1
|
Schumacher MM, Santambrogio J. Cortisol and the Dexamethasone Suppression Test as a Biomarker for Melancholic Depression: A Narrative Review. J Pers Med 2023; 13:jpm13050837. [PMID: 37241007 DOI: 10.3390/jpm13050837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
The dexamethasone suppression test (DST) assesses the functionality of the HPA axis and can be regarded as the first potential biomarker in psychiatry. In 1981, a group of researchers at the University of Michigan published a groundbreaking paper regarding its use for diagnosing melancholic depression, reporting a diagnostic sensitivity of 67% and a specificity of 95%. While this study generated much enthusiasm and high expectations in the field of biological psychiatry, subsequent studies produced equivocal results, leading to the test being rejected by the American Psychiatric Association. The scientific reasons leading to the rise and fall of the DST are assessed in this review, suggestions are provided as to how the original test can be improved, and its potential applications in clinical psychiatry are discussed. An improved, standardized, and validated version of the DST would be a biologically meaningful and useful biomarker in psychiatry, providing a tool for clinicians caring for depressed patients in the areas of diagnosis, treatment, and prognosis, and predicting the risk of suicide. Additionally, such a test could be a crucial part in the generation of biologically homogenous patient cohorts, necessary for the successful development of new psychotropic medications.
Collapse
Affiliation(s)
| | - Jacopo Santambrogio
- Adele Bonolis AS.FRA. Onlus Foundation, 20854 Vedano al Lambro, Italy
- Presidio Corberi, ASST Brianza, 20812 Limbiate, Italy
| |
Collapse
|
2
|
Abstract
The aim of the current study was to compare the longitudinal clinical course of patients with a history of melancholic and nonmelancholic bipolar depression. Seventy-seven euthymic outpatients with bipolar disorder were categorized as melancholic or nonmelancholic through the clinician-rated Sydney Melancholia Prototype Index. Clinical course was assessed for a period longer than 48 months by time spent ill, density of affective episodes, severity and duration of depressive episodes, and time to depressive recurrence. The mean follow-up time was 69.05 months. Patients with melancholic depressions had more severe and longer depressive episodes during follow-up, whereas patients with nonmelancholic depressions had a shorter time to depressive recurrence and more subsyndromal depressive symptoms and affective instability. These findings highlight the heterogeneity inherent to the current construct of bipolar depression and position melancholia as an interesting target for comparison with nonmelancholic depressions in other external validators in the field of bipolar disorder.
Collapse
|
3
|
Bipolar Depression: A Historical Perspective of the Current Concept, with a Focus on Future Research. Harv Rev Psychiatry 2021; 29:351-360. [PMID: 34310532 DOI: 10.1097/hrp.0000000000000309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this narrative review is to trace the origin of the concept of bipolar depression and to expose some of its limitations. Bipolar depression is a broad clinical construct including experiences ranging from traditional melancholic and psychotic episodes ascribed to "manic-depressive insanity," to another heterogeneous group of depressive episodes originally described in the context of binary models of unipolar depression (e.g., psychogenic depression, neurotic depression). None of the available empirical evidence suggests, however, that these subsets of "bipolar" depression are equivalent in terms of clinical course, disability, family aggregation, and response to treatment, among other relevant diagnostic validators. Therefore, the validity of the current concept of bipolar depression should be a matter of concern. Here, we discuss some of the potential limitations that this broad construct might entail in terms of pathophysiological, clinical, and therapeutic aspects. Finally, we propose a clinical research program for bipolar depression in order to delimit diagnostic entities based on empirical data, with subsequent validation by laboratory or neuroimaging biomarkers. This process will then aid in the development of more specific treatments.
Collapse
|
4
|
Hein M, Lanquart JP, Loas G, Hubain P, Linkowski P. Alterations of neural network organisation during rapid eye movement sleep and slow-wave sleep in major depression: Implications for diagnosis, classification, and treatment. Psychiatry Res Neuroimaging 2019; 291:71-78. [PMID: 31416044 DOI: 10.1016/j.pscychresns.2019.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/08/2019] [Accepted: 08/07/2019] [Indexed: 01/15/2023]
Abstract
The aim of this study was to empirically investigate the network organisation during rapid eye movement sleep (REMS) and slow-wave sleep (SWS) using the effective connectivity measured using the Granger causality to identify new potential biomarkers for the diagnosis, classification, and potential favourable response to treatment in major depression. Polysomnographic data were analysed from 24 healthy individuals and 16 major depressed individuals recruited prospectively. To obtain the 19×19 connectivity matrix of all possible pairwise combinations of electrodes by the Granger causality method from our electroencephalographic data, we used the Toolbox MVGC multivariate Granger causality. The computation of network measures was realised by importing these connectivity matrices into the EEGNET Toolbox. Major depressed individuals (versus healthy individuals) and those with endogenous depression (versus those with neurotic depression) present alterations of small-world network organisation during REMS, whereas major depressed individuals with potential favourable response to electroconvulsive therapy (versus those with potential unfavourable response) have a less efficient small-world network organisation during SWS. Thus, alterations in network organisation during REMS could be biomarkers for the diagnosis and classification of major depressive episodes, whereas alterations of network organisation during SWS could be a biomarker to predict potential favourable response to treatment by electroconvulsive therapy.
Collapse
Affiliation(s)
- Matthieu Hein
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université Libre de Bruxelles, ULB, Brussels, Belgium.
| | - Jean-Pol Lanquart
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - Gwenolé Loas
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - Philippe Hubain
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - Paul Linkowski
- Erasme Hospital, Department of Psychiatry and Sleep Laboratory, Université Libre de Bruxelles, ULB, Brussels, Belgium
| |
Collapse
|
5
|
A meta-analysis of cognitive performance in melancholic versus non-melancholic unipolar depression. J Affect Disord 2016; 201:15-24. [PMID: 27156095 DOI: 10.1016/j.jad.2016.04.039] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recently there is increasing recognition of cognitive dysfunction as a core feature of Major Depressive Disorder (MDD). The goal of the current meta-analysis was to review and examine in detail the specific features of cognitive dysfunction in Melancholic (MEL) versus Non-Melancholic (NMEL) MDD. METHODS An electronic literature search was performed to find studies comparing cognitive performance in MEL versus NMEL. A meta-analysis of broad cognitive domains (processing speed, reasoning/problem solving, verbal learning, visual learning, attention/working memory) was conducted on all included studies (n=9). Sensitivity and meta-regression analyses were also conducted to detect possible effects of moderator variables (age, gender, education, symptom severity and presence of treatments). RESULTS MEL patients were older and more severly depressed than NMEL subjects. The MEL group was characterized by a worse cognitive performance in attention/working memory (ES=-0.31), visual learning (ES=-0.35) and reasoning/problem solving (ES=-0.46). No difference was detected in drug-free patients by sensitivity analyses. No effect was found for any of our moderators on the cognitive performance in MEL vs NMEL. CONCLUSION Our findings seem to support a moderate but specific effect of melancholic features in affecting the cognitive performance of MDD, in particular as regards visual learning and executive functions.
