Effect of clomipramine and lithium on fenfluramine-induced hormone release in major depression

Association Between 5-HTTLPR Polymorphism and Tics after Treatment with Methylphenidate in Korean Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

The purpose of this study is to examine the relationship between 5-HTTLPR polymorphism (44-bp insertion/deletion polymorphism of serotonin transporter gene) and methylphenidate (MPH) treatment response, as well as the association between the adverse events of MPH treatment and 5-HTTLPR polymorphism in children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

A total of 114 children with ADHD (mean age 9.08 ± 1.94 years) were recruited from the child psychiatric clinic in a hospital in South Korea. We have extracted the genomic DNA of the subjects from their blood lymphocytes and analyzed 5-HTTLPR polymorphism of the SLC6A4 gene. All children were treated with MPH for 8 weeks, with clinicians monitoring both the improvement of ADHD symptoms and the side effects. We compared the response to MPH treatment and adverse events among those with the genotype of 5-HRRLPR polymorphism.

RESULTS

There was no significant association between the 5-HTTLPR genotype and the response to MPH treatment in children with ADHD. Subjects with the S/L+L/L genotype tended to have tics and nail biting (respectively, p < 0.001, p = 0.017).

CONCLUSIONS

The results of this study do not support the association between the 5-HTTLPR polymorphism and treatment response with MPH in ADHD. However, our findings suggest the association between 5-HTTLPR polymorphism and the occurrence of tics and nail-biting as an adverse event of methylphenidate. This may aid in our understanding of the genetic contribution and genetic susceptibility of a particular allele in those ADHD patients with tics or nail biting.

Growth hormone, cortisol and prolactin responses to physical exercise: higher prolactin response in depressed patients

This study was designed to compare growth hormone, cortisol and prolactin responses to physical exercise in depressed patients and healthy comparison subjects. Patients fulfilled the DSM-IV diagnostic criteria for current major depressive disorder; subjective depressive symptoms were rated with Montgomery-Asberg Depression Rating Scale (MADRS) immediately before the experiment. Growth hormone, cortisol and prolactin were measured before and immediately after physiologically stressful bicycle cardiopulmonary exercise test. After exercise, there were three additional hormone measurements, with 30-min intervals. No significant difference was found in baseline growth hormone, cortisol or prolactin levels between patients and the control group. Plasma growth hormone and cortisol levels increased significantly during physical exercise in both patients and controls and returned to baseline in 90 min. There was no significant difference in growth hormone or cortisol responses to physical exercise between the two groups. However, prolactin levels increased only in the depressed patients group during the exercise. We hypothesize that acute exercise may have a stronger effect on serotonin (5-HT) release in depressed patients, which is reflected in increased plasma prolactin concentration.

A neurochemically distinct dorsal raphe-limbic circuit with a potential role in affective disorders

The serotonergic system arising from the dorsal raphe nucleus (DR) has long been implicated in psychiatric disorders, and is considered one site of action of classical anxiolytic and antidepressant agents. Recent studies implicate the DR as a site of action of novel anxiolytic and antidepressant agents that target neuropeptide systems, such as corticotropin-releasing factor (CRF) and neurokinin 1 (NK1) antagonists. The present study identified unique characteristics of the dorsomedial DR that implicate this particular subregion as a key component of a circuit, which may be targeted by these diverse psychotherapeutic agents. First, it was observed that a cluster of CRF-containing cell bodies was present in the dorsomedial DR of colchicine-treated rats. Dual-labeling immunohistochemistry revealed that almost all CRF-containing neurons were serotonergic, implicating CRF as a cotransmitter with serotonin in this subpopulation of DR neurons. Moreover, dendrites laden with immunoreactivity for NK1 had a striking topographic distribution surrounding and extending into the dorsomedial subregion of the DR, suggesting that NK1 receptor ligands may selectively impact the dorsomedial DR. Finally, anterograde tract tracing from the dorsomedial DR combined with CRF immunohistochemistry revealed that CRF-containing axons from this subregion project to CRF-containing neurons of the central nucleus of the amygdala. Taken together, the present results reveal a circuit whereby NK1 receptor activation in the dorsomedial DR can impact on limbic sources of CRF that have been implicated in emotional responses. This circuit may be relevant for understanding the mechanism of action of novel psychotherapeutic agents that act through NK1 or CRF receptors.

