Hypothalamic-pituitary-adrenal axis activity in depressive illness. Its relationship to classification

Affective Prosody and Its Impact on the Neurology of Language, Depression, Memory and Emotions

Based on the seminal publications of Paul Broca and Carl Wernicke who established that aphasic syndromes (disorders of the verbal-linguistic aspects of communication) were predominantly the result of focal left-hemisphere lesions, "language" is traditionally viewed as a lateralized function of the left hemisphere. This, in turn, has diminished and delayed the acceptance that the right hemisphere also has a vital role in language, specifically in modulating affective prosody, which is essential for communication competency and psychosocial well-being. Focal lesions of the right hemisphere may result in disorders of affective prosody (aprosodic syndromes) that are functionally and anatomically analogous to the aphasic syndromes that occur following focal left-hemisphere lesions. This paper will review the deductive research published over the last four decades that has elucidated the neurology of affective prosody which, in turn, has led to a more complete and nuanced understanding of the neurology of language, depression, emotions and memory. In addition, the paper will also present the serendipitous clinical observations (inductive research) and fortuitous inter-disciplinary collaborations that were crucial in guiding and developing the deductive research processes that culminated in the concept that primary emotions and related display behaviors are a lateralized function of the right hemisphere and social emotions, and related display behaviors are a lateralized function of the left hemisphere.

Neuroendocrine Stress System in Bipolar Disorder

Hormones have a crucial part in the progress and manifestation of a wide variety of different behaviors. The main influence of the neuroendocrine system on behavior is its action on the neurobiology of neuropsychiatric disorders and its relationship with the pharmacodynamics of medicines. Of all the neuroendocrine axes, the hypothalamic-pituitary-adrenal (HPA) axis has been the most extensively studied. There is evidence that disturbance in the HPA axis, the primary stress hormone system, could increase treatment resistance and relapse, worsen illness outcome, and cause cognitive deficits. Glucocorticoids mediate their actions in negative feedback binding in two different cytoplasmatic receptors described as mineralocorticoid receptors (MRs) and glucocorticoid receptors (GRs). Different psychopathologies underlying bipolar disorders are supposed to involve persistent dysfunctions in the expression and role of both MR and GR in the hippocampus. We review and analyze the evidence related to the correlation between bipolar disorders and the consequences and impact of stressful life events on the HPA axis, exploring the importance of these findings in bipolar disorders and as potential new targets for treatment.

Exploration de l’influence noradrénergique (par le dosage du MHPG urinaire) sur le test de freinage à la dexaméthasone chez les déprimés

Une hyperactivité de l’axe hypothalamo-hypophyso-cortico-surrénalien est souvent objectivée dans les dépressions majeures ou endogènes, particulièrement par le test de freinage à la dexaméthasone (DST).

Certaines hypothèses évoquent un dysfonctionnement noradrénergique pour expliquer cette anomalie.

Afin de rechercher les liens entre l’axe HPA et une anomalie du métabolisme de la noradrénaline (NA) cérébrale, 47 déprimés majeurs ont été étudiés.

Pour chaque déprimé étaient mesurés l’excrétion urinaire du MHPG de 24 heures et un test de freinage à la dexaméthasone était effectué.

Aucune corrélation n’est retrouvée entre l’âge et la sévérité de la dépression d’une part et d’autre part, l’excrétion du MHPG et les chiffres de cortisolémie pré et post dexaméthasone. Par contre, il existe une corrélation positive entre l’âge et l’excrétion du MHPG et entre l’âge et la cortisolémie post dexaméthasone, entre la durée du sevrage thérapeutique et la cortisolémie pré dexaméthasone et surtout, entre la cortisolémie pré DST et post DST.

Aucune corrélation ne peut âtre retrouvée entre l’excrétion du MHPG et la cortisolémie maximale post dexaméthasone.

Il n’y a pas de différence d’excrétion urinaire du MHPG entre les suppresseurs et les non suppresseurs qui sont au nombre de 19 (40 %).

Lorsque les déprimés sont séparés en hauts excréteurs et bas excréteurs de MHPG, il existe une tendance significative des déprimés hauts excréteurs à présenter un pourcentage supérieur de non suppresseurs.

L’étude ne confirme pas l’hypothèse hyponoradrénergique de l’échappement à la dexaméthasone. Elle tend plutôt à démontrer une association entre une hyperactivité de l’axe HPA et une excrétion urinaire élevée de MHPG.

De nombreux facteurs peuvent peut-âtre expliquer les difficultés à mettre en évidence les liens entre l’échappement au freinage par la dexaméthasone et une anomalie du métabolisme de NA cérébrale lorsque des mesures biologiques périphériques sont utilisées.

Loss of Glutamate Decarboxylase 67 in Somatostatin-Expressing Neurons Leads to Anxiety-Like Behavior and Alteration in the Akt/GSK3β Signaling Pathway

Major depressive disorder (MDD) is a highly prevalent psychiatric disorder worldwide. Several lines of evidence suggest that the dysfunction of somatostatin (SOM) neurons is associated with the pathophysiology of MDD. Importantly, most SOM neurons are γ-aminobutyric acid (GABA) interneurons. However, whether the dysfunction of GABAergic neurotransmission from SOM neurons contributes to the pathophysiology of MDD remains elusive. To address this issue, we investigated the emotional behaviors and relevant molecular mechanism in mice lacking glutamate decarboxylase 67 (GAD67), an isoform of GABA-synthesizing enzyme, specifically in SOM neurons (SOM-GAD67 mice). The SOM-GAD67 mice exhibited anxiety-like behavior in the open-field test without an effect on locomotor activity. The SOM-GAD67 mice showed depression-like behavior in neither the forced swimming test nor the sucrose preference test. In addition, the ability to form contextual fear memory was normal in the SOM-GAD67 mice. Furthermore, the plasma corticosterone level was normal in the SOM-GAD67 mice both under baseline and stress conditions. The expression ratios of p-Akt^Ser473/Akt and p-GSK3β^Ser9/GSK3β were decreased in the frontal cortex of SOM-GAD67 mice. Taken together, these data suggest that the loss of GAD67 from SOM neurons may lead to the development of anxiety-like but not depression-like states mediated by modification of Akt/GSK3β activities.