Collapse
|
6
|
|
7
|
Laryea G, Muglia L, Arnett M, Muglia LJ. Dissection of glucocorticoid receptor-mediated inhibition of the hypothalamic-pituitary-adrenal axis by gene targeting in mice. Front Neuroendocrinol 2015; 36:150-64. [PMID: 25256348 PMCID: PMC4342273 DOI: 10.1016/j.yfrne.2014.09.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 08/05/2014] [Accepted: 09/11/2014] [Indexed: 12/17/2022]
Abstract
Negative feedback regulation of glucocorticoid (GC) synthesis and secretion occurs through the function of glucocorticoid receptor (GR) at sites in the hypothalamic-pituitary-adrenal (HPA) axis, as well as in brain regions such as the hippocampus, prefrontal cortex, and sympathetic nervous system. This function of GRs in negative feedback coordinates basal glucocorticoid secretion and stress-induced increases in secretion that integrate GC production with the magnitude and duration of the stressor. This review describes the effects of GR loss along major sites of negative feedback including the entire brain, the paraventricular nucleus of the hypothalamus (PVN), and the pituitary. In genetic mouse models, we evaluate circadian regulation of the HPA axis, stress-stimulated neuroendocrine response and behavioral activity, as well as the integrated response of organism metabolism. Our analysis provides information on contributions of region-specific GR-mediated negative feedback to provide insight in understanding HPA axis dysregulation and the pathogenesis of psychiatric and metabolic disorders.
Collapse
Affiliation(s)
- Gloria Laryea
- Neuroscience Graduate Program, School of Medicine, Vanderbilt University, Nashville, TN, United States; Center for Preterm Birth Research, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, United States.
| | - Lisa Muglia
- Center for Preterm Birth Research, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, United States.
| | - Melinda Arnett
- Center for Preterm Birth Research, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, United States.
| | - Louis J Muglia
- Center for Preterm Birth Research, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, United States; Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, ML 7009, Cincinnati, OH 45229, United States.
| |
Collapse
|
8
|
Personalized medicine in Alzheimer's disease and depression. Contemp Clin Trials 2013; 36:616-23. [PMID: 23816492 DOI: 10.1016/j.cct.2013.06.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 06/14/2013] [Accepted: 06/20/2013] [Indexed: 12/17/2022]
Abstract
Latest research in the mental health field brings new hope to patients and promises to revolutionize the field of psychiatry. Personalized pharmacogenetic tests that aid in diagnosis and treatment choice are now becoming available for clinical practice. Amyloid beta peptide biomarkers in the cerebrospinal fluid of patients with Alzheimer's disease are now available. For the first time, radiologists are able to visualize amyloid plaques specific to Alzheimer's disease in live patients using Positron Emission Tomography-based tests approved by the FDA. A novel blood-based assay has been developed to aid in the diagnosis of depression based on activation of the HPA axis, metabolic, inflammatory and neurochemical pathways. Serotonin reuptake inhibitors have shown increased remission rates in specific ethnic subgroups and Cytochrome P450 gene polymorphisms can predict antidepressant tolerability. The latest research will help to eradicate "trial and error" prescription, ushering in the most personalized medicine to date. Like all major medical breakthroughs, integration of new algorithms and technologies requires sound science and time. But for many mentally ill patients, diagnosis and effective therapy cannot happen fast enough. This review will describe the newest diagnostic tests, treatments and clinical studies for the diagnosis and treatment of Alzheimer's disease and unipolar, major depressive disorder.
Collapse
Key Words
- 5-HTT
- 5-HTTLPR
- 5-Hydroxytryptamine Transporter gene
- AD
- ADNI
- ADRDA
- Alzheimer's Disease Neuroimaging Initiative
- Alzheimer's Disease and Related Disorders Association
- Alzheimer's disease
- Aβ40
- Aβ42
- CREB
- CSF
- CT
- CV
- CYP2C19
- CYP2D6
- CYP450
- Coefficient of Variation
- Computed Tomography
- Cytochrome P450
- Cytochrome P450 2C19
- Cytochrome P450 2D6
- DNA
- DSM
- DSM-IV-TR
- DSM-V
- Deoxyribonucleic Acid
- Depression
- Diagnostic and Statistical Manual of Mental Disorders
- Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition
- Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition-Text Revision
- ELISA
- Enzyme-Linked Immunosorbent Assay
- Epigenetics
- FDA
- FK506-binding protein
- FKBP5
- Food and Drug Administration
- GRIA
- GRIK
- HPA
- IL28RA
- KCNK2
- MDDScore
- MRI
- MTC
- Magnetic Resonance Imaging
- Major Depressive Disorder Score
- Methylthioninium Chloride
- NINCDS
- National Institute of Neurological and Communicative Disorders and Stroke
- P-tau181P
- PAPLN
- PET
- Personalized medicine
- Positron Emission Tomography
- QC
- Quality Control
- RDoC
- RNA
- Research Domain Criteria
- Ribonucleic Acid
- SSRI
- STAR*D
- Selective Serotonin Reuptake Inhibitor
- Sequenced Treatment Alternatives to Relieve Depression
- Serotonin-Transporter-Gene-Linked Polymorphic Region
- T-tau
- Tau phosphorylated at threonine 181
- VNTR
- WHO
- World Health Organization
- beta-amyloid, amino acids 1–40
- beta-amyloid, amino acids 1–42
- cAMP response element-binding protein
- cerebrospinal fluid
- glutamate receptor, ionotropic, AMPA
- glutamate receptor, ionotropic, kainate
- hypothalamic–pituitary–adrenal
- interleukin 28 receptor, alpha (interferon, lambda receptor)
- papilin, proteoglycan-like sulfated glycoprotein
- potassium channel, subfamily K, member 2
- total Tau
- variable nucleotide terminal repeat
Collapse
|
9
|
Assessment of a multi-assay, serum-based biological diagnostic test for major depressive disorder: a pilot and replication study. Mol Psychiatry 2013; 18:332-9. [PMID: 22158016 DOI: 10.1038/mp.2011.166] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite decades of intensive research, the development of a diagnostic test for major depressive disorder (MDD) had proven to be a formidable and elusive task, with all individual marker-based approaches yielding insufficient sensitivity and specificity for clinical use. In the present work, we examined the diagnostic performance of a multi-assay, serum-based test in two independent samples of patients with MDD. Serum levels of nine biomarkers (alpha1 antitrypsin, apolipoprotein CIII, brain-derived neurotrophic factor, cortisol, epidermal growth factor, myeloperoxidase, prolactin, resistin and soluble tumor necrosis factor alpha receptor type II) in peripheral blood were measured in two samples of MDD patients, and one of the non-depressed control subjects. Biomarkers measured were agreed upon a priori, and were selected on the basis of previous exploratory analyses in separate patient/control samples. Individual assay values were combined mathematically to yield an MDDScore. A 'positive' test, (consistent with the presence of MDD) was defined as an MDDScore of 50 or greater. For the Pilot Study, 36 MDD patients were recruited along with 43 non-depressed subjects. In this sample, the test demonstrated a sensitivity and specificity of 91.7% and 81.3%, respectively, in differentiating between the two groups. The Replication Study involved 34 MDD subjects, and yielded nearly identical sensitivity and specificity (91.1% and 81%, respectively). The results of the present study suggest that this test can differentiate MDD subjects from non-depressed controls with adequate sensitivity and specificity. Further research is needed to confirm the performance of the test across various age and ethnic groups, and in different clinical settings.