Effects of sertraline treatment on plasma cortisol, prolactin and thyroid hormones in female depressed patients

The aim of the study was to evaluate the effects of 4 and 24 weeks of sertraline treatment (average dose 42.5 mg/day) on plasma hormone levels in 15 female patients with major depression. Baseline levels of triiodothyronine (T(3)) were lower, while cortisol, prolactin (PRL), thyroid-stimulating hormone (TSH), and thyroxin (T(4)) levels did not differ from the values in 16 female controls. There was a positive correlation between the scores on the Montgomery-Asperg Depression Rating Scale and baseline cortisol levels. Treatment with sertraline for 4 weeks increased plasma cortisol levels, while 24 weeks of sertraline treatment increased plasma T(3) levels in depressed patients. Neither 4, nor 24 weeks of sertraline treatment affected PRL, T(4) and TSH levels in depressed patients. The data show different and time-dependent effects of sertraline treatment on plasma cortisol, PRL and thyroid hormones in female depressed patients.

Marker gene polymorphisms in hyperkinetic disorder--predictors of clinical response to treatment with methylphenidate?

Gene polymorphisms of the dopamine D4 receptor (DRD4) and serotonin transporter (5-HTT) are under discussion as potential genetic risk factors for hyperkinetic disorder (HD). In this disorder, treatment with the psychostimulant methylphenidate (MPH; Ritalin) induces calming effects and amelioration in only 70% of the patients. MPH blocks the reuptake of dopamine, thus enhancing synaptic dopamine which in turn antagonizes the release of prolactin (PL). Genotyping HD patients for DRD4 and 5-HTT polymorphisms and measuring PL concentrations, we report on an association between the combination DRD4*7/5HTT LL genotype and a reduced improvement in general functioning accompanied by different PL levels upon MPH treatment. Thus, our study supports the hypothesis that marker gene polymorphism may be helpful in identifying MPH non-responders.

Serotonin in mania and in the mechanism of action of mood stabilizers: a review of clinical studies

OBJECTIVES

Serotonin (5-hydroxytryptamine, 5-HT) was implicated in the pathophysiology of manic-depressive illness as early as 1958. Although extensive evidence has accumulated since then to support 5-HT's role in depression, relatively fewer studies examined its role in mania. The purpose of this paper was to review and summarize the current state of knowledge on the role of 5-HT in mania and its treatment.

METHODS

We systemically reviewed clinical studies of 1) 5-HT function in mania and 2) 5-HT in the mechanism of action of mood stabilizers, including lithium and anticonvulsants.

RESULTS

Review showed that cerebrospinal fluid, postmortem, platelet, neuroendocrine challenge, and tryptophan depletion studies provided some evidence to support the hypothesis that a 5-HT deficit is involved in mania and that enhancement of 5-HT neurotransmission exerts a mood-stabilizing effect.

CONCLUSIONS

There is some evidence from clinical studies for the contribution of 5-HT in mania and in the mechanism of action of mood stabilizers. However, it is very likely that other neurotransmitters also play important roles. Future directions for research include 1) in vivo study of 5-HT receptor subtypes using positron emission tomography, 2) investigation of the interaction between 5-HT and other neurotransmitter systems, and 3) determination of the relationships between diagnostic subtypes of mania and 5-HT function and other neurotransmitter systems.