Bipolar affective disorder and borderline personality disorder: Differentiation based on the history of early life stress and psychoneuroendocrine measures

INTRODUCTION

Borderline Personality Disorder (BPD) and Bipolar Affective Disorder (BD) have clinical characteristics in common which often make their differential diagnosis difficult. The history of early life stress (ELS) may be a differentiating factor between BPD and BD, as well as its association with clinical manifestations and specific neuroendocrine responses in each of these diagnoses.

OBJECTIVE

Assessing and comparing patients with BD and BPD for factors related to symptomatology, etiopathogenesis and neuroendocrine markers.

METHODOLOGY

The study sample consisted of 51 women, divided into 3 groups: patients with a clinical diagnosis of BPD (n = 20) and BD (n = 16) and healthy controls (HC, n = 15). Standardized instruments were used for the clinical evaluation, while the history of ELS was quantified with the Childhood Trauma Questionnaire (CTQ), and classified according to the subtypes: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The functioning of the hypothalamic-pituitary-adrenal (HPA) axis was evaluated by measuring a single plasma cortisol sample.

RESULTS

Patients with BPD presented with more severe psychiatric symptoms of: anxiety, impulsivity, depression, hopelessness and suicidal ideation than those with BD. The history of ELS was identified as significantly more prevalent and more severe in patients (BPD and BP) than in HC. Emotional abuse, emotional neglect and physical neglect also showed differences and were higher in BPD than BD patients. BPD patients had greater severity of ELS overall and in the subtypes of emotional abuse, emotional neglect and physical neglect than BD patients. The presence of ELS in patients with BPD and BP showed significant difference with lower cortisol levels when compared to HC. The endocrine evaluation showed no significant differences between the diagnoses of BPD and BD. Cortisol measured in patients with BPD was significantly lower compared to HC in the presence of emotional neglect and physical neglect. A significant negative correlation between the severity of hopelessness vs cortisol; and physical neglect vs cortisol were found in BPD with ELS. The single cortisol sample showed a significant and opposite correlations in the sexual abuse diagnosis-related groups, being a negative correlation in BD and positive in BPD.

DISCUSSION

Considering the need for a multi-factorial analysis, the differential diagnosis between BPD and BD can be facilitated by the study of psychiatric symptoms, which are more severe in the BPD patients with a history of early life stress. The function of the HPA axis assessed by this cortisol measure suggests differences between BPD and BP with ELS history.

CONCLUSION

The integrated analysis of psychopathology, ELS and neuroendocrine function may provide useful indicators to differentiate BPD and BD diagnoses. These preliminary data need to be replicated in a more significant sample with improved and multiple assessments of HPA axis activity.

Impact, Diagnosis, Phenomenology, and Biology

This section provides summaries of the epidemiology, phenomenology, nosology, and the suspected biological substrates of the depressive disorders. It particularly emphasizes the historical evolution of the pertinent diagnostic constructs and the prognostic import both of the various diagnostic groupings and of the individual symptoms and symptom clusters.

Corticosterone oscillations during mania induction in the lateral hypothalamic kindled rat-Experimental observations and mathematical modeling

Changes in the hypothalamic-pituitary-adrenal (HPA) axis activity constitute a key component of bipolar mania, but the extent and nature of these alterations are not fully understood. We use here the lateral hypothalamic-kindled (LHK) rat model to deliberately induce an acute manic-like episode and measure serum corticosterone concentrations to assess changes in HPA axis activity. A mathematical model is developed to succinctly describe the entwined biochemical transformations that underlay the HPA axis and emulate by numerical simulations the considerable increase in serum corticosterone concentration induced by LHK. Synergistic combination of the LHK rat model and dynamical systems theory allows us to quantitatively characterize changes in HPA axis activity under controlled induction of acute manic-like states and provides a framework to study in silico how the dynamic integration of neurochemical transformations underlying the HPA axis is disrupted in these states.

Morning cortisol levels in schizophrenia and bipolar disorder: a meta-analysis

Increased peripheral levels of morning cortisol have been reported in people with schizophrenia (SZ) and bipolar disorder (BD), but findings are inconsistent and few studies have conducted direct comparisons of these disorders. We undertook a meta-analysis of studies examining single measures of morning cortisol (before 10 a.m.) levels in SZ or BD, compared to controls, and to each other; we also sought to examine likely moderators of any observed effects by clinical and demographic variables. Included studies were obtained via systematic searches conducted using Medline, BIOSIS Previews and Embase databases, as well as hand searching. The decision to include or exclude studies, data extraction and quality assessment was completed in duplicate by LG, SM and AS. The initial search revealed 1459 records. Subsequently, 914 were excluded on reading the abstract because they did not meet one or more of the inclusion criteria; of the remaining 545 studies screened in full, included studies were 44 comparing SZ with controls, 19 comparing BD with controls, and 7 studies directly comparing schizophrenia with bipolar disorder. Meta-analysis of SZ (N=2613, g=0.387, p=0.001) and BD (N=704, g=0.269, p=0.004) revealed moderate quality evidence of increased morning cortisol levels in each group compared to controls, but no difference between the two disorders (N=392, g=0.038, p=0.738). Subgroup analyses revealed greater effect sizes for schizophrenia samples with an established diagnosis (as opposed to 'first-episode'), those that were free of medication, and those sampled in an inpatient setting (perhaps reflecting an acute illness phase). In BD, greater morning cortisol levels were found in outpatient and non-manic participants (as opposed to those in a manic state), relative to controls. Neither age nor sex affected cortisol levels in any group. However, earlier greater increases in SZ morning cortisol were evident in samples taken before 8 a.m. (relative to those taken after 8 a.m.). Multiple meta-regression showed that medication status was significantly associated with morning cortisol levels in SZ, when the effects of assay method, sampling time and illness stage were held constant. Heightened levels of morning cortisol in SZ and BD suggest long-term pathology of the hypothalamic-pituitary-adrenal (HPA) axis that may reflect a shared process of illness development in line with current stress-vulnerability models.

The Brain Derived Neurotrophic Factor and Personality

The study of the biological basis of personality is a timely research endeavor, with the aim of deepening our understanding of human nature. In recent years, a growing body of research has investigated the role of the brain derived neurotrophic factor (BDNF) in the context of individual differences across human beings, with a focus on personality traits. A large number of different approaches have been chosen to illuminate the role of BDNF for personality, ranging from the measurement of BDNF in the serum/plasma to molecular genetics to (genetic) brain imaging. The present review provides the reader with an overview of the current state of affairs in the context of BDNF and personality.

