a patient with hepatitis C and psychiatric illness in preparation for antiviral therapy: a case report and discussion

The standard of care treatment for chronic hepatitis C viral infection (HCV) is a combination of pegylated interferon alfa and ribavirin for 24-48 weeks according to the virus genotype. This therapy is known to have multiple neuropsychiatric side effects. A major concern when evaluating a patient for HCV treatment with a known history of a psychiatric disorder is the risk that the patient's psychiatric disorder will flare or become unmanageable. The possibility of precipitating depression, confusion, mania, psychosis, hallucinations, or suicidal ideation or attempt is frequently an obstacle to treatment. We present the case of a 50 year-old man with HCV and an extensive psychiatric history involving alcoholism, depression, and suicidality who participated in a psychoeducation group to help prepare him for treatment with pegylated interferon alfa/ribavirin therapy. Though the patient derived much benefit from the psychoeducation group, by the time of evaluation for HCV treatment two months after the group ended he had relapsed back into a depressive episode with suicidal thoughts. His acute psychiatric status made him unacceptable for pegylated interferon alfa/ribavirin therapy. Psychoeducation groups show promise for helping patients with chronic medical illness to be ready for and endure intensive medical treatment that has substantial psychiatric side effects. The challenge is to help patients overcome barriers to treatment, particularly psychosocial problems, because available treatments are increasingly effective.

Suicide risk in hepatitis C and during interferon-alpha therapy: a review and clinical update

Chronic hepatitis C (CHC) affects over 170 million individuals worldwide and is a growing public health concern. Despite the availability of CHC treatment, specifically interferon-α and ribavirin, treatment of CHC is limited by concerns about psychiatric side effects including risks of suicide. Although depression has been the focus of neuropsychiatric complications from interferon-alpha (IFNα), emerging evidence has contributed to our understanding of IFNα-induced suicidal ideation and attempts. Using Pubmed, we performed a literature review of all English articles published between 1989 and April 1, 2010 on suicide in untreated and IFNα-treated patients with CHC. References in all identified review articles were scanned and included in our review. A total of 17 articles were identified. Studies have suggested that the first 12 weeks of IFNα therapy are the high-risk period. Moreover, the emergence of suicidal ideation can be linked to neuropsychiatric abnormalities, specifically serotonin depletion. Pretreatment with antidepressant treatment should be reserved for high-risk groups, as this may reduce the risk of depression and thus decrease the suicide risk indirectly. Although there is a paucity of literature on suicide and suicide risk during IFNα therapy for CHC, recent studies on IFNα-induced depression have provided some potential insights into suicide in this patient population. Further research examining the effects of pharmacological and nonpharmacological interventions on suicide risk during IFNα treatment is needed.

Risk factors for the development of depression in patients with hepatitis C taking interferon-α

Interferon-α, currently used for the treatment of hepatitis C, is associated with a substantially elevated risk of depression. However, not everyone who takes this drug becomes depressed, so it is important to understand what particular factors may make some individuals more 'at risk' of developing depression than others. Currently there is no consensus as to why interferon-induced depression occurs and the range of putative risk factors is wide and diverse. The identification of risk factors prior to treatment may allow identification of patients who will become depressed on interferon, allowing the possibility of improved treatment support and rates of treatment adherence. Here, we consolidate and review the literature on risk factors, and we discuss the potential confounds within the research examined in order to better isolate the risk factors that may be important in the development of depression in these patients and which might help predict patients likely to become depressed on treatment. We suggest that interactions between psychobehavioral, genetic, and biological risk factors are of particular importance in the occurrence of depression in patients with hepatitis C taking interferon-α.

Association between increased tryptophan degradation and depression in cancer patients

PURPOSE OF REVIEW

A high percentage of patients with malignant disease develops mood disorders or even depression. This review provides an overview, how immune activation and tryptophan degradation might contribute to the development of depression.

RECENT FINDINGS

Neurobiochemical changes caused by immune activation are supposed to be involved in the development of mood disorders, especially depression, in cancer patients. Within Th1-type immune response the enzyme indoleamine 2,3-dioxygenase (IDO) is induced, which degrades the essential amino acid tryptophan to form kynurenine derivatives. Enhanced immune-mediated tryptophan degradation is reflected by decreased plasma tryptophan levels and increased kynurenine concentrations in parallel with elevated concentrations of Th1-type immune activation marker neopterin. IDO activation has been demonstrated in patients with various kinds of cancer, and it has also been shown to predict a worse outcome of patients. Recent data also indicate strongly, that immune-mediated tryptophan degradation is crucially involved in the development of depression: IDO activation leads to the accumulation of neurotoxic metabolites, which are supposed to induce depressive-like behaviour. Furthermore immune-mediated tryptophan deprivation might also impair serotonin synthesis, as tryptophan is the precursor of this important neurotransmitter.