Interactions of lithium and drugs that affect signal transduction on behaviour in rats

The therapeutic mechanism of the action of lithium in the treatment of bipolar affective disorder is not known, in spite of a burgeoning number of biochemical studies linking lithium to signal transduction processes. This article reviews a decade of studies examining the behavioural manifestations of manipulating inositol, cyclic adenosine monophosphate (cAMP) and G proteins in rats. Inositol, forskolin, dibutyryl cAMP and pertussis toxin all interacted with lithium when rearing behavior was measured. Lithium potentiated the increase in locomotion induced by injections of cholera toxin into the nucleus accumbens, consistent with the hypothesis that it inactivates inhibitory G proteins. More specific interactions were found between lithium and inositol following cholinergic and serotonergic stimulation. Inositol, but not forskolin, attenuated lithium-pilocarpine seizures and the enhancement of the serotonin syndrome; however, inositol had no effect on lithium-induced attenuation of wet dog shakes following an injection of 5-hydroxytryptophan. Behavioural evidence supports biochemical findings suggesting that lithium's interactions with the phoshphatidyl inositol and cyclic AMP signal transduction systems may be relevant to its therapeutic effects in bipolar disorder. Further research on more specific behaviours may elucidate the relevant pharmacological mechanisms underlying the therapeutic effect of lithium.

Prolactin response to d-fenfluramine in major depression before and after treatment with serotonin reuptake inhibitors

BACKGROUND

Central serotonin dysfunction is thought to be involved in the etiology of major depression. Serotonergic challenge studies before and after treatment of depressed patients have yielded conflicting results; however, these studies have not focused on the effect of antidepressant treatment with selective serotonin reuptake inhibitors (SSRIs) on serotonergic challenge studies.

METHODS

The authors studied 19 outpatients with major depressive disorder using prolactin response to d-fenfluramine as a measure of central serotonergic functioning. Testing of patients was conducted just before and right after 8 weeks of treatment with either fluoxetine (n = 10) or fluvoxamine (n = 9) as part of a randomized, double-blind treatment trial. Blood samples for prolactin were collected prior to administration of d-fenfluramine (0.5 mg/kg) and then over the next 5 hours.

RESULTS

Unlike previous studies in which antidepressant treatment produced an enhanced prolactin response to fenfluramine, in this study there was no increase in prolactin response to d-fenfluramine following SSRI treatment. In fact, prolactin response to d-fenfluramine was significantly diminished after treatment with fluvoxamine but not fluoxetine.

CONCLUSIONS

The implications of these findings are discussed with regard to possible mechanisms of action of SSRI treatment.

Psychoneuroendocrinology of depression. Prolactin

Prolactin provides us with a window to the brain in our quest for understanding the psychobiology of depression, since the regulation of its release involves some of the monamine neurotransmitter systems that have been implicated in the pathophysiology of depression. Investigation examining basal prolactin plasma concentrations in depressed patients, including assessments of the rhythm of prolactin release, have not provided clear, consistent findings. Further exploration of the precise mechanisms involved in serotonin-stimulated prolactin release should shed light on the pathophysiology of abnormal prolactin responsivity in depression, and by extension, the psychobiologic basis of depression.

Breast enlargement during chronic antidepressant therapy

Recent reports of mammoplasia during selective serotonin re-uptake inhibitor (SSRI) therapy suggested that this side effect may be more common than previously reported. We examined 59 women receiving > or = 2 months treatment with an SSRI or venlafaxine for changes in breast size in relation to menopausal status, weight gain and duration of drug therapy. Serum prolactin, estradiol and beta-hCG were also measured before and during treatment in a subgroup of patients. Twenty-three out of 59 patients (39%) reported some degree of mammoplasia. Significantly more SSRI vs. venlafaxine patients reported mammoplasia (p < 0.01). Eighty-four percent with mammoplasia had weight gain vs. 30% without mammoplasia (p < 0.001). The rate of mammoplasia was unrelated to age, menopausal status or duration of treatment. Serum prolactin increased during treatment in the paroxetine subgroup (p < 0.03). In conclusion, antidepressant-induced mammoplasia may be more common than previously expected.