Are there meaningful biomarkers of treatment response for depression?

During the past decades, the prevalence of affective disorders has been on the rise globally, with only one out of three patients achieving remission in acute treatment with antidepressants. The identification of physiological markers that predict treatment course proves useful in increasing therapeutic success. On the basis of well-documented, recent findings in depression research, we highlight and discuss the most promising biomarkers for antidepressant therapy response. These include genetic variants and gene expression profiles, proteomic and metabolomic markers, neuroendocrine function tests, electrophysiology and imaging techniques. Ultimately, this review proposes an integrative use of biomarkers for antidepressant treatment outcome.

[Contributions of cortisol suppression tests to understanding of psychiatric disorders: a narrative review of literature]

Activity of the hypothalamic-pituitary-adrenal axis had been studied for the past half century, when some researchers noted that some patients with Cushing's syndrome and severe mood disorders had high baseline cortisol levels, which resulted in an inhibited response in the 1mg dexamethasone suppression test. Altered dexamethasone suppression test results were subsequently found in many psychiatric diseases, including anorexia nervosa, obsessive-compulsive disorder, degenerative dementia, bipolar disorders, and schizophrenia. The relationship between high baseline cortisol levels and stress has also been studied. Some researches on the genesis of borderline personality disorder focused on traumatic childhood backgrounds. Other investigations aimed at elucidating the relationship between traumatic backgrounds and some psychiatric disorders noted that patients with post-traumatic stress disorder and borderline personality disorder showed an enhanced cortisol suppression with low cortisol doses (0.5 mg). Recent studies showed that use of an ultra-low dose of cortisol during the dexamethasone suppression test may be helpful for detecting disorders with hyperactivity of the hypothalamic-pituitary-adrenal axis. Recent advances in neuroimaging support the existence of hyperactivity of the hypothalamic-pituitary-adrenal axis in patients with borderline personality disorder, relating a decreased pituitary gland volume to major traumatic backgrounds and suicidal attempts. The purpose of this paper is to make a narrative review of research using dexamethasone suppression test in psychiatric disorders, in order to ascertain its value as a supplemental diagnostic test or as a prognostic marker.

Cortisol and depression: three questions for psychiatry

BACKGROUND

Cortisol plays a multifaceted role in major depression disorder (MDD). Diurnal rhythms are disturbed, there is increased resistance to the feedback action of glucocorticoids, excess cortisol may induce MDD, basal levels may be higher and the post-awakening cortisol surge accentuated in those at risk for MDD. Does this suggest new avenues for studying MDD or its clinical management?

METHOD

The relevant literature was reviewed.

RESULTS

Cortisol contributes to genetic variants for the risk for MDD and the way that environmental events amplify risk. The corticoids' influence begins prenatally, but continues into adulthood. The impact of cortisol at each phase depends not only on its interaction with other factors, such as psychological traits and genetic variants, but also on events that have, or have not, occurred previously.

CONCLUSIONS

This review suggests that the time is now right for serious consideration of the role of cortisol in a clinical context. Estimates of cortisol levels and the shape of the diurnal rhythm might well guide the understanding of subtypes of MDD and yield additional indicators for optimal treatment. Patients with disturbed cortisol rhythms might benefit from restitution of those rhythms; they may be distinct from those with more generally elevated levels, who might benefit from cortisol blockade. Higher levels of cortisol are a risk for subsequent depression. Should manipulation of cortisol or its receptors be considered as a preventive measure for some of those at very high risk of future MDD, or to reduce other cortisol-related consequences such as long-term cognitive decline?

Plasma cortisol in first episode drug-naïve mania: differential levels in euphoric versus irritable mood

BACKGROUND

Dysregulation of HPA axis has been widely described in subjects with bipolar disorder (BD), including changes in cortisol levels during mood episodes and euthymia. However, most of the studies were done with medicated BD patients with variable length of illness, which was shown to interfere on peripheral cortisol levels. Therefore, the present study aims to evaluate plasma cortisol levels in drug-naïve BD subjects during the first manic episode, as well as investigate the relationship between plasma cortisol levels and manic symptomatology.

METHODS

Twenty-six drug-naïve patients were enrolled meeting criteria for a first manic episode in bipolar I disorder. Severity of mania was assessed using the Young Mania Rating Scale (YMRS). The control group included 27 healthy subjects matched by age and gender. Cortisol was quantified using a direct radioimmunoassay.

RESULTS

Plasma cortisol levels were decreased during first manic episode compared to healthy controls. Higher cortisol levels were positively associated with the presence of irritability (dysphoria), while elated mania showed lower cortisol levels compared to controls.

LIMITATION

Data including larger samples are lacking.

CONCLUSION

Higher cortisol in dysphoric mania compared to predominantly elated/euphoric mania may indicate a clinical and neurobiological polymorphic phenomenon, potentially involving a higher biological sensitivity to stress in the presence of irritable mood. The present findings highlight the importance to add a dimensional approach to the traditional categorical diagnosis for future neurobiological studies in BD.