SUMMARY

Immune-mediated tryptophan degradation appears to be crucially involved in the development of depression.

A multidisciplinary therapeutic approach for reducing the risk of psychiatric side effects in patients with chronic hepatitis C treated with pegylated interferon α and ribavirin

GOALS

To evaluate the effectiveness of psychiatric counseling in reducing the rate of development of psychiatric side effects of antiviral therapy with interferon-α and ribavirin among study participants compared with standard clinical monitoring alone.

BACKGROUND

Interferon-α is used to treat chronic hepatitis C. Interferons may induce adverse events that usually, but not always, reverse within a few days after the end of therapy.

STUDY

Two hundred eleven patients with chronic hepatitis C, genotype 1b were treated with peginterferon and ribavirin for 48 weeks in a prospective trial. Two groups were randomly created. Group A was interviewed by a team of gastroenterologists, psychiatrists, and psychologists and treated with psychotherapy once a month. Group B was monitored once a month according to a conventional protocol that did not include psychotherapy. SVR (sustained viral response), severe psychiatric symptom onset, and mood progression were assessed (P calculated using Fisher exact test, Friedman test, Dunn posttest, and Mann-Whitney U-test).

RESULTS

At baseline, there was no difference in depressive symptoms or liver histologic score between the 2 groups. The onset rate of severe psychiatric manifestations was 4.7% (Group A) and 16.1% (Group B) between the 24th and 36th weeks (P<0.01). Fifteen participants in Group A and 39 in Group B required antidepressants and benzodiazepines (P<0.05).

CONCLUSIONS

Patients can develop depressive symptoms during interferon therapy. Multidisciplinary medical treatment with psychiatric counseling provided during the treatment of chronic hepatitis C may contribute to the decrease or prevent the higher rates of depression associated with interferon treatment.

What can post-mortem studies tell us about the pathoetiology of suicide?

Suicide is a major public health concern; however, its neurobiology is unclear. Post-mortem brain tissue obtained from suicide victims and normal controls offers a useful method for studying the neurobiology of suicide. Despite several limitations, these studies have offered important leads in the neurobiology of suicide. In this article, we discuss some important findings resulting from these studies, focusing on serotonergic mechanisms, signal transduction systems, neuroendocrine studies and immune function abnormalities in suicide. These studies suggest that abnormalities of certain receptor subtypes, components of signaling systems such as protein kinase C and protein kinase A, transcription factors such as cyclic AMP response element-binding protein and neurotrophins may play an important role in the pathophysiology of suicide. These studies also suggest abnormalities of hypothalamic-pituitary-adrenal axis system components, feedback mechanisms and cytokines, which are chemical mediators of the immune functions. Post-mortem brain tissue offers an opportunity for future studies, such as genetic and epigenetic studies.

Prevalence of hepatitis C in two inpatient psychiatry populations

OBJECTIVE

Psychiatric populations may be particularly at risk of hepatitis C (HCV), less likely to receive appropriate interventions and at greater risk of liver damage due to comorbid substance abuse. This study sought to determine the prevalence of HCV in two inpatient psychiatric populations of seriously mentally ill patients and the relationship to risk factor screening.

METHOD

Two inpatient units were chosen in similar socio-economic areas. Persons admitted to these wards over the course of the study were invited to participate and provided with pre-test counselling. Where informed consent was obtained, individuals were included in the study. It was planned to screen all consenting patients. However, funding was reduced for one site meaning that only patients with identified risk factors could be screened there.

RESULTS

Around 18% of psychiatric inpatients admitted to risk factors for HCV. The prevalence of HCV with screening of all consenting patients in unit A was 3.2%. With selective screening in unit B, 41.7% of those with identified risk factors tested positive. These results compare to the Australian community rate of approximately 1.1%.

CONCLUSION

Results are consistent with elevated rates of HCV in mentally ill populations elsewhere in the world, and provide support for selective screening.