Collapse
|
10
|
Morris MC, Compas BE, Garber J. Relations among posttraumatic stress disorder, comorbid major depression, and HPA function: a systematic review and meta-analysis. Clin Psychol Rev 2012; 32:301-15. [PMID: 22459791 PMCID: PMC3340453 DOI: 10.1016/j.cpr.2012.02.002] [Citation(s) in RCA: 321] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 12/31/2011] [Accepted: 02/03/2012] [Indexed: 12/16/2022]
Abstract
Exposure to traumatic stress is associated with increased risk for posttraumatic stress disorder (PTSD) and alterations of hypothalamic-pituitary-adrenocortical (HPA) function. Research linking traumatic stress with HPA function in PTSD has been inconsistent, however, in part due to (a) the inclusion of trauma-exposed individuals without PTSD (TE) in control groups and (b) a failure to consider comorbid major depressive disorder (MDD) and moderating variables. This meta-analysis of 47 studies (123 effect sizes, N=6008 individuals) revealed that daily cortisol output was lower for PTSD (d=-.36, SE=.15, p=.008) and PTSD+MDD (d=-.65, SE=.25, p=.008) groups relative to no trauma controls (NTC); TE and NTC groups did not differ significantly from each other. Afternoon/evening cortisol was lower in TE (d=-.25, SE=.09, p=.007) and PTSD (d=-.27, SE=.12, p=.021) groups and higher in PTSD+MDD groups (d=.49, SE=.24, p=.041) relative to NTC. Post-DST cortisol levels were lower in PTSD (d=-.40, SE=.12, p<.001), PTSD+MDD (d=-.65, SE=.14, p<.001), and TE groups (d=-.53, SE=.14, p<.001) relative to NTC. HPA effect sizes were moderated by age, sex, time since index event, and developmental timing of trauma exposure. These findings suggest that enhanced HPA feedback function may be a marker of trauma-exposure rather than a specific mechanism of vulnerability for PTSD, whereas lower daily cortisol output may be associated with PTSD in particular.
Collapse
Affiliation(s)
- Matthew C Morris
- Center for Molecular and Behavioral Neuroscience, Meharry Medical College, 1005 Dr. D.B. Todd, Jr., Boulevard, Nashville, TN 37208, USA.
| | | | | |
Collapse
|
11
|
|
12
|
Harkness KL, Stewart JG, Wynne-Edwards KE. Cortisol reactivity to social stress in adolescents: role of depression severity and child maltreatment. Psychoneuroendocrinology 2011; 36:173-81. [PMID: 20688438 DOI: 10.1016/j.psyneuen.2010.07.006] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 05/14/2010] [Accepted: 07/06/2010] [Indexed: 12/27/2022]
Abstract
This study examined the hypothesis that depressed adolescents with a history of childhood maltreatment will show greater cortisol reactivity to psychological stress challenge than those without, and this relation will be moderated by level of depression severity. Seventy-one adolescents were exposed to the Trier Social Stress Test. Salivary cortisol was assessed at baseline, immediately before the challenge, after the challenge, and during an extended recovery period. Childhood maltreatment was assessed with a rigorous contextual interview and rating system. Adolescents with a history of maltreatment produced higher and more prolonged levels of cortisol in response to the challenge than did adolescents with no maltreatment, but only among those with a mild/moderate level of depression severity. Those with moderate/severe depression exhibited a blunted cortisol response regardless of child maltreatment history. These findings indicate that depression is a heterogeneous syndrome, and that both depression severity and child maltreatment history should be considered in studies examining biological stress reactivity.
Collapse
Affiliation(s)
- Kate L Harkness
- Department of Psychology, Queen's University, Kingston, ON, Canada.
| | | | | |
Collapse
|
13
|
Cerqueira JJ, Almeida OFX, Sousa N. The stressed prefrontal cortex. Left? Right! Brain Behav Immun 2008; 22:630-8. [PMID: 18281193 DOI: 10.1016/j.bbi.2008.01.005] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Revised: 01/04/2008] [Accepted: 01/05/2008] [Indexed: 11/26/2022] Open
Abstract
The prefrontal cortex (PFC) plays an important role in the integration of cognitive and affective behavior and regulating autonomic and neuroendocrine functions. This region of the brain, which may be considered analogous to the RAM memory of a computer, is important for translating stressful experience into adaptive behavior. The PFC responds to stress and modulates the response to stress through regulation of the hypothalamic paraventricular nucleus (PVN) which, in turn, controls sympathoadrenal and hypothalamic-pituitary-adrenal (HPA) activity. Interestingly, the latter convey the signals that link the CNS with the immune system. The present review highlights findings that contribute to elucidate the involvement of the PFC in the control of behavioral and neuroendocrine responses to chronic stress. It also considers the implications of these regulatory links for disorders of the nervous and immune systems.
Collapse
Affiliation(s)
- João J Cerqueira
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | | | | |
Collapse
|
14
|
Taylor MA, Fink M. Restoring melancholia in the classification of mood disorders. J Affect Disord 2008; 105:1-14. [PMID: 17659352 DOI: 10.1016/j.jad.2007.05.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 05/21/2007] [Accepted: 05/29/2007] [Indexed: 11/27/2022]
Abstract
The present DSM criteria for major depression poorly identify samples for treatment selection, prognosis, and assessments of pathophysiology. Melancholia, in contrast, is a disorder with definable clinical signs that can be verified by laboratory tests and treatment response. It identifies more specific populations than the present system and deserves individual identification in psychiatric classification. Its re-introduction will refine diagnosis, prognosis, treatment selection, and studies of pathophysiology of a large segment of the psychiatrically ill.
Collapse
Affiliation(s)
- Michael Alan Taylor
- Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, United States
| | | |
Collapse
|
15
|
Perlman WR, Webster MJ, Herman MM, Kleinman JE, Weickert CS. Age-related differences in glucocorticoid receptor mRNA levels in the human brain. Neurobiol Aging 2007; 28:447-58. [PMID: 16540204 DOI: 10.1016/j.neurobiolaging.2006.01.010] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Revised: 01/07/2006] [Accepted: 01/29/2006] [Indexed: 10/24/2022]
Abstract
Glucocorticoids and their receptors (GRs) are implicated in dynamic cognitive and neuroendocrine processes mediated by the prefrontal cortex and hippocampus. Additionally, a primary defect in forebrain GR levels can mimic symptoms of depression. We hypothesized that changes in GR mRNA levels may occur in the human brain across the life span thus positioning GR to differentially influence behavior and disease susceptibility. Following in situ hybridization with a riboprobe for human GR mRNA, we employed quantitative film autoradiography to measure expression levels in the prefrontal cortex and hippocampus in five age groups (infants, adolescents, young adults, adults, and aged) and in primary visual and visual association cortices for comparison. We detected a main effect of age group on cortical, but not hippocampal GR mRNA, with greater cortical expression in adolescents and adults than in infants or the aged. Increased GR mRNA in prefrontal cortex during adolescence and adulthood suggests that human GR-mediated forebrain regulation of cognition and the neuroendocrine stress response may be more salient during late maturation and at maturity.