Anorexia nervosa: a unified neurological perspective

The roles of corticotrophin-releasing factor (CRF), opioid peptides, leptin and ghrelin in anorexia nervosa (AN) were discussed in this paper. CRF is the key mediator of the hypothalamo-pituitary-adrenal (HPA) axis and also acts at various other parts of the brain, such as the limbic system and the peripheral nervous system. CRF action is mediated through the CRF1 and CRF2 receptors, with both HPA axis-dependent and HPA axis-independent actions, where the latter shows nil involvement of the autonomic nervous system. CRF1 receptors mediate both the HPA axis-dependent and independent pathways through CRF, while the CRF2 receptors exclusively mediate the HPA axis-independent pathways through urocortin. Opioid peptides are involved in the adaptation and regulation of energy intake and utilization through reward-related behavior. Opioids play a role in the addictive component of AN, as described by the "auto-addiction opioids theory". Their interactions have demonstrated the psychological aspect of AN and have shown to prevent the functioning of the physiological homeostasis. Important opioids involved are β-lipotropin, β-endorphin and dynorphin, which interact with both µ and κ opioids receptors to regulate reward-mediated behavior and describe the higher incidence of AN seen in females. Moreover, ghrelin is known as the "hunger" hormone and helps stimulate growth hormone (GH) and hepatic insulin-like-growth-factor-1(IGF-1), maintaining anabolism and preserving a lean body mass. In AN, high levels of GH due to GH resistance along with low levels of IGF-1 are observed. Leptin plays a role in suppressing appetite through the inhibition of neuropeptide Y gene. Moreover, the CRF, opioid, leptin and ghrelin mechanisms operate collectively at the HPA axis and express the physiological and psychological components of AN. Fear conditioning is an intricate learning process occurring at the level of the hippocampus, amygdala, lateral septum and the dorsal raphe by involving three distinct pathways, the HPA axis-independent pathway, hypercortisolemia and ghrelin. Opioids mediate CRF through noradrenergic stimulation in association with the locus coeruleus. Furthermore, CRF's inhibitory effect on gonadotropin releasing hormone can be further explained by the direct relationship seen between CRF and opioids. Low levels of gonadotropin have been demonstrated in AN where only estrogen has shown to mediate energy intake. In addition, estrogen is involved in regulating µ receptor concentrations, but in turn both CRF and opioids regulate estrogen. Moreover, opioids and leptin are both an effect of AN, while many studies have demonstrated a causal relationship between CRF and anorexic behavior. Moreover, leptin, estrogen and ghrelin play a role as predictors of survival in starvation. Since both leptin and estrogen are associated with higher levels of bone marrow fat they represent a longer survival than those who favor the ghrelin pathway. Future studies should consider cohort studies involving prepubertal males and females with high CRF. This would help prevent the extrapolation of results from studies on mice and draw more meaningful conclusions in humans. Studies should also consider these mechanisms in post-AN patients, as well as look into what predisposes certain individuals to develop AN. Finally, due to its complex pathogenesis the treatment of AN should focus on both the pharmacological and behavioral perspectives.

A randomised controlled study of risperidone and olanzapine for schizophrenic patients with neuroleptic-induced acute dystonia or parkinsonism

The objective of this study was to compare the effects of risperidone and olanzapine in schizophrenic patients with intolerant extrapyramidal side effects (EPS) on first generation antipsychotics. We conducted an 8-week, rater-blinded, flexible dose study. Seventy patients with schizophrenia, who met the DSM-IV research criteria of having neuroleptic-induced acute dystonia or parkinsonism, were randomly assigned to risperidone or olanzapine group. The primary outcome was a comparison of the incidence of concomitant anticholinergic drugs usage between the groups to manage their acute dystonia and parkinsonism. The average doses of risperidone and olanzapine from baseline to study end point were 1.8-3.5 mg/day and 7.7-11.7 mg/day, respectively. There were no significant differences in demographic data, severity of EPS or psychotic symptoms between the groups at baseline assessment. Patients taking risperidone had significantly higher incidence of using anticholinergic drugs to manage acute dystonia or parkinsonism overall during the study (OR = 5.17, 95%CI = 1.49-17.88, P = 0.013). There was no significant between-group difference in the changing of rating scales of EPS and psychotic symptoms. The results of our study favour olanzapine as a better choice in schizophrenic patients with intolerant EPS. Double-blinded, fixed dose and different ethnical study for EPS-intolerant schizophrenic patients is needed to confirm the results of our study.

A systematic review of hypothalamic-pituitary-adrenal axis function in schizophrenia: implications for mortality

There is convincing evidence that environmental stress plays a significant role in modifying both mental and physical health. The biological mechanisms linking stress to ill health are not fully understood, but significant evidence points to a central role of the stress axes; the hypothalamic- pituitary-adrenal (HPA) axis and the sympathetic nervous system. Together these two systems link the brain and the body and are crucial in maintaining homeostasis as well as improving an organism's survival chances in the face of environmental challenge. There is evidence of altered HPA axis function in people with a range of mental disorders, and this may in part explain the poor physical health of people with psychotic, mood and anxiety disorders. This paper systematically reviews HPA axis function in people with schizophrenia and relates this to the pattern of physical health seen in this disease. In summary, the evidence suggests people with schizophrenia can experience both hyper- and hypo-function of the HPA axis. It is likely that this contributes to the pattern of poor physical health and premature mortality suffered by people with schizophrenia, in particular the high rates of cardiovascular and metabolic disturbance.

Differential patterns of HPA activity and reactivity in adult posttraumatic stress disorder and major depressive disorder

Despite a number of overlapping symptoms, individuals with posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) often display hypothalamic-pituitary-adrenal (HPA) profiles that appear quite different from one another. This review describes the patterns of HPA-axis activity and reactivity in healthy individuals compared to individuals with these two disorders. Measures of HPA-axis activity and reactivity include cortisol levels at rest, in response to the dexamethasone suppression test (DST), and in response to psychological stress. The research reviewed presents the possibility of diagnostic specificity with regard to HPA function. In particular, the differential response pattern to the DST suggests that, while it cannot be considered a pure diagnostic tool, it should be one measure taken into consideration during diagnosis.

Dexamethasone suppression test

A connection between a high level of plasma cortisol and psychopathology has long been observed. In depressive patients increased plasma cortisol and non-suppression to the dexamethasone suppression test (DST) has often been described. In this study it was found that endogenously depressed patients more often than non-endogenously depressed patients showed abnormal results to the DST. No difference was found in delta MAX TSH between suppressors and non-suppressors to the DST.

Combined biological tests for suicide prediction

Disturbances in serotonin neuroregulation and in hypothalamic-pituitary-adrenal axis activity are both likely, and possibly independent, factors in the genesis of suicidal behavior. This analysis considers whether clinically accessible measures of these two disturbances have additive value in the estimation of risk for suicide. Seventy-four inpatients with RDC major or schizoaffective depressive disorders entered a prospective follow-up study from 1978-1981, underwent a dexamethasone suppression test (DST) and had fasting serum cholesterol levels available in the medical record. As reported earlier, patients who had had an abnormal DST result were significantly more likely to commit suicide during follow-up. Serum cholesterol concentrations did not differ by DST result and low cholesterol values were associated with subsequent suicide when age was included as a covariate. These results indicate that, with the use of age-appropriate thresholds, serum cholesterol concentrations may be combined with DST results to provide a clinically useful estimate of suicide risk.

