Role of estrogen in the aetiology and treatment of mood disorders

IL-10 modulates depressive-like behavior

The role of pro-inflammatory cytokines in psychiatric disorders has been the focus of great research attention in recent years. Paradoxically, the same is not true for anti-inflammatory cytokines. In the present study, we assessed the behavioral profile of animals with altered expression of the anti-inflammatory cytokine IL-10. We performed a battery of tests to assess anxiety, depressive-like and cognitive behaviors in mice overexpressing IL-10 (PMT10) and IL-10(-/-) animals; in the later mice we also tested the behavioral effect of IL-10 administration. In the forced-swimming test, IL-10(-/-) females displayed increased depressive-like behavior; importantly, this phenotype was reverted by the injection of IL-10. Moreover, mice overexpressing IL-10 presented a decreased depressive-like behavior. Despite the presence of a similar trend, male animals did not reach significant differences in depressive-like behavior. Assessment in the open-field showed that the absence of IL-10 decreased the percentage of time spent in the center of the arena in both male and female mice, while male animals overexpressing IL-10 revealed an opposite behavior. For both sexes, imbalance in IL-10 levels did not affect spatial reference memory. In conclusion, variations in IL-10 expression are associated with an altered depressive-like behavior, but do not influence cognitive performance. Interestingly, IL-10 imbalance produced more profound behavioral changes in females than in male animals. This is in accordance with clinical data demonstrating an increased susceptibility of women to mood disorders, suggesting an interplay between anti-inflammatory cytokines and sexual steroids.

Influence of a physical fitness course on menstrual cycle characteristics

AIM

Exercise is commonly cited as a remedy for menstrual symptoms. The purpose of the present study was to evaluate the effect of a period of exercise on physical and psychological symptoms of menstruation, dysmenorrhea, oligomenorrhea and amenorrhea.

METHODS

Participants of the study were 250 students of Shiraz University who enrolled in a fitness course. The study design was semi-experimental with one group. Prior and after 12 weeks of a physical fitness program, our subjects completed questionnaires on menstrual distress. The physical fitness training program included physical fitness exercises (cardiovascular endurance, muscular endurance, agility, speed, strength; duration: 90 min, frequency: twice weekly, intensity: 50 to 70% of maximum heart rate). The t test was used for analysis of the data.

RESULTS

Physical premenstrual symptoms (p = 0.005), psychological premenstrual symptoms (p = 0.019), dysmenorrhea (p = 0.0001) and oligomenorrhea (p = 0.034) were significantly reduced after the training program. There was no difference in the incidence of amenorrhea before and after the training program (p = 0.162).

CONCLUSION

Our findings indicate that selected physical fitness exercises positively influenced menstrual symptoms.

Estradiol-sertraline synergy in ovariectomized rats

This study investigated estradiol (E(2)) modulation of the antidepressant effects of a selective serotonin (5-HT) reuptake inhibitor (SSRI; sertraline) and a tricyclic antidepressant (imipramine) as measured by the forced swim test (FST) followed by assessment of gene and protein expression for the 5-HT transporter (SERT) and multiple 5-HT receptors. Female Sprague-Dawley rats were ovariectomized (OVX) and two-thirds of the rats received E(2) implants (OVE). 4 weeks later, implants were withdrawn in half of the OVE rats (OVW) to capture a time point when E(2) levels were rapidly declining. Rats in each hormone group were treated with vehicle, sertraline (10 mg/kg) or imipramine (10 mg/kg), 24, 5 and 1h before the FST. Immediately after the FST, midbrain, hippocampus and prefrontal cortex tissue was removed and frozen for analysis of gene expression via quantitative real-time PCR (midbrain tissue) and protein expression via Western blot (prefrontal cortex and hippocampal tissue). In the FST, sertraline decreased immobility and increased swimming in OVE rats, as well as increased swimming in OVW rats. In contrast, no sertraline effect was observed in OVX rats. Rats treated with imipramine showed increased climbing but no changes in immobility or swimming. No changes in protein expression were detected in any treatment group. However, in vehicle-treated rats, E(2) increased midbrain SERT mRNA expression, with no effect on midbrain mRNA for the 5-HT receptors. In sertraline-treated rats, E(2) decreased 5-HT(2A) receptor mRNA, and E(2)-withdrawal increased 5-HT(1A), 5-HT(2A) and 5-HT(2C) receptor mRNA. In imipramine-treated rats, E(2) (and E(2)-withdrawal) did not affect mRNA expression for any of the target genes. Thus, E(2) synergized behaviorally and neurochemically with an SSRI but not a tricyclic antidepressant.

Estrogen receptor gene 1 variants are not associated with suicidal behavior

Estrogen is thought to be involved in the pathophysiology of depression and suicidal behaviors. We studied gene variants of estrogen receptor alpha (rs827421, rs1913474, rs1801132, rs722207, rs974276 and rs910416) in 167 German suicide attempters (affective spectrum n=107, schizophrenia spectrum n=35, borderline personality disorder n=25), 92 German individuals who committed suicide and 312 German healthy subjects. Single markers and haplotype analysis in relation to suicidal behaviors (suicide attempters/completers) did not reveal any significant association. These were also not associated with related features, such as violence or impulsivity of suicide attempt, State-Trait Anger Expression Inventory (STAXI) and Questionnaire for Measuring Factors of Aggression (FAF) scores. In conclusion, our study does not support the hypothesis that estrogen receptor alpha gene variants are major contributors to suicide or to anger- or aggression-related behaviors.

Stress and glucocorticoid footprints in the brain-the path from depression to Alzheimer's disease

Increasingly, stress is recognized as a trigger of depressive episodes and recent evidence suggests a causal role of stress in the onset and progression of Alzheimer's disease (AD) pathology. Besides aging, sex is an important determinant of prevalence rates for both AD and mood disorders. In light of a recent meta-analysis indicating that depressed subjects have a higher likelihood of developing AD, a key message in this article will be that both depression and AD are stress-related disorders and may represent a continuum that should receive more attention in future neurobiological studies. Accordingly, this review considers some of the cellular mechanisms that may be involved in regulating this transition threshold. In addition, it highlights the importance of addressing the question of how aging and sex interplay with stress to influence mood and cognition, with a bias towards consideration of neuroplastic events in particular brain regions, as the basis of AD and depressive disorders.

Atypical depression, somatic depression and anxious depression in women: are they gender-preferred phenotypes?

BACKGROUND

Both depression and anxiety disorders affect women at rates significantly greater than men. Women also have a documented higher frequency of comorbid depression and anxiety disorders, and a three-fold higher prevalence of atypical depression.

HYPOTHESES

These gender differences are mainly due to specific depressive phenotypes including anxious depression and atypical depression. The prevalence of comorbid anxiety and depression strongly suggests overlap of pathophysiological mechanisms-which in women are also affected by fluctuations in gonadal hormones. Similar efficacy of serotonergic antidepressants as treatment for anxiety disorders as well as depressions further underscores the blurred boundaries between these two descriptive entities.