Collapse
Affiliation(s)
- William R Perlman
- MiNDS Unit, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD 20892-1385, USA.
| | | | | | | | | |
Collapse
|
16
|
Assessment of HPA-axis function in posttraumatic stress disorder: pharmacological and non-pharmacological challenge tests, a review. J Psychiatr Res 2006; 40:550-67. [PMID: 16214171 DOI: 10.1016/j.jpsychires.2005.08.002] [Citation(s) in RCA: 332] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2005] [Revised: 07/15/2005] [Indexed: 01/03/2023]
Abstract
Posttraumatic stress disorder (PTSD) is typically accompanied by acute and chronic alterations in the stress response. These alterations have mostly been described in individuals under baseline conditions, but several studies have also used a challenge model to further assess the role of the hypothalamic-pituitary-adrenal (HPA) axis in the stress response. This paper reviews common methodology and research findings on HPA function in PTSD, and discusses the pathophysiological mechanisms underlying these findings. We reviewed the literature and selected all English-language, human subject, data driven, pharmacological and non-pharmacological challenge studies pertaining to the HPA axis, and in vitro leukocyte glucocorticoid receptor studies in adult PTSD subjects. Studies using a non-pharmacological stress paradigm (cognitive stress, trauma reminders) to stimulate the HPA axis showed an exaggerated cortisol response in PTSD. The most widely used pharmacological challenge with consistent results was the low dose dexamethasone-suppression test (DST). These DST studies showed enhanced cortisol suppression in subjects with PTSD. Different hypotheses have been purported to explain the alterations in HPA axis functioning in PTSD. The results of the reviewed challenge tests, however, did not exclusively support one of the hypothesized mechanisms. Further research assessing hormones at all levels of the HPA axis at both baseline and at challenge conditions with a proper stratification of study population, will be necessary for a better understanding of stress-responsivity on the level of the HPA axis in PTSD.
Collapse
|
17
|
|
18
|
Perlman WR, Webster MJ, Kleinman JE, Weickert CS. Reduced glucocorticoid and estrogen receptor alpha messenger ribonucleic acid levels in the amygdala of patients with major mental illness. Biol Psychiatry 2004; 56:844-52. [PMID: 15576061 DOI: 10.1016/j.biopsych.2004.09.006] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2004] [Revised: 09/07/2004] [Accepted: 09/08/2004] [Indexed: 11/15/2022]
Abstract
BACKGROUND The amygdala is a limbic structure involved in the stress response and the regulation of emotional behaviors, both of which are disrupted in patients with neuropsychiatric illnesses. Because glucocorticoids are mediators of the stress response, we hypothesized that glucocorticoid receptor (GR) messenger ribonucleic acid (mRNA) levels might be altered in the amygdala. We also hypothesized that estrogen receptor alpha (ERalpha) mRNA expression might be altered in the amygdala, on the basis of observed gender differences in mental illness. METHODS Using quantitative film autoradiography after in situ hybridization with human GR and ERalpha probes, we measured mRNA levels on adjacent amygdala sections in four groups (n = 15 each of subjects with schizophrenia, major depressive disorder, and bipolar disorder, and unaffected control subjects) provided by the Stanley Consortium. RESULTS We detected main effects of diagnosis and exposure to antidepressant medication on the levels of both mRNAs but no main effect of gender. Compared with control subjects, GR mRNA expression was reduced in the basolateral/lateral nuclei in schizophrenia and bipolar disorder. Estrogen receptor alpha mRNA levels were reduced in the basomedial nucleus in major depressive disorder and bipolar disorder. CONCLUSIONS Our results support and extend previous findings describing a pattern of steroid hormone mRNA alterations that differs depending on which brain region is being examined in a given mental illness.
Collapse
Affiliation(s)
- William R Perlman
- Clinical Brain Disorders Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, USA
| | | | | | | |
Collapse
|
19
|
Newport DJ, Heim C, Bonsall R, Miller AH, Nemeroff CB. Pituitary-adrenal responses to standard and low-dose dexamethasone suppression tests in adult survivors of child abuse. Biol Psychiatry 2004; 55:10-20. [PMID: 14706420 DOI: 10.1016/s0006-3223(03)00692-9] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Previous studies indicate that adverse childhood events are associated with persistent changes in corticotropin-releasing factor neuronal systems. Our aim was to determine whether altered glucocorticoid feedback mediates the neuroendocrine sequelae of childhood trauma. METHODS Standard and low-dose dexamethasone suppression tests (DST) were performed in women with a history of child abuse (n=19), child abuse and major depression (n=16), major depression and no childhood trauma (n=10), and no history of mental illness or childhood trauma (n=19). Secondary analysis with posttraumatic stress disorder (PTSD) as the organizing diagnosis was also conducted. RESULTS In the low-dose DST, depressed women with a history of abuse exhibited greater cortisol suppression than any comparator group and greater corticotropin suppression than healthy volunteers or nondepressed abuse survivors. There were no differences between nondepressed abuse survivors and healthy volunteers in the low-dose DST or between any subject groups in the standard DST. The PTSD analysis produced similar results. CONCLUSIONS Cortisol supersuppression is evident in psychiatrically ill trauma survivors, but not in nondepressed abuse survivors, indicating that enhanced glucocorticoid feedback is not an invariable consequence of childhood trauma but is more related to the resultant psychiatric illness in traumatized individuals.
Collapse
Affiliation(s)
- D Jeffrey Newport
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia 30322, USA
| | | | | | | | | |
Collapse
|
20
|
Webster MJ, Knable MB, O'Grady J, Orthmann J, Weickert CS. Regional specificity of brain glucocorticoid receptor mRNA alterations in subjects with schizophrenia and mood disorders. Mol Psychiatry 2003; 7:985-94, 924. [PMID: 12399952 DOI: 10.1038/sj.mp.4001139] [Citation(s) in RCA: 292] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2001] [Revised: 12/07/2001] [Accepted: 03/05/2002] [Indexed: 01/24/2023]
Abstract
Glucocorticoid receptors (GR) mediate the direct effects of glucocorticoids released in response to stress and the regulation of the hypothalamic-pituitary-adrenocortical (HPA) system through a negative feedback mechanism. Individuals with major mental illness, who often exhibit hypercortisolemia, may have down-regulated levels of GR mRNA. In situ hybridization for GR mRNA was performed on post-mortem specimens from patients suffering from depression, bipolar disorder, schizophrenia and from normal controls (n = 15 per group). In frontal cortex, GR mRNA levels were decreased in layers III-VI in the subjects with depression and schizophrenia. In inferior temporal cortex, GR mRNA levels were decreased in layer IV in all three diagnostic groups. In the entorhinal cortex, GR mRNA levels were decreased in layers III and VI in the bipolar group. In hippocampus, GR mRNA levels were reduced in the dentate gyrus, CA(4), CA(3) and CA(1) in the schizophrenia group. In the subiculum, GR mRNA levels were reduced in the bipolar group. These results suggest that GR dysregulation occurs in all three major psychiatric illnesses with variability according to anatomical site. The severity and heterogeneity of this reduction may underlie some of the clinical heterogeneity seen in these disorders.
Collapse
Affiliation(s)
- M J Webster
- Stanley Foundation Laboratory of Brain Research, Department of Psychiatry, Uniformed Services University of Health Sciences, Bethesda, MD 20814-4799, USA.
| | | | | | | | | |
Collapse
|
21
|
Abstract
BACKGROUND Previous studies have shown wide variation in plasma dexamethasone (DEX) concentrations following a standard 1-mg dexamethasone suppression test (DST), and significantly lower DEX concentrations in DST nonsuppressors compared with suppressors, suggesting that DEX pharmacokinetics/bioavailability is an important variable associated with DST nonsuppression. METHODS To determine the effect of plasma DEX levels on the DST in Chinese depressives, we measured plasma DEX and post-DEX cortisol levels at 4:00 PM in a group of 50 depressed outpatients, 28 anxiety outpatients, and 33 normal subjects during the course of 1-mg oral overnight DST. RESULTS We found a significant difference in the plasma DEX levels between DST nonsuppressors and suppressors in the depression group and overall subject population, and a significant negative correlation between the plasma DEX and cortisol levels in the depression, anxiety, and total groups. Within a DEX "window", the DST performance was enhanced, whereas the relationships between plasma DEX and post-DEX cortisol levels remained equally strong. CONCLUSIONS Our findings support a relationship between plasma DEX and post-DEX cortisol levels, a relationship that might be superimposed on the hypothalamic-pituitary-adrenal axis. Comparing our "window" range with those of previous studies, we suggest that Chinese depressives may have lower limits of plasma DEX window, and that ethnicity may be an intervening variable in both DST response and pharmacokinetics of DEX.