Hypothalamic-pituitary-adrenal axis and bipolar disorder

There is robust evidence demonstrating abnormalities of the HPA axis in bipolar disorder. Hypercortisolism may be central to the pathogenesis of depressive symptoms and cognitive deficits, which may in turn result from neurocytotoxic effects of raised cortisol levels. Manic episodes may be preceded by increased ACTH and cortisol levels, leading to cognitive problems and functional impairments. Identification and effective treatment of mood and cognitive symptoms of mood disorders are clinical goals, but currently available treatments may fall short of this ideal. Manipulation of the HPA axis has been shown to have therapeutic effects in preclinical and clinical studies, and recent data suggest that direct antagonism of GRs maybe a future therapeutic strategy in the treatment of mood disorders.

Age effects on cortisol levels in depressed patients with and without comorbid post-traumatic stress disorder, and healthy volunteers

BACKGROUND

Post-traumatic stress disorder (PTSD) and major depression are frequently comorbid. Age and major depression are associated with higher cortisol levels and dexamethasone resistance, whereas PTSD is associated with lower cortisol and dexamethasone supersensitivity. Therefore, we examined the effect of age on the hypothalamic-pituitary-adrenal (HPA) system in depressed patients with and without PTSD.

METHODS

Thirty-one depressed patients without PTSD, 12 depressed patients with PTSD, and 23 healthy volunteers were studied on 2 days. Subjects received single-blind placebo on day 1 and fenfluramine on day 2. Cortisol levels were drawn before challenge and for 5 h thereafter.

RESULTS

Cortisol levels increase with age in depressed patients without PTSD but not in depressed patients with PTSD or in healthy volunteers. Number of previous major depressive episodes was a predictor of the cortisol response to fenfluramine administration in depressed patients without PTSD.

CONCLUSIONS

The results of our study highlight the importance of considering age in psychobiology. Further research is needed to fully delineate the role of age in abnormalities of the HPA axis found in major depression and PTSD.

Personality pathology, depression and HPA axis functioning

Hypothalamic pituitary adrenal (HPA) axis functioning, as measured by the dexamethasone suppression test (DST), has been extensively investigated in major depressive disorder (MDD). Evaluating DST response in MDD patients while simultaneously considering clinically relevant personality disorders may further clarify the contribution of both personality pathology and HPA axis function to depressive symptoms. The present study measured personality pathology by administering the revised version of the Millon Clinical Multiaxial Inventory (MCMI-II) in a sample of 25 patients diagnosed with MDD. Analyses revealed that suppressors (n = 19) scored significantly higher than non-suppressors (n = 6) on six of the 13 MCMI-II personality disorder scales: Avoidant, Schizoid, Self-Defeating, Passive-Aggressive, Schizotypal and Borderline. Increased personality pathology was associated with normal suppression of cortisol following the DST. This suggests that suppression of the DST may be associated with depressive states linked with personality pathology while the more biologically based depression is associated with abnormal HPA pathophysiology. Copyright 2001 John Wiley & Sons, Ltd.

Use of the dexamethasone suppression test with DSM-III criteria in psychiatrically hospitalized adolescents

Although developmental factors may complicate the assessment of major affective disorder in the adolescent patient, studies suggest that the same descriptive criteria used in the assessment of the adult patient can be utilized to diagnose major depression in the adolescent patient. In order to determine if the dexamethasone suppression test (DST) has a similar sensitivity and specificity for DSM-III major depression in adolescents compared to that found in adult patients, we administered the DST to 55 adolescents admitted to an inpatient psychiatric unit. Each of the adolescents exhibited depressive symptoms; 23 fulfilled DSM-III criteria for major depressive syndromes (20 major depression; 3 schizoaffective), and 32 fulfilled the criteria for other DSM-III diagnoses. Of the 23 patients with major affective disorder, 10 (43%) exhibited nonsuppression of serum cortisol after dexamethasone. Of the 32 patients with depressive symptoms and other diagnoses, five (16%) exhibited nonsuppression; on follow up, three of the five nonsuppressors fulfilled criteria for major depression. These findings suggest that DSM-III criteria can be used to diagnose major depression in the adolescent patient and that the DST may play an important role in detecting or confirming the diagnosis of major depressive disorders in adolescent patients.

Use of the dexamethasone suppression test on a combined medicine-psychiatry inpatient unit

The dexamethasone suppression test (DST) appears to be a sensitive and specific biological marker for endogenous depression that can have important diagnostic and treatment implications. The authors present three case studies of patients treated on a combined medicine-psychiatric inpatient unit, and who presented with complex psychobiological illnesses. They discuss the usefulness of the DST in the hospital management of these patients from a diagnostic and treatment perspective.

Clinical picture and etiologic models of mixed states

Although conceptualized as polar opposites, manic and depressive symptoms often co-occur in bipolar disorder. This article explores the clinical characteristics, prevalence, biologic features, and response to treatments of mixed states. Issues of diagnosis and cause are considered. The course is often protracted beyond acute episodes, psychotic symptoms are common, and suicide is a major risk. Bipolar mixed states are over represented in women. Mixed states respond poorly to lithium salts; mood stabilizers, particularly divalproex, are the mainstay of modern treatment. Electroconvulsive therapy is also effective, and can be used in severe cases.

Plasma dexamethasone concentration and cortisol response during manic episodes

BACKGROUND

Despite the widespread study of the dexamethasone suppression test (DST) in patients diagnosed with major depression, it has been less well studied during manic and mixed states of bipolar disorder.

METHODS

Cortisol response to the administration of 1 mg of dexamethasone was studied in 44 patients diagnosed bipolar disorder, manic (n = 37) or mixed (n = 7). Dexamethasone levels and cortisol responses were compared between these groups. Four patients initially meeting criteria for bipolar disorder, mixed, and 7 patients initially meeting criteria for bipolar disorder, manic, all of whom were characterized as DST nonsuppressors, were retested after remission.

RESULTS

Dexamethasone levels were lower and cortisol levels higher in those patients diagnosed bipolar disorder, mixed. An inverse correlation was found between log-transformed dexamethasone levels and log-transformed cortisol levels at 3 PM (r = -.619, p < or = .001) and 10 PM (r = -.501, p < or = .001). In those subjects retested after remission, dexamethasone levels were higher and cortisol levels lower than during the manic and mixed states.