Evaluation of depression as a risk factor for treatment failure in chronic hepatitis C

The Major Depression Inventory (MDI) was used to estimate the value of routine medical interviews in diagnosing major depression among patients receiving peginterferon alfa-2a and ribavirin therapy for chronic hepatitis C virus (HCV) infection (n = 325). According to criteria from the MDI and Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 19 patients (6%) had major depression at baseline. An additional 114 (37%) developed depression while on HCV combination therapy, with baseline MDI score and female sex independently predicting the emergence of major depression during treatment in a multivariate analysis. Only 36 (32%) of the 114 patients developing major depression according to MDI/DSM-IV criteria were correctly diagnosed during routine medical interviews. The emergence of major depression frequently led to premature discontinuation of peginterferon/ribavirin therapy, and an on-treatment MDI score increment exceeding 30 points (i.e., a validated marker of idiopathic DSM-IV major depression) was correlated with impaired outcome of HCV therapy (P = 0.02). This difference was even more pronounced among patients with an on-treatment increase in MDI score greater than 35 points (P = 0.003).

CONCLUSION

We conclude that (1) depressive symptoms among patients undergoing HCV therapy are commonly overlooked by routine clinical interviews, (2) the emergence of depression compromises the outcome of HCV therapy, and (3) the MDI scale may be useful in identifying patients at risk for treatment-induced depression.

Management of nonresponsive hepatitis C

More than 50% of hepatitis C virus (HCV)-infected patients do not respond to the classical pegylated interferon (PEG-IFN)/ribavirin combination therapy. However, failing to respond to one course of treatment is not synonymous of therapy failure and retreatment is often beneficial. Alternative retreatment strategies include repeating the classical standard of care with an optimized drug regimen and adherence, including ribavirin serum concentration adjustment, correcting, if at all possible, comorbidities, and the addition of new specific anti-HCV molecules to the backbone of pegylated interferon/ribavirin. Options of retreatment should include consensus and natural interferons. For patients with advanced disease exposed to a high risk of lethal complications, customized maintenance therapy could be an effective option since it may slow down complications in some patients. Since low-dose interferon monotherapy is not sufficient, such a maintenance therapy remains to be verified via clinical trials. New possibilities of noninvasive assessment of fibrosis and the use of genetic tests to predict fibrosis progression and responsiveness to interferon are major emerging opportunities that run parallel to the revolution of the pharmacologic armentarium.

Major depression during interferon-alpha treatment: vulnerability and prevention

Major Depressive Disorder (MDD) during interferons (IFN-α) treatment can occur within a few months of therapy, and shares many homologies with other forms of MDD, Most patients are resilient to the side effect ofinterferon-induced depression (IFN-MDD), but 15% to 40% are vulnerable. Several studies have employed antidepressants to prevent the incidence of an IFN-MDD episode, and the results suggest that prophylactic antidepressants may be specifically useful in those with pre-existing subthreshold depressive symptoms andlor a history of prior MDD episodes. Several other potential markers of vulnerability for IFN-MDD have been implicated in assessments of nondepressed patients before they start IFN-α These include poor sleep quality, premorbid elevations in inflammatory cytokines, genetic polymorphisms in the serotonin system, personality, and social support. The interplay of these factors strongly predicts who is at risk for IFN-MDD, and indicates several potentially modifiable targets for the personalized prevention of IFN-MDD,

A review of sleep disturbance in hepatitis C

Sleep disturbances occur in up to 60% of patients with chronic hepatitis C (CHC) and is often interrelated with comorbid psychiatric disorders. Moreover, neuropsychiatric complications of interferon-alpha during CHC treatment can manifest as sleep problems. Newly diagnosed sleep disturbance occurs in up to 60% and 30% of untreated CHC patients and patients undergoing interferon-alpha therapy, respectively. However, the presentation of insomnia in patients with CHC is influenced by significant psychiatric comorbidity, such as depression, and medical conditions, such as anemia and hypothyroidism. Therefore, prompt recognition using screening tools and exclusion of comorbid conditions contributing sleep pathology can enhance treatment outcomes. Owing to the paucity of studies, treatment recommendations for sleep disorders in CHC patients are derived from recommendations from general sleep disorder treatment guidelines. Further research is needed to elucidate the efficacy of pharmacological and nonpharmacological treatments of sleep disorders in CHC patients.

Managing depression during hepatitis C treatment

OBJECTIVE

The prevalence of hepatitis C virus (HCV) infection in Canada is estimated to be 1% and expected to increase during the next decade. Mental illness, particularly depression, is common among HCV-infected patients and remains an obstacle to interferon-alpha (IFN-alpha) treatment. We summarize the risk factors for interferon-alpha-induced major depressive disorder (IFN-alpha-MDD) in HCV patients and the evidence for antidepressant prophylaxis and symptomatic antidepressant treatment of depression.