Collapse
Affiliation(s)
- I S Shiah
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | | | | |
Collapse
|
22
|
Akil H, Haskett RF, Young EA, Grunhaus L, Kotun J, Weinberg V, Greden J, Watson SJ. Multiple HPA profiles in endogenous depression: effect of age and sex on cortisol and beta-endorphin. Biol Psychiatry 1993; 33:73-85. [PMID: 8382535 DOI: 10.1016/0006-3223(93)90305-w] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We have previously shown that a number of depressed patients demonstrated a failure to suppress corticotrophic secretion, as measured by beta-Endorphin/beta-Lipotropin (beta-End/beta-LPH levels), following dexamethasone challenge. The current study is an extension and replication of these findings, as well as an analysis of some of the biological variables which may contribute to the variance in beta-End/beta-LPH nonsuppression. We continue to observe a high rate of beta-End/beta-LPH nonsuppression in depressed patients following dexamethasone; this escape at the pituitary level is even observed in a number of patients who demonstrate normal cortisol suppression. Advancing age, particularly in women, led to higher baseline cortisol, lower baseline beta-End/beta-LPH, and a greater likelihood of being a nonsuppressor on one or both measures.
Collapse
Affiliation(s)
- H Akil
- Department of Psychiatry, University of Michigan, Ann Arbor 48109-0720
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Keitner GI, Ryan CE, Kohn R, Miller IW, Norman WH, Brown WA. Age and the dexamethasone suppression test: results from a broad unselected patient population. Psychiatry Res 1992; 44:9-20. [PMID: 1461951 DOI: 10.1016/0165-1781(92)90065-b] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We examined the relationship between age and postdexamethasone serum cortisol concentration in 676 psychiatric inpatients with a variety of DSM-III diagnoses. Regardless of diagnosis, patients 65 years and older had significantly higher nonsuppression rates than those below age 65 (64% vs. 34%). The correlation between age and cortisol level was moderate, but significant. Aging is associated with increasing nonsuppression rates to dexamethasone, and this change is augmented by an affective disorder diagnosis. Levels of nonsuppression and age-cortisol correlations vary depending on dose of dexamethasone, diagnosis, and gender.
Collapse
Affiliation(s)
- G I Keitner
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI
| | | | | | | | | | | |
Collapse
|
24
|
Gupta SK, Ritchie JC, Ellinwood EH, Wiedemann K, Holsboer F. Modeling the pharmacokinetics and pharmacodynamics of dexamethasone in depressed patients. Eur J Clin Pharmacol 1992; 43:51-5. [PMID: 1505609 DOI: 10.1007/bf02280754] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
Changes in time course effected by cortisol suppression and the relationship of these changes to the plasma dexamethasone concentration of suppressor and non-suppressor patients are described in this report on a combined pharmacokinetic-pharmacodynamic model. Thirteen depressed patients (8 suppressors and 5 non-suppressors) received an intravenous dose (1.5 mg) of dexamethasone. The drug-induced effect changes are found to lag behind, in time, the plasma drug level changes. To accurately relate the temporal relationship of effect changes to plasma dexamethasone levels, a pharmacodynamic model (sigmoid-Emax) was combined with a pharmacokinetic model that incorporated an effect compartment. The magnitude of the time-lag was quantified by the half-time of equilibration between concentrations in the hypothetical effect compartment and the plasma dexamethasone levels (t1/2keo). The t1/2keo of the nonsuppressing group was about 50% of that of the suppressing group, indicating that for a given plasma level the onset and termination of effect for the nonsuppressing group is about two times more rapid than for the suppressing group. Moreover, the model can estimate the effect-site concentration that causes one-half of the maximal predicted effect (EC50), a measure of an individual's sensitivity to dexamethasone. The receptor sensitivity (as determined from the EC50 ratio) of the suppressing group was about twice that of the nonsuppressing group.
Collapse
Affiliation(s)
- S K Gupta
- Department of Psychiatry, Duke University Medical Center, Durham, NC
| | | | | | | | | |
Collapse
|
25
|
Abstract
Dysthymic disorder (DD) is a chronic subsyndromal depressive condition that has generated increasing interest since its formal introduction into the psychiatric nomenclature in 1980. Although DD was included among the affective disorders in DSM-III, this classification was controversial. Some clinical and family studies support an association between DD and major depression disorder (MDD), but there has been little additional research firmly establishing the diagnostic validity of DD or clarifying its relation to MDD and to personality disorders. In this article, the literature on the biology of DD is reviewed. Studies of rapid eye movement (REM) latency, electrodermal activity, and the thyroid axis show similarities between DD and MDD, but the findings are mixed. Other investigations, including the Dexamethasone Suppression Test (DST), catecholamines, and several other electroencephalogram (EEG) sleep variables, show more consistent differences between DD and MDD. These findings suggest that DD manifests primarily trait characteristics of depression, thus differentiating it from the state characteristics of MDD. The methodological problems and implications of these studies, and suggestions for future research, are discussed.
Collapse
Affiliation(s)
- R H Howland
- Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh School of Medicine, PA 15213
| | | |
Collapse
|
26
|
Abstract
In this psychopathological study, the subjective experience of anxiety was investigated in depressive patients by means of a semistructured interview. Both International Classification of Diseases-9 (ICD-9) diagnostic criteria (melancholia or neurotic depression; N = 160 or 93, respectively) and the DSM-III classification system (major depressive episode with or without "melancholia"; N = 63 or 153, respectively) were applied. Anxiety can be identified in virtually all patients examined. In contrast, the themes of anxiety are subject to substantial differences. There is a statistically significant correlation between the extent of anxiety and the severity of depression by the Hamilton Depression Scale (Ham-D). However, a distinction between anxiety and depression is possible in the majority of cases if the contents of anxiety are taken into account.
Collapse
Affiliation(s)
- H Kuhs
- Department of Psychiatry, University of Münster, Germany
| |
Collapse
|
27
|
Costello CG, Scott CB. Primary and secondary depression: a review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1991; 36:210-7. [PMID: 2059939 DOI: 10.1177/070674379103600310] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- C G Costello
- Department of Psychology, University of Calgary, Alberta
| | | |
Collapse
|
28
|
Mitchell P, Smythe G, Parker G, Wilhelm K, Hickie I, Brodaty H, Boyce P. Hormonal responses to fenfluramine in depressive subtypes. Br J Psychiatry 1990; 157:551-7. [PMID: 2131137 DOI: 10.1192/bjp.157.4.551] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In order to study putative differences in central neurotransmitter function in depressive subtypes, serum cortisol and prolactin responses to the putative serotonin agonist fenfluramine were examined in 30 subjects with major depression. Patients with endogenous depression (melancholia) as defined by each of ICD-9, DSM-III, RDC and Newcastle scale demonstrated a reduced prolactin response to 60 mg oral fenfluramine when compared with non-endogenous subjects. This was independent of either prolactin or cortisol baseline levels, and indicates that there are differences in brain neurotransmitter function in the endogenous and non-endogenous subtypes of depression. Basal prolactin levels were reduced in bipolar compared with unipolar subjects, and delusional compared with non-delusional patients, although there were no differences in the prolactin responses to fenfluramine between these subgroups. Basal cortisol levels and cortisol response to fenfluramine did not distinguish between any of the subtypes.