CONCLUSIONS

Symptoms of depression and anxiety may be a departure point for differential diagnosis in which dimensionally-based phenotypes substantiated by pathobiology would replace current descriptive entities. It is suggested that at least some biologically-based dysphorias may be specific to women, ensuing from the combination of specific vulnerabilities, and complex interactions between brain mechanisms and gonadal hormones.

Region- and sex-specific modulation of anxiety behaviours in the rat

Recent studies in both animals and humans indicate that gonadal hormones have profound control over emotional states, and certainly contribute to the increased occurrence of psychiatric illness in women. Reports, as reviewed here, suggest that two important regions of the limbic system, the central nucleus of the amygdala (CeA) and the bed nucleus of the stria terminalis (BNST), control different aspects of emotional behaviour. Short-term cue-specific emotional responses, like Pavlovian fear conditioning, require activation of the CeA, while long-duration and contextual emotional responses, are dependant on the BNST. There is accumulating experimental evidence that gender and sex hormones specifically modulate BNST-mediated anxiety behaviours. Moreover, the functional separation between the CeA and the BNST may be exaggerated during lactation in the rat, a time of profound hormonal and behavioural change. In this study, the effects of sex hormones on fear and anxiety are reviewed with an emphasis on the differential effects of these hormones on functions subserved by the BNST as opposed to the CeA. Studies, as highlighted here, looking at sex hormone and gender effects on the ability of corticotrophin-releasing factor and bright ambient light to enhance startle, emphasise the importance of understanding both the effect of, and brain region where, gonadal hormones exert their control over emotional behaviour.

Neonatal serotonin depletion alters behavioral responses to spatial change and novelty

Multiple brain disorders that show serotonergic imbalances have a developmental onset. Experimental models indicate a role for serotonin as a morphogen in brain development. To selectively study the effects of serotonin depletions on cortical structural development and subsequent behavior, we developed a mouse model in which a serotonin neurotoxin, 5,7-dihydroxytryptamine (5,7-DHT), is injected into the medial forebrain bundle (mfb) on the day of birth. Littermates with saline injections into the mfb and age matched mice served as controls. This study characterized the extent and duration of serotonergic denervation after the selective neonatal lesion and investigated effects on exploratory behavior, spatial learning and anxiety in mice of both sexes. We report significant decreases in the serotonergic (5-HT) innervation to cortex and hippocampus, but not to subcortical forebrain structures in 5,7-DHT-lesioned mice. The depletion of 5-HT fibers in cortical areas was long lasting in lesioned mice but autoradiographic binding to high affinity 5-HT transporters was only transiently reduced. Male but not female lesioned mice reduced their exploration significantly in response to spatial rearrangement and object novelty, suggesting increased anxiety in response to change but normal spatial cognition. Our data show that developmental disruptions in the serotonergic innervation of cortex and hippocampus are sufficient to induce permanent, sex specific, behavioral alterations. These results may have significant implications for understanding brain disorders presenting with cortical morphogenetic abnormalities and altered serotonin neurotransmission, such as autism, schizophrenia and affective disorders.

Estradiol effects on the dopamine transporter - protein levels, subcellular location, and function

Background

The effects of estrogens on dopamine (DA) transport may have important implications for the increased incidence of neurological disorders in women during life stages when hormonal fluctuations are prevalent, e.g. during menarche, reproductive cycling, pregnancy, and peri-menopause.

Results

The activity of the DA transporter (DAT) was measured by the specific uptake of ³H-DA. We found that low concentrations (10^-14 to 10^-8 M) of 17β-estradiol (E₂) inhibit uptake via the DAT in PC12 cells over 30 minutes, with significant inhibition taking place due to E₂ exposure during only the last five minutes of the uptake period. Such rapid action suggests a non-genomic, membrane-initiated estrogenic response mechanism. DAT and estrogen receptor-α (ERα) were elevated in cell extracts by a 20 ng/ml 2 day NGFβ treatment, while ERβ was not. DAT, ERα and ERβ were also detectable on the plasma membrane of unpermeabilized cells by immunocytochemical staining and by a fixed cell, quantitative antibody (Ab)-based plate assay. In addition, PC12 cells contained RNA coding for the alternative membrane ER GPR30; therefore, all 3 ER subtypes are candidates for mediating the rapid nongenomic actions of E₂. At cell densities above 15,000 cells per well, the E₂-induced inhibition of transport was reversed. Uptake activity oscillated with time after a 10 nM E₂ treatment; in a slower room temperature assay, inhibition peaked at 9 min, while uptake activity increased at 3 and 20–30 min. Using an Ab recognizing the second extracellular loop of DAT (accessible only on the outside of unpermeabilized cells), our immunoassay measured membrane vs. intracellular/nonvesicular DAT; both were found to decline over a 5–60 min E₂ treatment, though immunoblot analyses demonstrated no total cellular loss of protein.

Conclusion

Our results suggest that physiological levels of E₂ may act to sequester DAT in intracellular compartments where the transporter's second extramembrane loop is inaccessible (inside vesicles) and that rapid estrogenic actions on this differentiated neuronal cell type may be regulated via membrane ERs of several types.

Metabolism of exogenous sex steroids and effect on brain functions with a focus on tibolone

Around the menopause, changes in ovarian secretion of steroids result in changes in brain function: hot flushes and sweating later followed by changes in mood, libido and cognition. The relationship between sex steroids and brain functions are reviewed, with focus on hormonal treatments, in particular tibolone, on the postmenopausal brain and on associations between tissue levels and brain functions. Data on steroid levels in human brain are limited. Exogenous oestrogens alone or combined with progestagens reduce hot flushes and sweating, and may favourably affect anxiety, depression and mood. Testosterone alone or combined with E(2) improves libido and mood. Tibolone reduces hot flushes and sweating, and improves mood and libido, but does not stimulate endometrium or breast, like oestrogens. Tibolone is an ideal compound for studying steroid levels and metabolism in brain in view of its structural differences from endogenous steroids and its extensive metabolism required to express its endocrine effects. Brain levels of tibolone metabolites were measured in ovariectomized cynomolgus monkeys receiving tibolone for 36 days. Compared to serum, higher levels of the oestrogenic 3alpha/beta-hydroxytibolone and the androgenic/progestagenic Delta(4)-tibolone, and lower levels of sulphated metabolites are found in various brain regions. The high levels of oestrogenic metabolites in the hypothalamus explain hot flush reduction. Combined with the presence of Delta(4)-tibolone, the tibolone-induced increase in free testosterone through SHBG reduction explains androgenic effects of tibolone on mood and libido. The levels of tibolone metabolites in the monkey brain support tibolone's effects on brain functions.