CONCLUSIONS

Disturbances in the hypothalamic-pituitary-adrenal axis are observed frequently during mixed states of bipolar disorder, but are also not uncommon in purely manic episodes. These changes appear to be state dependent and revert with treatment.

Comparative studies of the biological distinction between unipolar and bipolar depressions

Although unipolar depression and bipolar depression are considered distinct entities both by clinicians and researchers, it is not clear whether a pathophysiological distinction, which is the bridge between etiology and treatment, exists between these two conditions. The objective of this paper was to systematically review the studies that examined the biological differences between unipolar and bipolar depression. Using computerized Medline and manual searches, we located and reviewed studies that directly compared patients with unipolar depression with bipolar depressed patients on at least one biological variable. The results showed that patients with bipolar depression had lower levels of urinary NE and its metabolites and lower platelet MAO activity, and higher platelet free and stimulated intracellular calcium levels compared with unipolar depressed patients, but none of the variables examined appeared to differentiate the two groups consistently. We discuss some of the methodological flaws that might have contributed to this, and suggest that further studies should control for such confounding variables.

All roads lead to depression: clinically homogeneous, etiologically heterogeneous

Manias, and particularly depressions, are syndromes not disease. Considerable data support the fact that depressions, though similar clinically, are of heterogeneous etiologies. We can separate depressions generally into those that are endogenous/psychotic and those that occur in the context of marked emotional instability. Familial pure depressive disease is a specific example of the former, depression spectrum diseases a specific example of the latter. These are separable on the basis of personality, clinical, follow-up, familial and treatment variables.

Noradrenergic receptor sensitivity in obsessive compulsive disorder: II. Cortisol response to acute clonidine administration

Sensitivity of pre-synaptic alpha-2- and post-synaptic alpha-1- and beta-adrenoceptors was investigated in 15 patients with obsessive-compulsive disorder (OCD) and in 15 age- and sex-matched healthy controls, by measuring cortisol responses to saline administration and to inhibition by clonidine (clon), a noradrenergic receptor agonist. Basal values of cortisol and responses to administration of saline and of clon were the same in patients and controls.

Depression spectrum disease with and without depression in first-degree relatives

Family history was assessed in 211 outpatients with unipolar major depression and diagnoses were rendered according to Winokur et al. (Winokur et al. (1978) J. Nerv. Ment. Dis. 166, 764-768) family history typology. The subclassification of Depression Spectrum Disease with Alcoholism and Depression (DSDA + D) was applied to those patients reporting at least one first-degree relative suffering from alcoholism and another first-degree relative suffering from depression (n = 103), while Depression Spectrum Disease with Alcoholism (DSDA) was applied to those patients with at least one first-degree relative suffering from alcoholism, but none suffering from depression (n = 108). These two groups were compared on demographic, clinical and biological characteristics. They were also compared with 162 patients who reported the presence of depression and absence of alcoholism in first-degree relatives, designated as Familial Pure Depressive Disease (FPDD) by the Winokur et al. (1978) classification. Results revealed that the DSDA + D group was younger, had an earlier age at onset of depression and experienced more episodes of depression than did the DSDA group. No differences were found between the two groups on biological measures. The FPDD group was more similar to the DSDA + D group than the DSDA group in terms of age at onset and number of depressives episodes. However, the FPDD group had a longer length of illness than either of the DSD groups. These data suggest that the DSD group should be more narrowly defined (excluding those with a positive family history of depression) in future clinical research studies.

Effects of hCRH on sleep and body temperature rhythms

We investigated the effects of human corticotropin-releasing hormone (hCRH) on the sleep structure and body temperature rhythms of seven healthy young men. Polysomnographic recordings were obtained and body temperatures were monitored continuously for 48 h in each subject following the intravenous administration of saline or of 100 micrograms hCRH. The administration of hCRH was associated with a significant phase-advancement in body temperature rhythm vs the saline control. The administration of hCRH affected non-rapid eye movement (NREM) sleep by reducing significantly slow wave sleep (SWS) and sleep efficiency, whereas the percentage of sleep stages 1 and 2 were increased significantly. These changes in body temperature rhythms and sleep structure induced by hCRH resembled those observed in patients with endogenous depression, except for the findings during rapid eye movement (REM) sleep. We hypothesize that a hypersecretion of hCRH in patients with endogenous depression may help to explain the changes in body temperature rhythms and sleep structure often reported in such patients.

An augmented escape of androstenedione from suppression by dexamethasone in melancholia: relationships to intact ACTH and cortisol nonsuppression

To further examine the association between basal and postdexamethasone (DST) pituitary and adrenal activity in depression, the authors measured intact adrenocorticotropic hormone (ACTH), androstenedione and cortisol, both in baseline and post-DST conditions, in 63 depressed subjects (14 minor, 33 simple major and 16 melancholic subjects). It was found that post-DST androstenedione, cortisol and ACTH values were significantly higher in melancholic than in minor depressed subjects. There were highly significant correlations between plasma androstenedione and ACTH both in baseline and post-DST conditions. The significant intercategory differences in post-DST androstenedione were determined by differences in post-DST ACTH. Basal and post-DST androstenedione values were significantly higher in men than in women and both values were significantly and negatively related to age. There were highly significant, positive relationships between cortisol and ACTH and between cortisol and androstenedione both in baseline and post-DST conditions. The results corroborate our hypotheses that, in depression, pituitary (ACTH) and adrenal (cortisol and androstenedione) hormonal secretion are tightly coupled in post-DST conditions and that the augmented escape of ACTH-target hormones in melancholia is, in part, related to that of pituitary ACTH.