Collapse
Affiliation(s)
- P Mitchell
- School of Psychiatry, University of New South Wales, Sydney
| | | | | | | | | | | | | |
Collapse
|
29
|
Vogel G, Neill D, Hagler M, Kors D. A new animal model of endogenous depression: a summary of present findings. Neurosci Biobehav Rev 1990; 14:85-91. [PMID: 2183099 DOI: 10.1016/s0149-7634(05)80164-2] [Citation(s) in RCA: 158] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In 1982 our laboratory proposed a new animal model of endogenous depression. The proposal was that in rats, neonatally administered clomipramine (CLI) will produce adult animals that model endogenous depression. We summarize here several tests of the validity of the model. Results were that after neonatal CLI, adult male rats showed behavioral abnormalities of the human disorder: decreased sexual, aggressive, and intracranial self-stimulation activities, as well as motor hyperactivity in a stressful situation. Preliminary evidence suggested that behavioral abnormalities in rats (sexual, aggressive, and motor) briefly treated with antidepressant treatments (imipramine, REM sleep deprivation) begin to normalize. Lastly, after neonatal CLI, the adult rats showed REM sleep abnormalities of endogenous depression, viz, low REM latency, frequent sleep onset REM periods, and abnormal temporal course of REM rebound after REM sleep deprivation. These results supported the hypothesis that in rats neonatal CLI produced adult animals that modelled endogenous depression.
Collapse
Affiliation(s)
- G Vogel
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA 30306
| | | | | | | |
Collapse
|
30
|
Ritchie JC, Belkin BM, Krishnan KR, Nemeroff CB, Carroll BJ. Plasma dexamethasone concentrations and the dexamethasone suppression test. Biol Psychiatry 1990; 27:159-73. [PMID: 2294980 DOI: 10.1016/0006-3223(90)90646-j] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Altered bioavailability or altered pharmacokinetics of dexamethasone (dex) may contribute to a positive Dexamethasone Suppression Test (DST) in psychiatric patients. We measured plasma dex and plasma cortisol concentrations in 32 patients with primary major depressive disorder (MDD), 14 patients with other psychiatric disorders, and 16 normal controls. Cortisol was measured by the competitive protein binding (CPB) assay and dex by RIA (IgG Corp.). Additionally, cortisol was measured by a fluorescent polarization immunoassay (FPIA) available on the Abbott TDx analyzer in an attempt to validate this method for use in the DST. The agreement between FPIA and CPB cortisol results was excellent. Depressed nonsuppressors, by definition, had significantly higher mean plasma cortisol concentrations than depressed suppressors, psychiatric controls, and normal volunteers at 8:00 AM, 3:00 PM, and 10:00 PM postdex. When DST nonsuppressors and suppressors were compared regardless of diagnostic group, plasma dex concentrations were significantly lower (p less than 0.01) in the DST nonsuppressors. There was a significant negative correlation between plasma cortisol levels and plasma dex levels across all subjects at 8:00 AM (r = -0.365, n = 44, p less than 0.05). When the subjects were sorted by diagnostic category, there was a strong, but not statistically significant, trend toward lower plasma dex concentrations in the melancholic nonsuppressors versus the melancholic suppressors and between the psychiatric control non-suppressors and the corresponding suppressor group. These relationships disappeared when we restricted our analyses to an empirically derived middle range of plasma dex concentrations within which the DST results were considered to be valid. We conclude that bioavailability or pharmacokinetics of dex may significantly contribute to DST results. Further investigation is needed to determine whether or not the quantification of dex and its metabolites and their determination at which specific timepoints during the DST will enhance the predictive or interpretive value of the DST in psychiatric patients.
Collapse
Affiliation(s)
- J C Ritchie
- Department of Psychiatry, Duke University, Durham, NC 27710
| | | | | | | | | |
Collapse
|
31
|
Valdés M, García L, Treserra J, de Pablo J, de Flores T. Psychogenic pain and depressive disorders: an empirical study. J Affect Disord 1989; 16:21-5. [PMID: 2521646 DOI: 10.1016/0165-0327(89)90050-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A sample of 31 patients of both sexes suffering from psychogenic pain disorder (DSM-III) were studied in order to test if their clinical and biological features as well as their response to antidepressant treatment support the hypothesis that relates this syndrome to depressive disorders. Biological variables were basal cortisol and dexamethasone suppression test, and treatment consisted of daily administration of 100-175 mg of imipramine for a period of 5 months. Mood state was evaluated by the Hamilton scale and pain was assessed through visual analogue scales immediately before starting treatment and 3 months later. There was a low prevalence of non-suppressors (9.6%) and all patients significantly improved in mood and pain after antidepressant treatment. However, general results support both the hypothesis linking psychogenic pain to depressive disorders and its possible understanding in terms of failed adjustment processes.
Collapse
Affiliation(s)
- M Valdés
- Department of Psychiatry and Medical Psychology, School of Medicine, University of Barcelona, Spain
| | | | | | | | | |
Collapse
|
32
|
Abstract
Thirty depressed inpatients aged 7-16 yrs were compared for salivary hypercortisolism with a control group of 16 inpatients of mixed diagnosis matched for age and sex. Four cortisol samples were taken over a 48 hr period: 8 a.m. and 11 p.m. on the first day; then, with 1 mg of dexamethasone given immediately after the second sample, at 4 p.m. and 11 p.m. on the second day. All except the 8 a.m. value were significantly greater (P less than 0.03) in the depressed group. A 4 nmol/l cutoff for the 4 p.m. sample gave 48% sensitivity and 91% specificity for discriminating depressed cases (P = 0.03). The results indicate that the salivary method for estimating cortisol levels in children and adolescents with depression warrants further study.
Collapse
Affiliation(s)
- D M Foreman
- Department of Postgraduate Medicine, University of Keele, U.K
| | | |
Collapse
|
33
|
Watkins S, Harris B, Cook N, Thomas R, Riad-Fahmy D. Performance of the dexamethasone suppression test in depressive illness according to ICD and DSM-III classification systems. Br J Psychiatry 1988; 152:554-8. [PMID: 3167410 DOI: 10.1192/bjp.152.4.554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The performance of the dexamethasone suppression test was assessed in 90 consecutive admissions with a diagnosis of depression, categorised according to two classification systems (DSM-III and ICD-9). Non-suppression was found in most of the diagnostic categories, but there was a highly significant association with the DSM-III classification 'major depressive episode with melancholia' (52%) in comparison with the ICD group 'manic-depressive illness-depressed' (29%).
Collapse
|
34
|
Abstract
The blood counts of 80 patients with depression were examined (50 unipolar, 30 bipolar). Many had reduced numbers of circulating lymphocytes. This abnormality was more common in the unipolar group (52%) than in the bipolar group (27%). When those patients with an abnormal dexamethasone suppression test response in both groups were compared, the relative and absolute lymphocyte counts were significantly lower in unipolars. Although cortisol hypersecretion may reduce lymphocyte numbers it is not yet clear whether the findings can be satisfactorily explained in this way.