Sleep disorders in women: clinical evidence and treatment strategies

Sleep disorders are more prevalent in women than in men. Sex hormones modulate sleep-wake behaviors and mood and may contribute to heightened risk across the life cycle of women. Sleep disorders may have a unique expression in women, emerging throughout their reproductive life cycle. These conditions require careful treatment strategy to manage medical, hormonal, and behavioral contributing factors to poor sleep efficiency and impaired quality of life. This review focuses on clinical evidence for sleep disorders in women and discusses existing evidence of risk factors and treatment options for insomnia and sleep-disordered breathing in women.

Increased limbic phosphorylated extracellular-regulated kinase 1 and 2 expression after chronic stress is reduced by cyclic 17β-estradiol administration

Chronic stress induced neuronal changes that may have consequences for subsequent stress responses. For example, chronic stress in rats rearranges dendritic branching patterns and disturbs the phosphorylation of extracellular-regulated kinase 1 and 2 (ERK) 1/2 throughout the limbic system. Stress-induced psychopathology occurs more often in women, however, most of studies have been done in male rats. Therefore, we studied the effect of stress in female rats. Other studies show that estradiol can modulate neuronal plasticity and might protect against stress-induced aberrations. To investigate the role of estradiol in stress responses we manipulated the hormone levels. Ovariectomized rats were cyclically treated with vehicle or with 17beta-estradiol-benzoate (1x in 4 days, 10 microg/250 g, s.c.) and subjected to either acute (3 days) or chronic (22 days) stress. In ovariectomized rats, the number of c-Fos positive cells in the infralimbic and prelimbic cortex of the prefrontal cortex and in the medial and basolateral amygdala was increased after acute stress. Moreover, acute stress reduced the number of phosphorylated ERK1/2 positive neurons in the prefrontal cortex of ovariectomized rats. Chronic stress, on the other hand, abolished normal patterns of c-Fos immunoreactivity in the prefrontal cortex and amygdala and increased the prefrontocortical phosphorylation of ERK1/2 in ovariectomized rats. Cyclic estradiol treatment preserved the neuronal reactivity in the infralimbic cortex after chronic stress and prevented sustained accumulation of phosphorylated ERK1/2. Therefore, cyclic estradiol administration apparently preserves the integrity of signal transduction cascades in limbic structures, which may protect against the harmful consequences of recurrent stress.

Estradiol and tryptophan depletion interact to modulate cognition in menopausal women

Despite an abundance of data in animals, there is little research in humans regarding how estrogen and serotonin (5-HT) may interact to influence cognition. Through the use of estrogen treatment (ET) and tryptophan depletion (TRP-D) in a within-subject design involving healthy menopausal women, we have manipulated both estrogen and 5-HT in order to evaluate their individual and joint effects. Although neither manipulation influenced visuospatial learning, a significant interaction suggested that estrogen exerted a protective effect on verbal memory, such that TRP-D impaired performance to a greater extent before the administration of ET. In consonance with this finding, ET was associated with a small, but positive mood effect on the day following active TRP-D. In addition, ET significantly improved letter-cued verbal fluency with and without TRP-D. Finally, time since last menstrual period was significantly associated with verbal memory scores, such that longer length of hypogonadism resulted in decreased verbal memory performance. These data support the interaction of estrogen and 5-HT in nonreproductive behavior in humans as well as highlight the role of ovarian steroids in cognition.

Interaction between TPH1 and GNB3 genotypes and electroconvulsive therapy in major depression

We studied the association between tryptophan hydroxylase 1 (TPH1) A218C and G-protein beta-3 subunit (GNB3) C825T polymorphisms and treatment response in electroconvulsive therapy (ECT). The sample consisted of 119 patients with major depressive disorder (MDD) and 398 controls. Neither TPH1 nor GNB3 polymorphisms are associated with treatment response. However, subjects carrying TPH1 CC genotype are more likely to belong to the patient sample than to the controls. In female subjects, T-allele of GNB3 polymorphism increases the risk of being a treatment-resistant patient with MDD. Moreover, in females the combination of TPH1 CC and GNB3 CT + TT genotype is associated with an increased risk of belonging to the patient group.

Exercise training effects on premenstrual distress and ovarian steroid hormones

Preliminary studies suggest that moderate physical activity may reduce both premenstrual distress (PD) and the ovarian steroid hormones, progesterone and estradiol, which have been implicated in PD. We attempted to replicate these findings, while exploring possible relationships between hormone levels and PD. In a cross-sectional study, 20 moderate exercisers and 34 sedentary women completed PD symptom questionnaires and collected urine samples, daily, throughout a complete menstrual cycle. PD was calculated as the difference in symptom scores reported during the average of the 4 days prior to menses and the average of the 4 days closest to mid-cycle. Urine samples taken from the last quarter of the menstrual cycle were analyzed for urinary estrone glucoronide (E1G) and pregnanediol glucoronide. In a prospective study the same measures were used with 14 sedentary women before and after a 24-week moderate exercise-training program. In the cross-sectional study, exercising women reported lower Pain symptoms, and had lower peak E1G levels than did sedentary women. The baseline PD symptoms loneliness, crying, and skin blemishes with were statistically significantly and positively correlated with pregnanediol glucoronide levels in the cross-sectional study. In the prospective study, exercise reduced the global PD symptom score, including the Water Retention and Pain scales, and reduced pregnanediol glucoronide and peak E1G levels. Moderate aerobic exercise may lessen both PD symptoms and late luteal phase ovarian hormone levels. An exercise program may benefit women with progesterone-related premenstrual affect disturbance.

The relation between menarche and the age of first symptoms in a multiple sclerosis cohort

BACKGROUND

Previously, multiple sclerosis (MS) has been thought to be associated with changes in hormone levels. This study investigates the association between the age of menarche and the age of onset of the first symptoms of MS.

METHODS

A complete list of patients diagnosed with MS in the province of Newfoundland and Labrador was constructed. The age of menarche for our entire relapsing remitting female MS (RRMS) population was requested by mailout survey. Age of symptom onset was ascertained by chart review.

RESULTS

A 74% rate of return on the survey results was obtained (150 RRMS patients). A linear regression model demonstrated that the age of first symptoms increased by 1.16 years as the age of menarche increased by one year (R2 = 0.69, P = 0.04). Another analysis showed that the average age of first symptoms for women with reported menarche from 10 to 12 years was 28.96 years compared with 31.83 years for a reported menarche from 13 to 15 years, a significant difference (P = 0.047, t-test).

CONCLUSIONS

This study suggests that menarche may be related to the pathogenesis of MS.