5-HT brain function in affective disorder: d,l-fenfluramine-induced hormone release and clinical outcome in long-term lithium/carbamazepine prophylaxis

Prolactin (PRL) and Cortisol (CORT) responses to d,l-fenfluramine (FEN) challenge (60 mg) were examined in patients with affective disorders on two occasions under euthymic conditions: drug-free before admission to prophylactic treatment and after about 9 months of medication with lithium or carbamazepine. Response to treatment was assessed by a complex algorithm using continuous ratings in outpatient clinic over a period of 2 years. In general, treatment resulted in a delayed and diminished CORT release (n.s.); subgroup analysis revealed an attenuated CORT response (P < 0.05) in responders, whereas nonresponders showed no change in CORT secretion pattern except an enhanced CORT baseline value (P < 0.05). Cross-sectional comparison of responders with nonresponders under medication yielded a trend for greater CORT stimulation in nonresponders. This result was not affected by FEN/NorFEN or lithium/carbamazepine serum levels, baseline CORT values, age, sex, diagnostic distribution, number of appointments to the outpatient clinic or duration of medication at the time of FEN test session. Before onset of prophylactic medication responders and nonresponders could not be discriminated significantly regarding stimulated hormone release, probably due to the small sample size (n = 17). CORT response to FEN was increased in drugfree unipolar patients compared to bipolar (P < 0.05) and to schizoaffective patients (P < 0.1). In accordance with its well-documented presynaptic 5-HT-agonistic action lithium medication resulted in a significantly greater increase in CORT release than carbamazepine (P < 0.05). Evaluation of PRL stimulation showed patterns of secretion quite similar to those of CORT, without reaching statistical significance in most cases. Perhaps due to methodological differences in assessing treatment response, these data do not confirm former results, which supposed an enhanced 5-HT net activity in long-term prophylactic lithium treatment. Because of high interindividual variances of hormone parameters, the FEN-test procedure is not a useful tool for the prediction of therapeutical outcome in terms of clinical routine use. Relations of stimulated hormone response as a marker of central serotoninergic activity and clinical outcome are discussed.

Long-term antidepressant treatment restores clonidine's effect on growth hormone secretion in a genetic animal model of depression

We have recently demonstrated that various doses of clonidine failed to increase growth hormone (GH) in Fawn-hooded (FH) rats (a rat strain suggested to represent a genetic model of depression). In the present study, we investigated whether long-term antidepressant treatment might normalize clonidine's effect on GH secretion in male FH rats. Long-term (16 days) treatment with the tricyclic antidepressant, imipramine (5 mg/kg/day), the 5-HT uptake inhibiting antidepressant, fluoxetine (2.5 mg/kg/day), and the noradrenergic uptake inhibiting antidepressant, desipramine (5 mg/kg/day), accentuated clonidine's effect on GH levels. On the other hand, long-term treatment with the monoamine oxidase type-A inhibiting antidepressant, clorgyline (1 mg/kg/day) and the alpha 2-noradrenergic antagonists, yohimbine and 1-phenylpiperazine (1 mg/kg/day, each) did not modify clonidine's effect. These findings suggest enhancement of 5-HT2c receptor-mediated function following long-term treatment with uptake inhibiting antidepressants in a genetic animal model of depression.

The neuroendocrine response to d-fenfluramine in women with premenstrual depression

An oral d-fenfluramine neuroendocrine challenge test was carried out in 17 women with premenstrual depression and 14 controls, twice in each subject, once in the late luteal phase when mood change was likely to be at its worst (i.e. premenstrual) and once postmenstrually. Women weighing < 65 kg received 15 mg, the remainder 30 mg of d-fenfluramine. Although there was considerable individual variability, a substantial average prolactin response was observed in both groups but no phase, group or group x phase interaction effects were found. Oestradiol levels were significantly higher during the postmenstrual test but showed no relationship to prolactin response. Cortisol showed a more modest response to the drug and a phase effect was found, with cortisol increase being greater during the postmenstrual test in both groups. In contrast to earlier findings with i.v. L-tryptophan challenge, the present study failed to show any difference in neuroendocrine response between women with premenstrual depression and controls. These results suggest that 5-hydroxy-tryptophan2 receptor function is unaltered in perimenstrual mood disorder although other interpretations of the negative findings are discussed.