METHODS

We searched MEDLINE, EMBASE, and CINAHL for randomized controlled or quasi-experimental trials evaluating antidepressant prophylactic and symptomatic treatment approaches for depression emerging during IFN-alpha treatment. Manual searches of references listed in review articles, case series, and anecdotal reports supplemented our literature search.

RESULTS

A total of 9 trials involving prophylactic and symptomatic treatment approaches for IFN-alpha-MDD are summarized in our review. Antidepressant pretreatment is beneficial for patients with elevated baseline depressive symptoms and a preexisting history of IFN-alpha-MDD. Although limited evidence exists for several antidepressant agents, much of the evidence suggests that selective serotonin reuptake inhibitors (SSRIs) are safe and efficacious in treating depressive symptoms secondary to IFN-alpha therapy.

CONCLUSION

Both antidepressant pretreatment and symptomatic treatment are viable strategies for treating IFN-alpha-MDD. Improved treatment outcomes and early identification of depression during HCV treatment can be achieved using an integrated medical and mental health treatment approach.

A preliminary study of cytokines in suicidal and nonsuicidal adolescents with major depression

BACKGROUND

Increased systemic cytokine levels, modulators of the immune system, have been repeatedly documented in adult and adolescent major depressive disorder (MDD). This preliminary study extends this work to test the role of cytokines in suicidal symptomatology in adolescent MDD. Hypotheses were that acutely suicidal depressed adolescents would have: (1) increased plasma levels of interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and IL-1beta, and (2) a proinflammatory/antiinflammatory cytokine imbalance (indexed by plasma IFN-gamma/IL-4), compared to nonsuicidal depressed adolescents and healthy controls.

METHODS

Twelve suicidal adolescents with MDD (7 females [58%]; 5 medication-free/naïve), 18 nonsuicidal adolescents with MDD (12 females [67%]; 8 medication-free/naïve), and 15 controls (8 females [53%]) were enrolled. MDD had to be of at least 6 weeks duration, with a minimum severity score of 40 on the Children's Depression Rating Scale-Revised. Plasma cytokines were examined using enzyme-linked immunosorbent assays. Nonparametric tests were used to compare subject groups.

RESULTS

Unexpectedly, suicidal adolescents with MDD had significantly decreased plasma TNF-alpha concentrations compared to nonsuicidal adolescents with MDD (1.33 +/- 2.95 pg/mL versus 30.9 +/- 110.9 pg/mL; p = 0.03). IFN-gamma was increased in both suicidal and nonsuicidal adolescents with MDD compared to controls (2.14 +/- 6.22 and 4.20 +/- 14.48 versus 0.37 +/- 0.64; p < 0.02, p = 0.005). Findings remained evident when controlled for age and gender.

CONCLUSIONS

Our preliminary findings suggest that immune system dysregulation may be associated with suicidal symptomatology in adolescent MDD. These findings should be replicated in larger samples with medication-free adolescents.

Psychiatric problems in patients infected with hepatitis C before and during antiviral treatment with interferon-alpha: a review

OBJECTIVE

Neuropsychiatric symptoms are common in patients with chronic hepatitis C (CHC) and can potentially be exacerbated by interferon-alpha treatment. Such symptoms can contribute to problems with treatment adherence, which can significantly compromise epidemiological virus control. This review summarizes current knowledge about the etiology, course, and management of neuropsychiatric symptoms in patients with CHC.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULTS

Psychopathological syndromes that occur during interferon-alpha treatment frequently have atypical features that may complicate their recognition using standard diagnostic criteria. In addition, prospective studies in this area often exclude patients with psychiatric disorders and have methodological disparities that make it difficult to develop guidelines for management of psychiatric side effects induced by interferon-alpha. Despite the high prevalence of chronic hepatitis C virus (HCV) infection in patients with psychiatric and substance use disorders, neuropsychiatric concerns often lead to the exclusion of such patients from interferon-alpha treatment, inappropriately depriving them of the potential benefits of this therapy.

CONCLUSION

Consultation-liaison psychiatrists should become familiar with the clinical spectrum of presentations associated with HCV infection as well as with related neuropsychiatric symptoms in order to promote the creation of multidisciplinary teams who specialize in the care of patients with HCV infections. More studies are needed to define neuropsychiatric syndromes that can be induced by interferon-alpha and to clarify best assessment and treatment procedures for these syndromes. It is also important to create and evaluate psychoeducational programs for all patients with chronic HCV infections, even those with low risk of complications, in order to promote adherence to therapy and optimize patients' quality of life.