Involvement of corticosteroids in the processing of stressful life-events. A possible implication for the development of depression

In a sub-population of endogenously depressed patients, disturbances of the hypothalamic-pituitary-adrenal axis can be observed. Increased cortisol and CRH levels combined with normal ACTH concentrations have often been reported. Corticosteroids appear to play a role in the mood changes, in depressed subjects. However, their mechanism of action is unknown. In animal experiments, the involvement of corticosteroids in stressor-induced learning was investigated. Three paradigms were used. In the Porsolt swimtest an animal had to learn to adapt to an inescapable situation. In the lithium chloride conditioned taste aversion an animal learned to avoid sugar water. In the amphetamine sensitization a second injection of amphetamine caused a potentiated response, because of conditioning. All three conditions appeared to be stressful because they induced a corticosterone release. When adrenalectomized (ADX) mice were compared to control animals it appeared that, in all three paradigms, their memory function was disturbed. The data indicated that this was a specific glucocorticoid-mediated effect since corticosterone and dexamethasone injections were able to reverse the ADX-induced deficit. The ADX-induced disturbances were only observable at moderate stress levels. More severe stressors (lower water temperature in the Porsolt swimtest, higher lithium chloride and amphetamine doses) also made ADX mice remember their previous experiences. The results suggest that corticosteroids are involved in the consolidation of stressful events and the corresponding coping responses. They play, however, only a role in the case of moderate stressors. In ADX animals no stressor-induced corticosterone increase can occur and therefore these animals only remember severe stressors. In a depressed patient basal steroid levels are increased and consequently very mild stressors, which induce only a small extra steroid release, will be remembered. The remembering of all these negative experiences might be of importance for the development and maintenance of the depression.

Personality disorder, symptoms and dexamethasone suppression in depression

The presence of Personality Disorder (PD) in depressed patients admitted to the acute wards of a psychiatric hospital was assessed using Tyrer's Personality Assessment Schedule, and its relationship to depressive symptoms, improvement after 2 weeks, and the dexamethasone suppression test was examined. 75.4% of the sample met Tyrer's criteria for a PD diagnosis. The initial symptoms of patients with personality disorder did not differ from those without PD. However patients with PD improved more slowly, and had significantly higher symptom scores after 2 weeks. Patients with PD also showed previous history of more depressive episodes, a younger first age of onset, and more frequent and severe previous suicide attempts, in addition to history of unstable marriage. No difference in dexamethasone suppression was found. These findings suggest that presence of personality disorder is related primarily to course of illness and life history, rather than symptom pattern.

Effect of war-induced prolonged stress on cortisol of persons with type II diabetes mellitus

The study was designed to assess the impact of protracted, war-induced stress on cortisol levels and glycemic control in persons with Type II diabetes mellitus. A randomly selected sample of 44 displaced Type II diabetic persons was compared with a group of diabetic persons matched for sex, age, weight, duration of diabetes, and type of treatment who had not been forced to leave their homes. The self-reported stress, depression level, serum cortisol, fasting blood glucose, and glycosylated hemoglobin were compared. The two groups were found to be significantly different in scores for self-reported stress and depression level. Passive coping patterns prevailed in the displaced group. The serum cortisol levels correlated positively with self-reported stress, negatively with active coping patterns, and were significantly higher in the displaced persons group. No significant differences were found between the group on the variables measuring glycemic control. The results indicate that prolonged stress need not worsen glycemic control in Type II diabetic patients.

The role of stress in interpreting the dexamethasone suppression test

Stress has been implicated as a major confounding factor in the interpretation of Dexamethasone Suppression Test (DST) results. This study was designed to examine the effects of stress on DST results. Fifty patients with high levels of acute, chronic, and environmental stress participated in the study. Each patient was given a comprehensive psychiatric and psychological assessment, a routine administration of dexamethasone, and blood tests of cortisol values. The results indicate that the three measures of stress do not appear to affect levels of cortisol suppression, however, all three measures of stress predicted depression. As expected, DST cortisol levels were related to depression. Results are discussed in terms of their implications for understanding the associations among stress, depression and DST results.

Hypothalamic-pituitary-adrenocortical function in mixed and pure mania

There is little information about hypothalamic-pituitary-adrenocortical (HPA) axis function in mania, particularly in mixed states. We therefore investigated HPA function and its relationship to clinical state in 19 hospitalized manic patients meeting Schedule for Affective Disorders and Schizophrenia - Research Diagnostic Criteria for acute manic episodes, compared patients with and without a mixed presentation, and examined correlations between HPA activity and behavior. Data were available from 13-16 patients. Behavioral and biochemical analyses were conducted during a 15-d placebo period. Patients with mania had elevated cerebrospinal fluid (CSF) and urinary free cortisol excretion compared with healthy subjects, and did not differ from depressed patients in any cortisol measures. Mixed manics had significantly higher morning plasma cortisol, postdexamethasone plasma cortisol and CSF cortisol than pure manics. Five of 7 mixed manics and 3 of 9 pure manics were dexamethasone suppression test (DST) nonsuppressors. Afternoon plasma cortisol and CSF cortisol correlated significantly with depressed mood; urinary free cortisol correlated with anxiety. None of the cortisol measures correlated with mania or agitation scores. These data suggest that increased cortisol secretion is a characteristic of the depressed state in mixed manics, although pure manics may also have increased DST nonsuppression.

Psychoendocrinological aspects of affective disorders

Psychoendocrinological studies have opened a new approach to understanding affective disorders. In this study, the links of affective illnesses to changes in endocrine secretions--particularly adrenal, gonadal, growth, pineal, thyroidal, and prolactin--were reviewed with the object of adding to the number of depressed whose symptoms can be relieved.

A multivariate study of simultaneous escape from suppression by dexamethasone of urinary free cortisol, plasma cortisol, adrenocorticotropic hormone and beta-endorphin in melancholic patients

To investigate the relationships between pre- and postdexamethasone hypothalamic-pituitary-adrenal (HPA) axis functioning in depression, we measured the levels of baseline and postdexamethasone urinary free cortisol (UFC), plasma cortisol, adrenocorticotropic hormone (ACTH) and beta-endorphin. We found that dexamethasone significantly suppressed all hormone levels. All 4 postdexamethasone hormones--but not their baseline levels--were significantly higher in melancholic subjects than in minor and simple major depressives. We have accumulated evidence that the melancholic and minor depression groups form discrete classes in postdexamethasone HPA axis hormone levels; this supports the biological heterogeneity hypothesis of melancholia. We found that a combination of the postdexamethasone UFC and beta-endorphin values yielded the most significant diagnostic tool for melancholia. Our results suggest that the measurements of both hormones may constitute the most accurate index reflecting the HPA axis escape from suppression by dexamethasone in melancholia. By means of pathway analysis, we determined the causal relationships between age, dexamethasone circulating levels, diagnostic depression classification and the various baseline and postdexamethasone hormone values.