Collapse
|
35
|
Evans DL, Nemeroff CB. The clinical use of the dexamethasone suppression test in DSM-III affective disorders: correlation with the severe depressive subtypes of melancholia and psychosis. J Psychiatr Res 1987; 21:185-94. [PMID: 3585807 DOI: 10.1016/0022-3956(87)90018-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The utility of the dexamethasone suppression test (DST) as an adjunct in the diagnosis of major depression remains controversial. While the research utility of the DST has been confirmed, the clinical utility has been questioned. We studied 166 consecutive admissions to a general, non-research unit who either met DSM-III criteria for major depression of had depressive symptoms associated with other DSM-III diagnoses. Using a 5 micrograms/dl criterion, non-suppression of serum cortisol after dexamethasone was observed in 63% of patients with DSM-III major depression. Patients with the most severe subtypes of major depression (melancholia and psychosis) showed both the highest rate of serum cortisol non-suppression and the highest post-DST serum cortisol concentrations. These findings from the clinical setting where the test, if found useful, will be used ultimately suggest that the DST is both sensitive and specific for the diagnosis of major depression. Future research will determine the potential role of the DST as an adjunct to the clinical assessment and management of patients with major affective disorder.
Collapse
|
36
|
Kraemer HC. The methodological and statistical evaluation of medical tests: the dexamethasone suppression test in psychiatry. Psychoneuroendocrinology 1987; 12:411-27. [PMID: 3327077 DOI: 10.1016/0306-4530(87)90076-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Presented herein is a step-by-step discussion of the statistical evaluation of a medical test, using the literature concerning the DST to provide good and bad examples of its implementations. Specific topics of concern include: (1) conceptualization issues such as the definition of a test and its purpose; (2) implementation issues such as sampling and blindness; (3) analytic issues such as choice of statistical measures of quality; (4) issues of correct and realistic interpretation of results; and, finally (5) cost-benefit issues.
Collapse
Affiliation(s)
- H C Kraemer
- Department of Psychiatry and Behavioral Sciences, Stanford University, California 94305
| |
Collapse
|
37
|
Stangl D, Pfohl B, Zimmerman M, Coryell W, Corenthal C. The relationship between age and post-dexamethasone cortisol: a test of three hypotheses. J Affect Disord 1986; 11:185-97. [PMID: 2951406 DOI: 10.1016/0165-0327(86)90069-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Previous studies report that DST nonsuppressors are older than normal suppressors. Data are presented on 188 primary unipolar major depressive inpatients and 35 healthy controls. In males, age appeared to correlate positively with post-dexamethasone cortisols in depressed patients and normal controls, although mean levels were higher in depressives. Female controls showed no consistent relationship between age and post-dexamethasone cortisol. A positive relationship did exist for depressed women. However, the association disappeared when age-of-onset was entered into the model, suggesting that in females early onset may identify a subtype of depression with normal DST suppression.
Collapse
|
38
|
Abstract
In 17 depressed patients with initially abnormal results on the dexamethasone suppression test (DST), serial plasma samples for the determination of cortisol concentrations were taken every 10 days, following overnight dexamethasone administration at 11 p.m. Severity ratings were repeated on the days of blood sampling. There was a gradual normalization of the DST and progressive clinical improvement during selective antidepressant therapy. The DST was closely related (r = 0.573, P less than 0.005) to the patients' clinical mood level during the depressive episode. At the point where normalization of the DST occurred, the patients were still moderately severely ill. DST conversion occurred early in the treatment, i.e. after 23.9 (+/- 15.1) days, and preceded symptomatic improvement by 24.5 (+/- 18.1) days. Normalization of the DST was a predictor (r = 0.691, P less than 0.005) of the time of clinical improvement, but not of clinical recovery. The test was a biological discriminator between severe and less severe depressions. The time of symptomatic improvement (r = 0.505, P less than 0.05), but not of biological remission, depended on age; severe depressions lasted longer in the elderly patients.
Collapse
|
39
|
Abstract
Fifty-six depressive patients underwent a low-dose (0.5-mg) Dexamethasone Suppression Test (DST). Blood samples for cortisol assay were obtained twice on day 2, and the plots of the sum of the two cortisol values formed two groups, consisting, respectively, of suppressors and nonsuppressors. Nineteen (73.1%) of 26 patients with major depressive episodes (MDE) showed nonsuppression, as well as 12 of 15 MDE patients with melancholia, 3 of 3 with psychotic features, 3 of 4 with bipolar or atypical bipolar affective disorder, and 1 of 4 without melancholia. The specificity, calculated from the data of 53 patients (excluding 3 who were already known to be false-positive on the DST) was 85.2%, and the diagnostic confidence was 82.6%. The DSTs were reexamined in the 11 MDE patients showing nonsuppression, 8 of whom became suppressors with remission of the depressive symptoms.
Collapse
|
40
|
Zimmerman M, Coryell W. Dysfunctional Attitudes in endogenous and nonendogenous depressed inpatients. COGNITIVE THERAPY AND RESEARCH 1986. [DOI: 10.1007/bf01173470] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
41
|
Grunhaus L, Rabin D, Harel Y, Greden JF, Feinberg M, Hermann R. Simultaneous panic and depressive disorders: clinical and sleep EEG correlates. Psychiatry Res 1986; 17:251-9. [PMID: 3714908 DOI: 10.1016/0165-1781(86)90072-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Panic and depressive symptoms occur simultaneously in many depressed patients. To study the frequency of this association and to determine whether patients with simultaneous panic and major depression differed from those with only major depressive disorder (MDD) in clinical features and in sleep electroencephalographic (EEG) variables, we evaluated a total sample of 336 patients with MDD. Fifty-eight (17%) had both panic and MDD; 50 had complete data and were matched for age and severity of illness with other patients having only MDD. Patients with simultaneous panic and depression had significantly higher ratings for psychic and somatic anxiety, and rapid eye movement (REM) latencies approximating normal values. Patients with only MDD (without panic disorder) rated significantly higher in guilt feelings and had shorter REM latencies. Our results suggest that the simultaneous occurrence of panic and depression is relatively frequent, is accompanied by differences in sleep EEG variables, and may have implications for treatment.
Collapse
|
42
|
|
43
|
Zimmerman SL, Ostrow DG. Differentiating DST suppressors from nonsuppressors: a discriminant function analysis of clinical symptoms. Psychiatry Res 1986; 17:182-93. [PMID: 3704026 DOI: 10.1016/0165-1781(86)90046-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Ninety-seven patients who presented with depressive complaints were studied in an attempt to cross-validate a statistical model that uses items from the Hamilton Rating Scale for Depression (HRSD) to differentiate dexamethasone suppressors from nonsuppressors. Two split-sample discriminant function analyses (DFA) of data from this sample showed little agreement with either the original model or with each other. Accuracy of classification was acceptable for the derivation samples but was no better than chance for the validation samples. No single HRSD item was identified by all three DFAs as distinguishing between groups. The HRSD does not appear to be a reliable instrument for clinically distinguishing dexamethasone suppressors from nonsuppressors.