Estrogen-related receptors-stimulated monoamine oxidase B promoter activity is down-regulated by estrogen receptors

Although there are studies published about the neuroprotective effect of estrogen, little is known about the mechanisms and cellular targets of the hormone. Recent reports demonstrate that estrogen down-regulates the expression of monoamine oxidase A and B (MAO-A and MAO-B) in the hypothalamus of the Macaques monkey, both of which are key isoenzymes in the neurotransmitter degradation pathway. Additionally, estrogen-related receptor alpha (ERRalpha) up-regulates MAO-B gene expression in breast cancer cells. ERRalpha recognizes a variety of estrogen response elements and shares many target genes and coactivators with estrogen receptor alpha (ERalpha). In this study, we investigate the interplay of ERs and ERRs in the regulation of MAO-B promoter activity. We demonstrate that ERRalpha and ERRgamma up-regulate MAO-B gene activity, whereas ERalpha and ERbeta decrease stimulation in both a ligand-dependent and -independent manner. Ectopically expressed ERRalpha and ERRgamma stimulate the expression of MAO-B mRNA and protein as well as increase the MAO-B enzymatic activity in ER-negative HeLa cells. The ability of ERRs to stimulate MAO-B promoter activity was reduced in ER-positive MCF-7 and T47D cells. Several AGGTCA motifs of the MAO-B promoter are responsible for up-regulation by ERRs. Interestingly, ERalpha or ERbeta alone have no effect on MAO-B promoter activity but can down-regulate the activation function of ERRs, whereas glucocorticoid receptor does not. By using chromatin immunoprecipitation assay, we demonstrate that ERs compete with ERRs for binding to the MAO-B promoter at selective AGGTCA motifs, thereby changing the chromatin status and cofactor recruitment to a repressed state. These studies provide new insight into the relationship between ERalpha, ERbeta, ERRalpha, and ERRgamma in modulation of MAO-B gene activity.

Stress-induced sensitization of the limbic system in ovariectomized rats is partly restored by cyclic 17beta-estradiol administration

Chronic stress induces neurobiological alterations which have consequences for subsequent stress handling. In the current experiment, ovariectomized rats were subjected daily to a stressor for 21 days. Thereafter, the rats were treated for 21 days with 17beta-estradiol benzoate (10 microg/250 g, once every 4 days) or mirtazapine (10 mg/kg, daily). In this way, we were able to evaluate the ability of these compounds to reverse chronic stress-induced changes in the activity of the limbic system. After 21 days of recovery and treatment, the rats were re-exposed to the adverse environment of the initial stressor and perfused 2 h later. Ovariectomized rats displayed increased numbers of c-Fos-positive nuclei, after re-exposure to the stressor, in the paraventricular nucleus of the hypothalamus, dentate gyrus, medial prefrontal cortex and central and medial amygdala. Cyclic estradiol treatment attenuated the sensitization of the paraventricular nucleus and central amygdala. Mirtazapine increased the number of c-Fos-positive nuclei in the central amygdala and dentate gyrus. Long-term transcriptional changes induced by chronic stress were determined with DeltaFosB immunoreactivity. The medial prefrontal cortex showed an increased number of DeltaFosB-positive nuclei after chronic stress and this was not affected by estradiol or mirtazapine administration during recovery. In conclusion, cyclic estradiol administration reversed chronic stress-induced sensitization in the limbic system, the paraventricular nucleus and central amygdala of female rats, output regions of the limbic system involved in fear responses. Mirtazapine did not achieve this reversal of stress-induced aberrations in the limbic system after 21 days of treatment.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.

Influence of the post-ovariectomy time frame on the experimental anxiety and the behavioural actions of some anxiolytic agents

This study analyzes the long-term effects of ovariectomy on the basal experimental anxiety of rats and the influence of this condition on the anxiolytic properties of diazepam and the 5-HT(1A) receptor agonist 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT). Rats ovariectomized 3, 6 and 12 weeks previously, were tested in the burying behaviour paradigm and in an automatic activity counter. The highest values of time spent burying were observed in the 12-week group. In general, the 12-week group was more responsive to diazepam than the 3-week group, while 8-OH-DPAT showed similar effects on time spent burying, independently of how long ago the ovariectomy was done. Detection of anxiogenic-like behaviours by the shock-probe burying test in rats after chronic absence of gonadal hormones could help in the understanding of mood changes associated with human menopause.

Alteration in estrogen receptor alpha mRNA levels in frontal cortex and hippocampus of patients with major mental illness

BACKGROUND

Gender differences have been described in major mental illnesses (MMI). The dorsolateral prefrontal cortex (DLPFC) and hippocampus are estrogen-sensitive brain regions structurally and functionally altered in patients with MMI. We hypothesized that gender-specific alterations in DLPFC and hippocampus estrogen receptor alpha (ERalpha) mRNA levels may exist in MMI patients.

METHODS

We used Northern blot analysis to survey the expression of ERalpha mRNA transcripts in brain and body, detected by our human ERalpha riboprobe and in situ hybridization, to examine the expression pattern and quantify ERalpha mRNA levels in DLPFC and anterior hippocampus of patients with major depressive disorder (MDD), schizophrenia, and bipolar disorder compared with normal control subjects.

RESULTS

Northern blotting revealed brain-region-specific differences in expression levels of a 5 kb ERalpha mRNA transcript. By in situ hybridization, ERalpha mRNA was detected in all layers of DLPFC and all hippocampal subfields in all subjects. We detected greater DLPFC ERalpha mRNA expression in male compared with female MDD subjects and reduced ERalpha mRNA levels in the dentate gyrus of schizophrenics compared with control subjects.

CONCLUSIONS

Our results suggest that alterations in ERalpha mRNA levels exist in distinct telencephalic regions in male and female MDD patients, and in both genders in schizophrenia.

Effect of estrogen-serotonin interactions on mood and cognition

Both the neurotransmitter serotonin and the ovarian steroid estrogen have been implicated in the modulation of mood and cognition. Although significant functional interactions between estrogen and serotonin are acknowledged, the nature of their relationship has not been fully elucidated. Research using ovariectomized animals has identified estrogen-induced changes in serotonin transmission, binding, and metabolism in brain regions implicated in the regulation of affect and cognition. Studies in humans, particularly of menopausal women undergoing estrogen treatment, have provided some support for these findings and identified instances in which change in mood or cognition is accompanied by alterations in serotonin function and hormonal status. However, it is apparent that further research is required to understand the neural processes involved in the interplay between estrogen and serotonin. By reviewing animal and human data regarding estrogen and serotonin's effects on mood and cognition, the authors aim to better define their relationship and highlight areas for further research.

Cyclic estradiol replacement attenuates stress-induced c-Fos expression in the PVN of ovariectomized rats

Estradiol modulates stress reactions in female rats. Several studies showed anxiolytic effects of estradiol in behavioral tests, but the underlying mechanisms are still unclear. The aim of the current study was to explore how estradiol-treated rats respond to acute and chronic stress compared to ovariectomized rats. Ovariectomized rats received vehicle or 17beta-estradiol injections (10 microg/250 g) once every 4 days, which induced alternating high and low plasma 17beta-estradiol levels. Stress was presented by daily exposure to an adverse environment in which the animals received five footshocks for either 3 or 22 days. Under control conditions no differences were observed, but as soon as stress was applied, reactions of ovariectomized and estradiol-treated rats diverged. Both acute and chronic stress increased the c-Fos protein expression in the paraventricular nucleus (PVN) of the hypothalamus. Cyclic estradiol treatment reduced this stress-induced activation of the PVN, an effect that seems to be dependent on the plasma estradiol levels. No differences in stress-induced corticosterone responses were revealed between the treatment groups. An increase in the number of ERbeta-expressing cells in the PVN of ovariectomized and estradiol-treated rats during chronic stress implied increased ERbeta-mediated mechanisms during these conditions. The dampening effect of estradiol on the excessive stress-induced activity in the PVN may be beneficial for the animal in its response to chronic recurrent stress by reducing the output of the PVN.