Prenatal stress prevents the desensitization of the corticosterone response to TFMPP by desmethylimipramine, but not by phenelzine, in adult male offspring

Gravid female rats were subjected to one hour of restraint stress twice daily or left undisturbed from days 14-21 of gestation. Adult 105-day old male non-stressed (NS) and stressed (S) offspring were treated once daily with saline, desipramine (DMI) (10 mg/kg, sc) or phenelzine (5.0 mg/kg, sc) for 14 days. Twenty-four hours after the last injection, animals were challenged with saline or 1-(m-trifluoromethylphenyl)piperazine (TFMPP) (5.0 mg/kg, sc), a serotonin1B/2C (5-HT1B/2C) agonist, and plasma prolactin and corticosterone concentrations were measured one hour later. As compared to acute saline administration, TFMPP significantly increased prolactin and corticosterone concentrations in all groups. In NS offspring, both DMI and phenelzine treatment augmented the prolactin response, but blunted the corticosterone response, to TFMPP. In S offspring, the prolactin response to TFMPP also was augmented by phenelzine or DMI treatment, whereas the corticosterone response to TFMPP was blunted during phenelzine treatment. However, DMI treatment was not able to desensitize the corticosterone response to TFMPP in the S rats. The results indicate the adaptive capacity of 5-HT systems to DMI administration was compromised in adult animals exposed to stress in utero.

Long-term antidepressant treatments alter 5-HT2A and 5-HT2C receptor-mediated hyperthermia in Fawn-Hooded rats

We have recently demonstrated that hyperthermia induced by 1-(2,5-dimethoxy-4-iodophenyl)-2-aminopropane (DOI) and m-chlorophenylpiperazine (m-CPP) are separately mediated by selective stimulation of 5-HT2A and 5-HT2C receptors, respectively in Wistar rats. Furthermore, hyperthermia induced by either DOI or m-CPP was found to be significantly less in Fawn-Hooded rats (a rat strain suggested to represent a genetic model of depression) relative to Wistar rats. In the present study, we studied the effects of long-term antidepressant treatments on DOI (2.5 mg/kg)-induced and m-CPP (2.5 mg/kg)-induced hyperthermia in male Fawn-Hooded rats. Long-term (21 days) treatment with the tricyclic antidepressants, imipramine or clomipramine (each 5 mg/kg/day), attenuated DOI-induced hyperthermia, while m-CPP-induced hyperthermia was accentuated. On the other hand, long-term (21 days) treatment with the monoamine oxidase type-A inhibiting antidepressant, clorgyline (1 mg/kg/day), did not modify m-CPP-induced hyperthermia, but significantly attenuated DOI-induced hyperthermia. These findings demonstrate that long-term antidepressant treatments alter 5-HT2A and 5-HT2C receptor-mediated hyperthermia in a genetic animal model of depression.

Myo-inositol attenuates the enhancement of the serotonin syndrome by lithium

Lithium elicits opposite effects on two behavioural syndromes in rats: enhancement of the 5-HT1A-linked serotonin syndrome and attenuation of the 5-HT2-linked wet dog shakes. The ability of intracerebroventricular (ICV) myo-inositol or forskolin to reverse the enhancement of the serotonin syndrome by lithium was tested in rats that were fed chronic dietary lithium or control diet and injected with the serotonin agonist 5-MeODMT (5-methoxy-N, N-dimethyltryptamine). Lithium enhanced the total serotonin syndrome score and particularly flat posture and tremor. Inositol, but not forskolin, mitigated the effects of lithium. Inositol was also injected in the lateral ventricle of rats pretreated with chronic dietary lithium or regular rat chow for 3 weeks and injected with carbidopa and L-5-hydroxytryptophan (5-HTP). Lithium attenuated wet dog shakes, but inositol had no significant effect on lithium-treated or control rats. These findings suggest that the enhancement of the serotonin syndrome by lithium may be related to lithium-induced inositol depletion.