Collapse
|
44
|
Voigt KH, Bossert S, Bretschneider S, Bliestle A, Fehm HL. Disturbed cortisol secretion in man: contrasting Cushing's disease and endogenous depression. Psychiatry Res 1985; 15:341-50. [PMID: 2999859 DOI: 10.1016/0165-1781(85)90071-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A disturbed regulation of cortisol secretion is the principal pathology of Cushing's disease and is also the most widely reported neuroendocrine dysfunction in endogenous depression. Because additional clinical signs in both diseases indicated a hypothetical common pathway, we examined 17 patients suffering from Cushing's disease, following a protocol identical to that used in depressed patients (e.g., Hamilton Rating Scale for Depression, self-rating scales, and a clinical interview). Affective disorders, frequently observed in patients with Cushing's disease, were undetectable after surgical treatment (adrenalectomy or microadenomectomy of hypercortisolism). This was an unexpected result, since we found that recovered patients were still characterized by a disturbance of glucocorticoid feedback regulation, probably acting at the hypothalamic level. Our results, as well as numerous reports from others, failed to support the hypothesis that an impaired regulation of cortisol is directly linked to depressive illness.
Collapse
|
45
|
Abstract
Biological research in depression has concentrated on 'endogenous' depressions and over the past 30 years has been guided by the amine theory. Neuroendocrine abnormalities in depression have been reported for over 20 years and include changes in the hypothalamic-pituitary-adrenal and thyroid axes, in growth hormone and prolactin secretion. As neurotransmitters regulate neuroendocrine secretion, inter-relationships between neurochemical and neuroendocrine abnormalities may provide a window for understanding the pathophysiology of depression. The availability of these biological markers for depression opens new possibilities for research in psychiatric diagnosis and for management.
Collapse
Affiliation(s)
- Peter R. Joyce
- Sunnyside Hospital, Christ church, New Zealand
- Psychological Medicine, Christchurch Clinical School of Medicine
| |
Collapse
|
46
|
Zimmerman M, Stangl D, Coryell W. The research diagnostic criteria for endogenous depression and the dexamethasone suppression test: a discriminant function analysis. Psychiatry Res 1985; 14:197-208. [PMID: 3858892 DOI: 10.1016/0165-1781(85)90014-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Most studies examining the validity of the Research Diagnostic Criteria (RDC) for endogenous depression have been negative. RDC endogenous subtyping is not associated with short- or long-term treatment outcome, family history of affective disorder, or premorbid personality disorder. Studies examining its relationship to the dexamethasone suppression test (DST) are mixed; half report a significant association, and half do not. The RDC endogenous diagnosis may lack validity either because the criteria do not represent, or are not specific to, the endogenous subtype, or the diagnostic algorithm is inappropriate. In the present study, we conduct a discriminant function analysis on the 10 criteria for the endogenous subtype using DST results as the independent variable. We constructed a new diagnostic algorithm and cross-validated it on a second patient sample. In both samples the discriminant function classification was significantly associated with DST results, whereas the RDC algorithm was not.
Collapse
|
47
|
Schlechte JA, Sherman B. Lymphocyte glucocorticoid receptor binding in depressed patients with hypercortisolemia. Psychoneuroendocrinology 1985; 10:469-74. [PMID: 4089086 DOI: 10.1016/0306-4530(85)90086-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Despite elevated levels of serum and urinary cortisol, patients with depressive illness manifest none of the clinical stigmata of glucocorticoid excess. This hypercortisolemia in the absence of clinical effects suggests a state of hormone resistance and could be mediated by alterations in the glucocorticoid receptor. Earlier studies have shown that small doses of glucocorticoids cause a decrease in glucocorticoid receptor binding in normal human lymphocytes. White cells from depressed patients with significant hypercortisolemia would be expected to show a similar change in receptor concentration if peripheral tissues are adequately exposed to and sensitive to the hormone. In this study we compared the binding of [3H]dexamethasone to lymphocytes from normal subjects and depressed patients with hypercortisolemia. Lymphocytes from normal subjects had a mean receptor concentration of 10.2 +/- 0.66 fm/10(6) cells (S.E.M.) and a dissociation constant of 4.8 +/- 0.47 nM. Lymphocytes from depressed patients with abnormal 0800 h serum cortisol after dexamethasone had a mean receptor concentration of 8.8 +/- 0.75 fm/10(6) cells, which was not significantly different from that in lymphocytes from normal subjects or from depressed subjects with normal post-dexamethasone cortisol levels (9.4 +/- 0.95 fm/10(6) cells). Lymphocytes from depressed patients with elevated urinary free cortisol excretion (UFC) also had normal receptor concentration and binding affinity for dexamethasone. The lack of a change in lymphocyte glucocorticoid receptor concentration in the presence of cortisol excess suggests the possibility that hypercortisolemia in depressive illness represents a state of peripheral glucocorticoid resistance.
Collapse
|
48
|
Zimmerman M, Coryell W, Pfohl B, Stangl D. Four definitions of endogenous depression and the dexamethasone suppression test. J Affect Disord 1985; 8:37-45. [PMID: 3156910 DOI: 10.1016/0165-0327(85)90070-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We examined the relationship between the DST and 4 definitions of endogenous depression: DSM-III, Feinberg and Carroll, Newcastle and RDC. Endogenous patients had a significantly higher rate of nonsuppression than nonendogenous patients according to the DSM-III and Newcastle definitions but not according to the RDC and Feinberg and Carroll criteria. Moreover, the relationship between the DST and the DSM-III and Newcastle definitions was significant even after individually controlling for age, psychosis and weight loss. We review the literature on the relationship between the DST and the RDC definition of endogenous depression and suggest that interstudy differences in criteria application may be partially responsible for the inconsistent results across studies.
Collapse
|
49
|
Abstract
The Dexamethasone Suppression Test (DST) was performed in 91 patients (depressive, manic and schizophrenic) and 11 healthy control persons. It was found that more endogenously depressed patients than non-endogenously depressed patients showed abnormal test results. The results were markedly influenced by the time of blood sampling, the diagnostic criteria and the plasma cortisol concentration threshold.
Collapse
|
50
|
Berger M, Pirke KM, Doerr P, Krieg JC, von Zerssen D. The limited utility of the dexamethasone suppression test for the diagnostic process in psychiatry. Br J Psychiatry 1984; 145:372-82. [PMID: 6487910 DOI: 10.1192/bjp.145.4.372] [Citation(s) in RCA: 126] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
In 231 psychiatric in-patients, the 1 mg or 1.5 mg DST with blood samples at 0900 h, 1600 h and 2300 h and a post-dexamethasone plasma cortisol threshold of greater than or equal to 5 micrograms/dl were tested for their differential diagnostic utility in clinical psychiatry. Neither test significantly separated endogenous depressed patients from patients with other depressive or non-depressive psychiatric disorders. Studies of the 1 mg or 1.5 mg DST in 75 healthy subjects revealed about 12% of cortisol non-suppressors, when a post-dexamethasone cortisol threshold of greater than or equal to 5 micrograms/dl was used. This seemed to be an unacceptably low specificity of the test in normal subjects. A threshold criterion of greater than or equal to 8 micrograms/dl, however, yielded only 2.7% of non-suppressed normal subjects. Analyses of the DST data of the psychiatric patients, using a cortisol threshold of greater than or equal to 8 micrograms/dl, also failed to reveal a significantly higher specificity of the DST for endogenous depression. However, it was demonstrated that intervening variables such as stress due to hospital admission, drug withdrawal, suicidal turmoil, weight loss, as well as a low dexamethasone plasma level, enhance the rate of abnormal DST results in psychiatric in-patients, regardless of their diagnostic classification.
Collapse
|