Considerations in the management of bipolar disorder in women

OBJECTIVE

Recent research has emphasized important gender differences in the epidemiology, course, comorbidity and treatment of bipolar disorder. This article aims to provide an overview of these important findings in order to assist the clinician in treating women with bipolar disorder. Complex issues regarding the treatment of bipolar disorder during pregnancy and the post-partum period are discussed.

METHOD

A literature review was undertaken using Medline (1966-current), PsychInfo and PubMed databases. Search terms used were gender, sex, women, bipolar disorder, suicide, epidemiology, rapid cycling, mixed episode, treatment, mood stabilizers, antidepressants, antipsychotics, pregnancy, post-partum, menopause, lactation and breast-feeding.

RESULTS

The lifetime prevalence of bipolar I disorder is equal in men and women; however, bipolar II appears to be more common in women. Gender differences have been reported in the phenomenology, course and outcome of this condition. Some comorbid disorders, such as thyroid disease and anxiety disorders have more relevance to women. Increasingly, sex differences in the pharmacokinetics and pharmacodynamics of medications used in bipolar disorder are being reported.

CONCLUSIONS

There is increasing evidence for gender differences in a number of clinical features of bipolar disorder that have relevance to management. Although more studies are needed, it is important for clinicians to be aware of these issues to optimize treatment of women with this condition.

Estrogen enhances light-induced activation of dorsal raphe serotonergic neurons

The serotonergic system has been implicated in the modulation of physiological processes including circadian rhythms, learning, memory, mood and food intake. In females, cessation of ovarian function produces deleterious changes in all of these processes and estrogen treatment often ameliorates these conditions. Estrogen may produce these effects by acting on the midbrain raphe, an estrogen-sensitive region that receives direct projections from sensory systems. Here we examined the ability of estradiol to modulate neuronal responses of neurons within raphe nuclei to photic stimulation. Ovariectomized rats treated with estradiol or cholesterol were killed 1 h after the normal onset of light (Zeitgeber time 0) or after a 2-h phase advance (Zeitgeber time 22). In a second study, estradiol-treated ovariectomized rats under constant dark conditions were exposed to light 2 h before the subjective onset of circadian time [(CT)22] and killed 1 h later (CT23). The brains from all animals were processed for Fos and/or serotonin (5-HT) immunocytochemistry. Comparisons showed that the phase shift increased Fos immunoreactivity in all dorsal raphe nucleus (DRN) regions. Although estradiol did not alter the overall number of Fos-positive nuclei, it significantly increased the number of Fos/5-HT double-labelled cells in the medial and lateral DRN. In contrast, neither a phase shift nor estradiol altered the number of Fos-immunoreactive cells or the proportion of Fos-positive 5-HT cells in the median raphe nucleus. Results reveal that the DRN 5-HT system responds to changes in the light : dark cycle and that these responses are modulated by estrogen.

Treatment of menopause-related mood disturbances

More than 1.7 million American women are expected to reach menopause each year. Recent Canadian statistics show that a 50-year-old woman can now expect to live until her mid-80s, which implies living at least one-third of her life after menopause. The menopausal transition is typically marked by intense hormonal fluctuations, accompanied by vasomotor symptoms (eg, hot flashes, night sweats), sleeps disturbance, and changes in sexual function, as well as increased risk for osteoporosis, cardiovascular disease, and cognitive decline. More importantly, recent studies have demonstrated a significant association between menopausal transition and a higher risk for developing depression. In the post-Women's Health Initiative Study era, physicians and patients are questioning the safety and efficacy of long-term hormone therapy use. This article reviews the current literature on the benefits and risks of using hormone therapy for the treatment of menopause-related mood disturbances and alternate strategies currently available for the management of menopause-related problems, including antidepressants, complementary and alternative medicine, and selective estrogen receptor modulators.

Tamoxifen fails to affect central serotonergic tone but increases indices of anxiety in female rhesus macaques

The selective estrogen receptor modulator (SERM), tamoxifen, effectively slows the progression of estrogen-positive breast cancer and aids in the prevention of cancer in at-risk women. Tamoxifen is well characterized with regards to its effects on breast cancer, but its effects on other estrogen-related systems, particularly neural circuits regulating brain function and mood, are poorly understood. Using ovariectomized rhesus monkeys, we examined the effects of tamoxifen, with and without estrogen replacement therapy (ERT), on social behavior and central serotonin (5HT) systems thought to influence these behaviors. Relative to placebo treatments, estrogen treatment increased serotonergic tone, based on response in prolactin and cortisol to fenfluramine, a 5HT releasing agent. Tamoxifen neither blocked nor enhanced this effect, indicating it to be neither an antagonist nor an agonist on serotonergic activity. In contrast, CSF measures of the 5HT metabolite, 5HIAA, were not significantly affected by treatment. Tamoxifen-treated animals showed increases in measures of anxiety, compared with ERT-treated animals, suggesting that this SERM may be anxiogenic. Co-treatment with estrogen attenuated the anxiogenic properties of tamoxifen. These data show that tamoxifen administration increased anxiety levels, but the affect was not associated with differences in central levels of the serotonin tone.

Influence of a continuous combined HRT (2 mg estradiol valerate and 2 mg dienogest) on postmenopausal depression

OBJECTIVE

This randomized, double-blind, placebo-controlled study was planned to investigate the effects of continuous combined hormone replacement therapy (HRT) with 2 mg estradiol valerate and 2 mg dienogest (Climodien/Lafamme) over 24 weeks on postmenopausal depression.

METHOD

A total of 129 patients with a mild to moderate depressive episode according to ICD-10: F32.0, F32.1 in the context of a postmenopausal syndrome (ICD-10: N95.1) and a baseline score in the Hamilton depression scale (HAMD) > or =16 were included in the study. The primary target variable was depression severity as measured by the HAMD after 24 weeks of treatment. A four-point difference between HRT and placebo at the end of the study and, in addition, a final score < or =8 (corresponding to an improvement of > or =50% as compared to baseline) for the individual patient (responders analysis) were considered clinically relevant. Clinical global impression (CGI) of investigators (therapeutic and side-effects) at the end of the study was investigated. Secondary effects of HRT on depression severity caused by its effect on vasomotor symptoms or sleep disturbances (domino hypothesis) were taken into consideration. Also, the study addressed the question of whether the effect of HRT on depression severity depends on a history of premenstrual syndrome (PMS) or postnatal depression (PND).