Interleukin-1 receptor antagonist and incident depressive symptoms over 6 years in older persons: the InCHIANTI study

BACKGROUND

We test the hypothesis that in older persons higher plasma levels of inflammatory markers predict the development of depressive symptoms during a 6-year follow-up.

METHOD

This study is part of the InCHIANTI (Invecchiare in Chianti, aging in the Chianti area) study, a prospective population-based study of older persons. The sample consisted of 991 participants, ages 65 years and older. Serum levels of C-reactive protein, interleukin (IL)-1beta, IL-1 receptor antagonist (ra), tumor necrosis factor-alpha, IL-6, IL-6 receptor, and IL-18 were measured. Depressive symptoms were assessed at baseline and at the 3- and 6-year follow-ups with the Center for Epidemiological Studies-Depression Scale (CES-D). Depressed mood was defined as CES-D > 20. Potential confounders were baseline variables related to sociodemographic, somatic health, and functional status.

RESULTS

At baseline, IL-1ra levels were significantly higher (p = .004) in depressed compared with nondepressed participants. After adjustment for confounders, among subjects free of depression at baseline, those in the third and fourth IL-1ra quartiles compared with those in the lowest quartile had, respectively, a 2.32-fold (95% confidence interval: 1.21-4.42, p = .01) and 2.78-fold (95% confidence interval: 1.47-5.26, p = .002) higher risk of developing depressed mood during a 6-year follow-up.

CONCLUSIONS

In old age, persons with high plasma levels of IL1-ra had a higher risk of developing depressive symptoms over time. These findings suggest a potential causal role for inflammation in the development of depressive symptoms in older persons.

A potential role for pro-inflammatory cytokines in regulating synaptic plasticity in major depressive disorder

A growing body of data suggests that hyperactivation of the immune system has been implicated in the pathophysiology of major depressive disorder (MDD). Several pro-inflammatory cytokines, such as tumour necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1) have been found to be significantly increased in patients with MDD. This review focuses on these two cytokines based on multiple lines of evidence from genetic, animal behaviour, and clinical studies showing that altered levels of serum TNF-alpha and IL-1 are associated with increased risk of depression, cognitive impairments, and reduced responsiveness to treatment. In addition, recent findings have shown that centrally expressed TNF-alpha and IL-1 play a dual role in the regulation of synaptic plasticity. In this paper, we review and critically appraise the mechanisms by which cytokines regulate synaptic and neural plasticity, and their implications for the pathophysiology and treatment of MDD. Finally, we discuss the therapeutic potential of anti-inflammatory-based approaches for treating patients with severe mood disorders. This is a promising field for increasing our understanding of the mechanistic interaction between the immune system, synaptic plasticity, and antidepressants, and for the ultimate development of novel and improved therapeutics for severe mood disorders.

Immune system dysregulation in adolescent major depressive disorder

BACKGROUND

A large body of evidence suggests that immune system dysregulation is associated with Major Depressive Disorder (MDD) in adults. This study extends this work to adolescent MDD to examine the hypotheses of immune system dysregulation in adolescents with MDD, as manifested by significantly: (i) elevated plasma levels of cytokines (interferon [IFN]-gamma, tumor necrosis factor-alpha, interleukin [IL]-6, IL-1beta, and IL-4); and (ii) Th1/Th2 cytokine imbalance shifted toward Th1 as indexed by increased IFN-gamma/IL-4.

METHOD

Thirty adolescents with MDD (19 females; 13 medication-free/naïve; ages 12-19) of at least 6 weeks duration and a minimum severity score of 40 on the Children's Depression Rating Scale-Revised, and 15 healthy comparisons (8 females), group-matched for age, were enrolled. Plasma cytokines were examined using enzyme-linked immunosorbent assay. Mann-Whitney test was used to compare subjects with MDD and controls.

RESULTS

Adolescents with MDD had significantly elevated plasma IFN-gamma levels (3.38+/-11.8 pg/ml versus 0.37+/-0.64 pg/ml; p<0.003), and IFN-gamma/IL-4 ratio (16.6+/-56.5 versus 1.76+/-2.28; p=0.007). A trend for IL-6 to be elevated in the MDD group was also observed (1.52+/-2.88 pg/ml versus 0.49+/-0.90 pg/ml; p=0.09). Importantly, findings remained evident when medicated subjects were excluded.