Dexamethasone suppression test in schizophrenia: relationship to symptomatology, ventricular enlargement, and outcome

To relieve confusion about the clinical correlates and prognostic implications of the dexamethasone suppression test (DST) in schizophrenia, we conducted a DST in 44 schizophrenic inpatients at drug-free baseline and approximately 4 weeks after neuroleptic treatment. Patients were rated on positive, negative, and depressive symptoms at both times. A head computed tomography (CT) scan was performed and measures of ventricle-brain ratio (VBR) obtained. Clinical improvement was monitored at four weeks, and longer-term outcome assessed at 1 year. Seventeen of the 44 patients were DST nonsuppressors at baseline, and five of these remained nonsuppressors at 4 weeks posttreatment. Postdexamethasone plasma cortisol levels were correlated with negative symptoms at baseline (r = 0.45; p less than 0.01), but not after 4 weeks of neuroleptic treatment. Postdexamethasone plasma cortisols were not related to global severity, positive, or depressive symptoms at either timepoint or to VBR. Persistent nonsuppression was associated with poor outcome, but baseline postdexamethasone cortisol levels were unrelated to outcome at 4 weeks and 1 year. The literature on DST in schizophrenia is reviewed and attempts are made to reconcile discrepant findings and to discuss pathophysiological implications.

Steroids and depression

Patients with endogenous depression (major affective disorder) frequently have high cortisol levels, but the diurnal rhythm is usually maintained and they do not develop the physical signs of Cushing's syndrome. On the other hand, depression is a frequent feature of Cushing's syndrome regardless of etiology, and it is often relieved when the cortisol levels are reduced, by whatever means. The mechanisms of the hypercortisolemia and resistance to dexamethasone suppression commonly found in endogenous depression are poorly understood; contrary to expectations, ACTH levels are not clearly elevated. There is a striking difference in the psychiatric features seen in endogenous hypercorticism compared to those seen after exogenous administration of glucocorticoids or ACTH. This suggests that either there are other stimulating or modifying factors besides ACTH or that the steroids stimulated by ACTH or other peptides differ from those in control subjects, i.e. there may be an alteration in the metabolism of steroids in depression. Little is known about the metabolic changes or the many steroids besides glucocorticoids produced by the hyperactive steroid-producing tissue. Preliminary studies suggest that major depression may be improved by steroid suppression. It is hypothesized that steroids themselves may be important in causing and perpetuating depression.

Primary and secondary depression: a review

The literature on the distinction between primary and secondary depression is reviewed. The research data indicate that less severe, non life-threatening suicidal thoughts and behaviours occur more often in patients with secondary depression than in those with primary depression and that the prognosis for secondary depression after somatic forms of therapy is poorer than that for primary depression. The data also suggest that secondary depressives, unlike primary depressives, suffer from chronic dysphoria. It is concluded that, because the available evidence suggests that there are no qualitative differences between the episodes of primary and secondary depression, future research should concentrate on investigating the characteristics of different groups of patients with secondary depression rather than on comparisons between primary and secondary depression in general.

Children and adolescents with obsessive-compulsive disorder: the demographic and diagnostic characteristics of 61 Danish patients

To find children and adolescents with obsessive-compulsive disorder (OCD), a review was made of all the charts of the 4594 nonretarded, nonpsychotic patients treated at the Children's Psychiatric Hospital in Risskov, Denmark, as in- or outpatients from 1970 to 1986. Sixty-one children and adolescents (37 boys and 24 girls) fulfilled the DSM-III criteria for OCD. The frequency of OCD in a child psychiatric clientele was 1.33%, which supports earlier findings. Only 8 of the 61 children were actually discharged with a diagnosis of OCD (ICD-8 diagnosis). Most children were diagnosed as neurosis infantilis and about one fifth received a diagnosis of maladjustment. The possible reasons for this are discussed. It is concluded that it is hardly a matter of underdiagnosing OCD, but more likely an attempt to look upon the obsessive-compulsive symptoms as transient phenomena and perhaps an unwillingness among clinicians to use the diagnosis of OCD, which is often connected with a bad prognosis. Boys and girls with OCD did not differ significantly on important demographic items.

The prognostic significance of HPA-axis disturbance in panic disorder: a three-year follow-up

Seventy-seven patients with DSM-III panic disorder underwent a baseline dexamethasone suppression test (DST), participated in an 8-week controlled treatment trial, and provided follow-up interviews 2-4 years later. The 20 patients who had exhibited DST nonsuppression at baseline had more symptoms of anxiety, more work and social disability, and a greater likelihood of ongoing major depression than did patients who had had normal DST results. DST nonsuppression in panic disorder apparently indicates a more persistent and chronically disabling condition.

A revised interpretation of postdexamethasone ACTH and cortisol findings in unipolar depressed females

Baseline 8 a.m. adrenocorticotropic hormone (ACTH) and cortisol levels and the postdexamethasone ACTH/cortisol values at 8 a.m. and 4 p.m. were determined in 86 depressed females diagnosed using DSM-III criteria. Postdexamethasone ACTH and cortisol values were significantly correlated with their baseline levels. We have shown that regression analysis should be used to assess dexamethasone-induced changes as the residual ACTH and cortisol responses, with the relative effects of the baseline data on the hormone responses being partialed out. The residual ACTH and cortisol values were significantly increased in the most severely depressed females as compared to minor depressives. The residual ACTH responses were markedly correlated with the residual cortisol responses. Cortisol nonsuppression during a depressive episode appeared to be determined by an augmented ACTH escape from dexamethasone suppression. The residual ACTH and cortisol responses could prove to be the most sensitive reflection of the disorder in the negative feedback by dexamethasone on the pituitary. In clinical practice, the ratio ln (postdexamethasone ACTH): ln (basal ACTH) can be used, since this ratio is linearly correlated with the residual ACTH responses.

DST abnormality as a predictor of course in major depression

Seventy-six inpatients with major depression received a 1-mg dexamethasone suppression test (DST) and began a semi-annual follow-up lasting 5 years. The 20 subjects with abnormal baseline DST results were significantly more likely to make psychologically serious suicide attempts during follow-up though baseline suppressors were as likely as non-suppressors to make non-serious attempts. Patients who were non-suppressors at the beginning of follow-up were also more likely to develop'mania or hypomania, whether or not they had a bipolar diagnosis at intake.