RESULTS

The results showed a clear and clinically relevant reduction of depression severity under HRT after 24 weeks of treatment and superiority over placebo (p < 0.0005) in spite of a strong placebo effect. The effects of the estrogen-progestin combination thereby seemed only partially to be dependent on the improvement of vasomotor symptoms and sleep disturbances. Also, the effects of HRT could not be shown to be dependent on a history of PMS and/or PND, even though women with and without this history clearly differed in baseline depression scores (p < 0.0001). The assessment of CGI was positive: whereas HRT was clearly superior to placebo with regard to therapeutic effects (p = 0.0014), there were no differences with regard to side-effects (p = 0.35).

CONCLUSION

The combination of 2 mg estradiol valerate and 2 mg dienogest can be regarded as an effective and safe treatment option for women with mild to moderate depression in the context of postmenopausal syndrome.

Gonadal steroid modulation of the limbic-hypothalamic- pituitary-adrenal (LHPA) axis is influenced by social status in female rhesus monkeys

Chronic stress can have a deleterious effect on the re-productive axis that, for females, is manifested in an increased incidence of infertility. However, gonadal steroids may, in turn, affect a female's response to stress as measured by activity within the limbic-hypothalamic-pituitary-adrenal (LHPA) axis. What is not clear is whether a history of exposure to stress modifies the effect of gonadal steroids on LHPA responsivity. Rhesus monkeys present a unique opportunity to assess LHPA responsivity when housed socially in groups. Under these situations, monkeys exhibit a rich network of affiliation and have established social status hierarchies. Previous work indicates that socially subordinate macaque females are hypercortisolemic due to diminished gluco-corticoid negative feedback. The present study tested the hypothesis that estradiol (E2) would decrease gluco-corticoid negative feedback, assessed from a dexamethasone (DEX) suppression test, and increase the response to corticotropin releasing factor (CRF) and that these effects would be attenuated by co-treatment with P4. In addition, we also determined whether E2 and P4 would differentially affect LHPA responsiveness to pharmacological challenge in socially dominant compared with subordinate females. Endogenous gonadal hormone secretion in female rhesus monkeys (n = 7) was suppressed by continuous treatment with a sustained release formulation of the GnRH analog leuprolide acetate (Lupron Depot). The response to a combined DEX suppression-CRF stimulation test was assessed using a counterbalanced design during a placebo (control) treatment condition and during E2, P4, and E2 + P4 re-placement therapy. Females who were members of a large breeding group of 140 adults and juveniles of both sexes, were classified as dominant (n = 4) or subordinate (n = 3) based on the relative social dominance positions within the group. Plasma levels of cortisol were significantly higher during E2 replacement compared to the other treatment conditions following DEX suppression and stimulation with CRF.

Influence of 17beta-estradiol on the synthesis of reduced neurosteroids in the brain (in vivo) and in glioma cells (in vitro): possible relevance to mental disorders in women

Brain neurosteroids modulate gamma-aminobutyric acid type A (GABAA) receptor activity, thereby playing a role in mood disorders. Alterations in 17beta-estradiol (E2) and progesterone (P) are also known to play a significant role in psychopathology in women. The aim of the present study was to evaluate the synthesis of dihydroprogesterone (DHP), tetrahydroprogesterone (THP), and the activity of 5alpha-reductase (5alphaR) which regulates the reduction of P to DHP on exposure to supraphysiological levels of E2 in vitro (C6 glioma cells) and in vivo (mouse brain). The results showed that supraphysiological levels of E2 induced a decrease in the accumulation of both neurosteroids, probably by decreasing the activity of 5alphaR. We hypothesize that the high levels of E2 in pregnancy attenuate the increase in the conversion of P to THP in the brain and that the ratio of E2/P modulates the sedative effect of THP. This process may be relevant to psychopathological disorders that are ascribed to drastic alterations in estrogen levels, such as premenstrual syndrome, pregnancy-related mental disorders, and postpartum "blues".

Future antidepressants: what is in the pipeline and what is missing?

Monoamine reuptake inhibitors still reign in the treatment of major depression, but possibly not for long. While medicinal chemists have been able to reduce the side effects of these drugs, their delayed onset of action and considerable non-response rate remain problematic. Of late, serious questions have been raised regarding the efficacy of monoamine reuptake inhibitors. The present review presents an inventory of what is (and until recently was) in the antidepressant pipeline of pharmaceutical companies. Novel antidepressant compounds can be categorised into four groups depending on their target(s): (i) monoamine receptors; (ii) non-monoamine receptors; (iii) neuropeptide receptors; and (iv) hormone receptors. Other possible targets include components of post-receptor intracellular processes and elements of the immune system; to date, however, compounds specifically aimed at these targets have not been the subject of clinical trials. Development of several compounds targeted at monoamine receptors has recently been discontinued. At least five neurokinin-1 (NK(1)) receptor antagonists were until recently in phase II of clinical testing. However, the apparent interest in the NK(1) receptor should not be interpreted as representing a departure from the monoamine hypothesis since neurokinins also modulate monoaminergic systems. In the authors' view, development of future antidepressants will continue to rely on the serendipity-based monoamine hypothesis. However, an alternative approach, based on the hypothesis that chronic stress precipitates depressive symptoms, might be more productive. Unfortunately, clinical results using drugs targeted at components of the HPA axis have not been very encouraging to date. In the short run, the authors believe that augmentation strategies offer the best hope for improving the efficacy of antidepressant treatment. Several approaches to improve the efficacy of SSRIs are conceivable, such as concurrent blockade of monoamine autoreceptors and the addition of antipsychotics, neuromodulators or hormones (HPA axis and gender related). In the long-term, however, construction of a scientifically verified conceptual framework will be needed before more effective antidepressants can be developed. It can be argued that it is not depression itself that should be treated, but rather that its duration should be reduced by pharmacological means. Animal models that take this concept into consideration and identify mechanisms for acceleration of recovery from the effects of stress need to be developed.

Premenstrual symptoms and luteal suicide attempts

OBJECTIVE

If premenstrual symptoms (PMS) are temporally and specifically associated with suicidal attempts, suicide attempts in women with PMS should occur more frequently in the luteal phase.

METHOD

In a general hospital, 125 fertile female suicide attempters (and 83 blood donors as controls) with regular menstrual cycles were prospectively studied. A retrospective DSM-IV diagnosis of Premenstrual Dysphoric Disorder (PMDD) was made.

RESULTS

Attempts during the luteal phase were not more frequent in females with PMDD (34%,23/68) than in those without PMDD (35%, 20/57). The sample had enough power to detect medium and large effect sizes. As expected, there was a significantly higher frequency of PMDD in suicide attempters than in the controls (54% vs 6%; Fisher's exact test, p < or = 0.001).

CONCLUSION

This study was limited by the use of retrospective PMDD diagnosis but suggests that PMDD may not be associated with suicidal acts during the luteal phase,when PMS are present.