CONCLUSIONS

Findings suggest that immune system dysregulation may be associated with adolescent MDD, with an imbalance of Th1/Th2 shifted toward Th1, as documented in adult MDD. Larger studies with medication-free adolescents should follow.

The inflammatory & neurodegenerative (I&ND) hypothesis of depression: leads for future research and new drug developments in depression

Despite extensive research, the current theories on serotonergic dysfunctions and cortisol hypersecretion do not provide sufficient explanations for the nature of depression. Rational treatments aimed at causal factors of depression are not available yet. With the currently available antidepressant drugs, which mainly target serotonin, less than two thirds of depressed patients achieve remission. There is now evidence that inflammatory and neurodegenerative (I&ND) processes play an important role in depression and that enhanced neurodegeneration in depression may-at least partly-be caused by inflammatory processes. Multiple inflammatory-cytokines, oxygen radical damage, tryptophan catabolites-and neurodegenerative biomarkers have been established in patients with depression and these findings are corroborated by animal models of depression. A number of vulnerability factors may predispose towards depression by enhancing inflammatory reactions, e.g. lower peptidase activities (dipeptidyl-peptidase IV, DPP IV), lower omega-3 polyunsaturated levels and an increased gut permeability (leaky gut). The cytokine hypothesis considers that external, e.g. psychosocial stressors, and internal stressors, e.g. organic inflammatory disorders or conditions, such as the postpartum period, may trigger depression via inflammatory processes. Most if not all antidepressants have specific anti-inflammatory effects, while restoration of decreased neurogenesis, which may be induced by inflammatory processes, may be related to the therapeutic efficacy of antidepressant treatments. Future research to disentangle the complex etiology of depression calls for a powerful paradigm shift, i.e. by means of a high throughput-high quality screening, including functional genetics and genotyping microarrays; established and novel animal and ex vivo-in vitro models for depression, such as new transgenic mouse models and endophenotype-based animal models, specific cell lines, in vivo and ex vivo electroporation, and organotypic brain slice culture models. This screening will allow to: 1) discover new I&ND biomarkers, both at the level of gene expression and the phenotype; and elucidate the underlying molecular I&ND pathways causing depression; and 2) identify new therapeutic targets in the I&ND pathways; develop new anti-I&ND drugs for these targets; select existing anti-I&ND drugs or substances that could augment the efficacy of antidepressants; and predict therapeutic response by genetic I&ND profiles.

Safety of peginterferon in the treatment of chronic hepatitis C

BACKGROUND

Combination of 'pegylated' interferons (IFNs) plus ribavirin, the standard treatment of chronic hepatitis C (CHC), is frequently associated with side effects. Anticipation, recognition and proper management of these side effects are important to ensure compliance with therapy and achievement of sustained virologic response.

OBJECTIVE

To illustrate the side effect profile of pegIFN-alpha in the treatment of CHC.

METHODS

Studies and abstracts were identified through a computerized, English language literature search. Key search terms included peginterferon and CHC. Information available only in abstract form was retrieved from national and international hepatology associations.

RESULTS

Most adverse events occurring with combination therapy can be anticipated and managed appropriately; therefore, premature discontinuation of therapy owing to side effects is not required in most patients.

Occurrence, course and risk factors of depression during antiviral treatment for chronic hepatitis C in patients with inherited bleeding disorders: a prospective study

Treatment of hepatitis C virus (HCV) consists of pegylated interferon (IFN)-alpha and ribavirin for 24 or 48 weeks. An important side-effect of IFN-alpha is depression. The occurrence, course and risk factors of depression during antiviral treatment were studied prospectively in HCV patients with inherited bleeding disorders. The Beck Depression Inventory, indicating no, mild, moderate or severe depression, was administered to 47 patients before starting therapy, after 4, 12, 24 and 48 weeks of treatment, and 4 weeks after cessation of therapy. At baseline, five patients (11%) had mild depression. Depression worsened during treatment in three of these patients. In all five patients, (mild) depression persisted 4 weeks after treatment. Of the remaining 42 patients, 23 (55%) developed depression during treatment (14 mild, eight moderate and one severe), mostly (78%) during the first 12 weeks. Four weeks after cessation of treatment, three of 23 patients still had mild depression. The only independent risk factor for development of depression was a history of depression or other psychiatric problems (odds ratio 9.7). For patients with inherited bleeding disorders, depression is a significant, mostly transient, problem during HCV treatment. We recommend close monitoring of patients, especially those with previous psychiatric problems, to ensure adequate detection and treatment of depression during antiviral therapy.