Enhanced anorexic responses to m-chlorophenylpiperazine during lithium administration to fawn-hooded rats

In the present study, we investigated whether functional adaptational changes in the serotonergic neurotransmitter mechanisms regulating food intake following long-term lithium treatment in Fawn-Hooded rats (a rat strain suggested to represent a genetic model of depression) were different or similar to those previously observed in Wistar rats. Long-term (21-25 days) lithium treatment accentuated m-chlorophenylpiperazine (m-CPP, a 5-HT agonist) induced decreases in food intake. There was no significant difference in either brain m-CPP concentrations or hypothalamic norepinephrine, dopamine and 5-hydroxyindoleacetic acid concentrations between control and long-term lithium-treated rats following m-CPP. However, hypothalamic serotonin concentrations were significantly higher in long-term lithium-treated compared to saline-treated animals. This finding contrasts with our previous report demonstrating attenuation of m-CPP-induced anorexia in Wistar rats following similar long-term lithium treatment, and therefore suggests a differential adaptation in the serotonergic neurotransmitter mechanisms regulating food intake in a genetic animal model of depression.

Oral D-fenfluramine and neuroendocrine challenge: problems with the 30 mg dose in men

Ten healthy male volunteers of normal weight received 30 mg of D-fenfluramine, a putative selective releaser of 5-hydroxytryptamine (5-HT), and placebo by mouth in balanced order at a 1 week interval after a light breakfast. Blood was taken for estimation of plasma cortisol and prolactin, and the patients completed self rating scales for stress and arousal and rated themselves on visual analogue scales for mood, hunger and alertness at appropriate time points from 30 min before to 300 min after drug/placebo ingestion. There were no statistically discernible effects of D-fenfluramine on either hormone measures or subjective ratings. The failure to find effects may be due to a too low dose of D-fenfluramine and/or a lower sensitivity to the drug in men compared with women. More information is required on the dose/response relationship and drug absorption especially after food. However, the findings cast doubt on results already obtained employing this dose of the drug in studies that have included male subjects. Furthermore, the interpretation of earlier studies with D,L-fenfluramine at a dose of 60 mg is also made more uncertain by the failure to confirm that the more selective D-isomer produces equivalent effects.

Effect of lithium on the prolactin response to D-fenfluramine in healthy subjects

We assessed the effect of two regimens of lithium treatment (3 days and 2 weeks) on brain serotonin (5-HT) function in healthy subjects by measuring the prolactin (PRL) responses to the 5-HT releasing agent, d-fenfluramine (30 mg) before and after lithium administration. Neither regime of lithium treatment altered d-fenfluramine-induced PRL release. These results are in contrast to the facilitation produced by lithium of the PRL responses to the 5-HT precursor L-tryptophan. The data suggest that the ability of lithium to increase brain 5-HT neurotransmission in humans may depend on interactions with particular 5-HT receptor subtypes or specific mechanisms of 5-HT release.

Prolactin response to fenfluramine and placebo challenge following maintenance pharmacotherapy withdrawal in remitted depressed patients

Plasma prolactin (PRL) response to fenfluramine (FF) (60 mg orally) and placebo challenge was examined in eight remitted depressed patients who were withdrawn for 14 days from maintenance pharmacotherapy with clomipramine (CMI) plus lithium carbonate (Li) (n = 6) or Li alone (n = 2), 6 months after recovering from their major depressive episode. The patients had undergone identical FF challenge tests while drug free prior to commencing treatment with electroconvulsive therapy (ECT) (n = 4) or CMI supplemented with Li (n = 4) and after completing the above treatments. PRL response to FF in the remitted, drug-free state was significantly enhanced compared to the response prior to treatment (while depressed and drug-free) and not significantly different from the response following treatment with ECT (n = 4) or CMI plus Li (n = 4) 6 months before. Other work of a similar nature supports the view that enhanced serotonergically mediated hormone release in drug-withdrawn, remitted depressives, represents a long-standing change in central serotonergic responsiveness and not a continued effect of antidepressant treatment or a manifestation of medication withdrawal.