The fountain of mental youth. Search for homeostatic and adaptational hormonal processes

Successful mental aging may be defined as maintenance of youthful attitudes, cognitive and adaptational processes despite advanced age. Maintenance of homeostasis and efficient adaptational processes are of utmost importance. It is suggested that multiple hormonal systems and processes are involved in the multidimensional, interdependent, interrelated successful aging process. Changes in their interactions over time probably occur. A complex integrated regulatory homeostatic and normalcy system is proposed. Disruption on this regulating normalization process may cause disorders, as well as accelerated mental aging. Currently not much is known about maintenance of mental normalcy, as well as homeostatic and adaptational underlying mechanisms. Their elucidation would substantially contribute to understanding of well-being, disorders, and successful as well as unsuccessful aging.

Interaction between estrogens and antidepressants in the forced swimming test in rats

RATIONALE

Several reports suggest that estrogens possess antidepressant effects and could facilitate the action of some antidepressants.

OBJECTIVE

To analyze the interaction between three different types of estrogens, 17 beta-estradiol (E(2)), ethinylestradiol (EE(2)) or diethyl-stilbestrol (DES) and the antidepressants, fluoxetine (FLX) or desipramine (DMI) in ovariectomized female rats subjected to an animal model for the study of antidepressant compounds, the forced swimming test (FST).

METHODS

The effect of the combination of a sub-optimal dose of FLX (2.5 mg/kg) or DMI (2.5 mg/kg) with a sub-active dose of E(2 )(10 microg/kg), EE(2), (2.5 or 5 microg/kg) or DES (1 mg/kg) was analyzed in both the FST and the open field paradigm.

RESULTS

The combination of a sub-optimal dose of E(2) or DES with that of the antidepressant DMI resulted in a clear antidepressant-like effect, evidenced by a significant decrease in immobility accompanied by an increase in climbing behavior. Sub-optimal doses of either E(2) or DES also facilitated the antidepressant-like effect of a sub-optimal dose of FLX. In this case, a decrease in immobility with a concomitant increase in swimming behavior was observed. Finally, the combination of EE(2) with either DMI or FLX decreased immobility and induced an increase in both swimming and climbing behaviors. All combinations decreased rats' locomotor activity when evaluated in the open field test.

CONCLUSION

In the FST estrogens were able to facilitate the action of two different kinds of antidepressants; however, these effects were dependent on the type of estrogen used.

Lack of efficacy of estradiol for depression in postmenopausal women: a randomized, controlled trial

BACKGROUND

Estrogen has been considered as a potential antidepressant in postmenopausal women. Our goal was to study whether estrogen therapy is effective in treating depressive disorders in older postmenopausal women and to determine whether progestins are associated with a deterioration of mood.

METHODS

After 2 weeks of single-blind placebo treatment in 87 patients, 57 were randomly assigned to receive 8 weeks of treatment with estradiol (.1 mg/day; n = 31) or placebo (n = 26). All patients were then treated with medroxyprogesterone 10 mg/day for 2 weeks combined with the study patch. Depressive symptoms were rated with the 21-item Hamilton Depression and Center for Epidemiologic Studies Depression scales.

RESULTS

A clinically significant antidepressant effect of estradiol was excluded after 8 weeks of estradiol treatment. The estradiol group and placebo group improved in depressive symptoms at a similar rate based on the Hamilton Depression Scale (40% decreases in depression for estradiol vs. 44% for placebo). No significant increase in depressive symptoms was demonstrated with the use of progestins; however, positive affect decreased slightly with the use of combined estradiol-medroxyprogesterone compared with medroxyprogesterone alone (5.8%, p =.027).

CONCLUSIONS

Estradiol cannot be considered as an effective treatment in postmenopausal women with mild to moderate depression.

Gender differences in treatment response to sertraline versus imipramine in patients with nonmelancholic depressive disorders

There is evidence of gender differences in depressive disorders in terms of epidemiology and clinical manifestations. However, few studies have addressed the gender differences in terms of antidepressant treatment response in clinical practice. The aim of this study was to examine gender differences in the acute antidepressant response to sertraline and imipramine in nonmelancholic depressive disorders. A total of 239 patients with nonmelancholic major depression or dysthymia (DSM-III-R) and a score of >/=18 at baseline on the Hamilton Depression Rating Scale (HAM-D) were randomised in a 1:1 ratio treatment with flexible doses of sertraline (50-200 mg/day) or imipramine (75-225 mg/day) for 8 weeks in a multicenter, randomised, open-labeled, parallel group comparative trial. Depressive and anxiety symptoms were assessed using the HAM-D and the Hamilton Anxiety Rating Scale (HAM-A). Using HAM-D criteria, women were significantly more likely to respond to sertraline than to imipramine (72.2% vs. 52.1%, P=.008), whilst men respond similarly to sertraline and to imipramine (56.5% vs. 59.3%, P>.05). Response analysis based on HAM-A shows similar results (women: 68.9% vs. 43.6%, P=.001; men: 56.5% vs. 51.9%, P>.05). Women taking sertraline show statistically significant higher reductions in HAM-D, HAM-A, and in CGI-S than women taking imipramine. The proportion of women who dropped out due to adverse events was much lower in sertraline than in imipramine (10.9% vs. 27.8%, P=.006), with no differences between treatments in men (8.3% vs. 11.5%, P>.05). It was concluded that sertraline is more effective and better tolerated than imipramine in the acute treatment of nonmelancholic depressive disorders in women, whereas men responded similarly to sertraline and to imipramine.

The role of estrogen in mood disorders in women

Major depression is twice as common in women as men and depressive episodes appear to be more common in women with bipolar disorder. There is accumulating evidence that, in at least some women, reproductive-related hormonal changes may play a role in increasing the risk of depressive symptoms premenstrually, postpartum and in the perimenopausal period. In this review, the evidence for the role of hormonal fluctuations, specifically estrogen, in triggering depressive symptoms in a subgroup of women is summarized. In addition, the potential role of estrogen in triggering depressive symptoms via its effects on the serotonergic system, brain-derived neurotrophic factor and Protein Kinase C is reviewed.

Psychiatric disorders in older women

With increased longevity and an aging 'baby boomer' population, the numbers of women in older age groups in the United States will be increasing significantly over the coming years. Older women with schizophrenia and mood disorders that began in early adult life continue to need psychiatric treatment, although treatment considerations may require modification with age. In addition, late-onset depressive disorders are more common among older women than older men and may undermine physical and psychosocial well-being if inadequately treated. Late-onset schizophrenia and bipolar disorder are less common, but also affect older women more often than older men. Moreover, psychiatric concerns related to Alzheimer's disease and care giving are pertinent to this older population. Clinicians need to be knowledgeable about differences in epidemiology and clinical presentation that distinguish psychiatric disorders in older women from both men and from younger cohorts.

Sex steroid hormones and the neural control of breathing

We review evidence that sex steroid hormones including estrogen, progesterone and testosterone are involved in the central neural control of breathing. Sex hormones may exert their effects on respiratory motoneurons via neuromodulators, in particular, the serotonergic system. Recent studies have shown that levels of serotonin (5HT) in the hypoglossal and phrenic nuclei are greater in female than in male rats. Serotonin-dependent plasticity in hypoglossal and phrenic motor output also differs in male and female rats. Changing levels of gonadal hormones throughout the estrus cycle coincide with changing levels of 5HT in respiratory motor nuclei, and gonadectomy in male rats results in a decrease in 5HT-dependent plasticity in respiratory motor output. We speculate that sex steroid hormones are critically involved in adaptations in the neural control of breathing throughout life, and that decreasing levels of these hormones with increasing age may have a negative influence on the respiratory control system in response to challenge.

A differential response to nortriptyline and fluoxetine in melancholic depression: the importance of age and gender

OBJECTIVE

To consider the impact of age and gender on the antidepressant response to nortriptyline and fluoxetine in melancholic depression.

METHOD

Of 191 depressed patients, 113 met study criteria for melancholia. All patients were randomized to receive either fluoxetine or nortriptyline. Response rates, defined as an improvement of 60% or more on the Montgomery Asberg Depression Rating Scale over 6 weeks of antidepressant treatment on an intention to treat basis, were examined by age, and by age and gender.

RESULTS

Melancholic depressed patients 40 years or older, especially men, had a markedly superior response to nortriptyline compared with fluoxetine. Conversely, melancholic depressed patients, age 18-24 years, especially women, had a markedly superior response to fluoxetine.

CONCLUSION

Age and gender appear to be critical variables in understanding differential antidepressant responses to tricyclic antidepressants and selective serotonin reuptake inhibitors in melancholic depression.

Effect of reproductive hormones and selective estrogen receptor modulators on mood during menopause

Periods of intense hormonal fluctuations have been associated with heightened prevalence and exacerbation of underlying psychiatric illness, particularly the occurrence of premenstrual dysphoria, puerperal depression and depressive symptoms during perimenopause. It has been speculated that sex steroids such as estrogens, progestogens, testosterone and dehydroepiandrosterone (DHEA) exert a significant modulation of brain functioning, possibly through interactions with various neurotransmitter systems. It is therefore intuitive that abrupt alterations of these hormones would interfere with mood and behaviour. On the other hand, accumulating data suggest that hormonal interventions may also promote relief or even remission of depressive symptoms, as already demonstrated in studies with patients experiencing postpartum depression and perimenopausal depressive disorders. The extent to which perimenopause, alone, may increase the risk for depression is unclear. However, existing data strongly suggest that some women are particularly vulnerable to developing significant physical and psychological disturbances when entering perimenopause. This article reviews the effect of sex hormones and selective estrogen receptor modulators (SERMs) on mood among peri- and postmenopausal women. There are preliminary, though promising, data on the use of estradiol (particularly transdermal estradiol) to alleviate depression during perimenopause, use of a combination of estrogens and selective serotonin reuptake inhibitors for depression during the postmenopausal period, and the use of testosterone to improve psychological well-being and increase libido among women with induced menopause. Further studies would help to better delineate the usage of hormones as an antidepressant strategy (monotherapy or augmenting treatment) for peri- and postmenopausal women. A brief review of some nonhormonal interventions for the treatment of menopause-related symptoms that may significantly affect a woman's quality of life is also presented. There are some preliminary data suggesting the efficacy of antidepressants for the treatment of hot flushes; existing data on diet supplements and herbal products have shown more mixed results.

Trajectories of brain development: point of vulnerability or window of opportunity?

Brain development is a remarkable process. Progenitor cells are born, differentiate, and migrate to their final locations. Axons and dendrites branch and form important synaptic connections that set the stage for encoding information potentially for the rest of life. In the mammalian brain, synapses and receptors within most regions are overproduced and eliminated by as much as 50% during two phases of life: immediately before birth and during the transitions from childhood, adolescence, to adulthood. This process results in different critical and sensitive periods of brain development. Since Hebb (1949) first postulated that the strengthening of synaptic elements occurs through functional validation, researchers have applied this approach to understanding the sculpting of the immature brain. In this manner, the brain becomes wired to match the needs of the environment. Extensions of this hypothesis posit that exposure to both positive and negative elements before adolescence can imprint on the final adult topography in a manner that differs from exposure to the same elements after adolescence. This review endeavors to provide an overview of key components of mammalian brain development while simultaneously providing a framework for how perturbations during these changes uniquely impinge on the final outcome.

Gender differences in irritable bowel syndrome

In the United States and other Western cultures, a greater number of women seek health care services for symptoms of functional pain disorders, including irritable bowel syndrome, than men. Recent clinical trials indicate that gender differences in responsiveness to drug therapy also occur. Several lines of inquiry have focused on explaining this gender-related difference due to the higher prevalence of these disorders in women. Evidence of a physiologic component is based on gender differences in gastrointestinal transit time, visceral sensitivity, central nervous system pain processing, and specific effects of estrogen and progesterone on gut function. Additional factors may play a role, including gender-related differences in neuroendocrine, autonomic nervous system, and stress reactivity, which are related to bowel function and pain. However, the link between these measures and gut motility or sensitivity remains to be clarified. Psychological characteristics, including somatization, depression, and anxiety as well as a history of sexual abuse, may also contribute to gender-related differences in the prevalence of irritable bowel syndrome. Although gender differences in the therapeutic benefit of serotonergic agents have been observed, less is known about potential differences in responsiveness to nondrug therapies for irritable bowel syndrome.

Quality of life and menopause: the role of estrogen

The use of estrogen or hormone replacement therapy (ERT/HRT) in preventing disease in menopausal women has been well documented. Less attention has been paid to the menopausal symptoms that can impair the quality of life of menopausal women, such as hot flushes, sleep disorders, sexual dysfunction, and alterations in mood. Researchers have used a variety of methods to investigate these concerns. Decreases in ovarian hormones that occur with menopause have been implicated in these symptoms. Ovarian hormones affect the central nervous system and urogenital tissues directly via receptors for estrogen, progesterone, and androgens. Changes in the symptoms of menopause consequential to estrogen therapy reflect the effect of this therapy on these tissues. Evidence supporting the effectiveness of ERT/HRT in the treatment of symptoms affecting quality of life is growing and supports the use of ERT/HRT during menopause. Because the most dramatic hormonal changes associated with menopause are related to estrogen and because estrogen is usually coadministered with a progestogen in patients with an intact uterus, this review is focused primarily on ERT/HRT. Because androgen therapy may also improve quality of life by enhancing perimenopausal and postmenopausal sexual desire, function, and general well-being, a brief discussion of androgen supplementation of ERT/HRT is also included. The ideal doses and combinations of hormones must be determined on an individual basis, taking into consideration benefits, risks, and interactions of the different hormone therapies.