Neuroendocrine aspects of primary endogenous depression VIII. Pituitary-gonadal axis activity in male patients and matched control subjects

The association of hypogonadism with depression and its treatments

According to World Health Organization estimates, 5% of the adult population worldwide suffers from depression. In addition to the affective, psychomotor and cognitive symptoms which characterize this mood disorder, sexual dysfunction has been frequently reported among men suffering from depression. The most common sexual manifestations are decreased libido, erectile dysfunction and orgasmic disorder. In addition, epidemiological studies have documented a reduction of testosterone concentrations in men with depression and, for these reasons, depressive disorders appear as one possible cause of male functional hypogonadism. Moreover, some largely used antidepressant medications can cause or worsen sexual complaints, thus depression and its treatments rise several andrological-relevant issues. The other way round, men with hypogonadism can manifest depressed mood, anxiety, insomnia, memory impairment which, if mild, may respond to testosterone replacement therapy (TRT). However, the prevalence of functional hypogonadism in depression, and of depressive symptoms in hypogonadal men, is not known. Severe depressive symptoms do not respond to TRT, while the effect of treating major depression on functional hypogonadism, has not been investigated. Overall, the clinical relevance of each condition to the other, as well as the physiopathological underpinnings of their relationship, are still to be clarified. The present review summarizes current evidence on the influence of testosterone on mood and of depression on the hypothalamic-pituitary-testis axis; the clinical association between male hypogonadism and depression; and the reciprocal effects of respective treatments.

Testosterone, estradiol, DHEA and cortisol in relation to anxiety and depression scores in adolescents

Background Adrenal and sex hormone dysregulation have been independently associated with increased depression and anxiety. Cortisol can modify production of sex hormones and hormone-mood associations. This study evaluated associations and interplay of sex and adrenal hormones with depression and anxiety. Methods We assessed 545 Ecuadorian adolescents (11-17y, 50.4% female, ESPINA) for depression and anxiety symptoms using standardized scales. Testosterone, cortisol, dehydroepiandrosterone (DHEA), and estradiol (boys only) were measured in saliva. We performed logistic regression modeling to calculate odds ratios (OR) of elevated depression or anxiety (scores ≥60) comparing participants with low (<10th percentile) and elevated hormones (≥90th percentile) to normal concentrations (10th-90th percentile). Effect modification by cortisol and testosterone was assessed. Models adjusted for demographic, anthropometric, and circadian measures. Results In all participants, elevated testosterone (OR [95%CI:]=1.78 [0.98, 3.23]) and cortisol (OR=1.69 [0.95, 2.99]) were marginally associated with elevated anxiety scores. In boys, elevated estradiol was associated with elevated depression (OR=4.75 [1.95, 11.56]) and anxiety scores (OR=2.43 [1.01, 5.84]). In linear regression, estradiol was positively associated with depression (difference/10% hormone increase (β=0.45 [0.15, 0.75]) and anxiety scores (β=0.42 [0.13, 0.72]). Higher cortisol levels strengthened the depression association with estradiol in boys (β=0.54 [0.12, 0.96]), and with testosterone (β= -0.19 [-0.35, -0.03]) and DHEA (β= -0.12 [-0.22, -0.02]) in girls. Testosterone also modified associations. Limitations This was a cross-sectional analysis. Discussion Elevated testosterone, cortisol, and estradiol (≥90th percentile) were associated with altered mood. Cortisol and testosterone were considerable effect modifiers to the associations of most hormones with depression and anxiety.

Reduced plasma Fetuin-A is a promising biomarker of depression in the elderly

Depression affects 7% of the elderly population, and it often remains misdiagnosed or untreated. Peripheral biomarkers might aid clinicians by allowing more accurate and well-timed recognition of the disease. We sought to determine if plasma protein levels predict the severity of depressive symptomatology or distinguish patients from healthy individuals. The severity of depressive symptoms and global cognitive functioning were assessed by the Geriatric Depression Scale (GDS) and Mini-Mental State Examination (MMSE) in 152 elderly subjects, 76 of which with major depressive disorder (MDD). Plasma levels of 24 proteins were measured by multiplexing and analyzed as continuous predictors or dichotomized using the median value. The association between individual plasma proteins and MDD risk or depressive symptoms severity was investigated using multiple logistic and linear regressions including relevant covariates. Sensitivity analyses were performed excluding cognitively impaired individuals or non-acute patients with MDD. After adjusting for possible confounders and false discovery rate (FDR) correction, we found lower Fetuin-A levels in MDD patients vs. controls (p_FDR = 1.95 × 10^-6). This result was confirmed by the sensitivity and dichotomized analyses. Lower prolactin (PRL) levels predicted more severe depressive symptoms in acute MDD patients (p_FDR = 0.024). Fetuin-A is a promising biomarker of MDD in the elderly as this protein was negatively associated with the disorder in our sample, regardless of the global cognitive functioning. Lower PRL levels may be a peripheral signature of impaired neuroprotective processes and serotoninergic neurotransmission in more severely depressed patients.

Association of Testosterone Treatment With Alleviation of Depressive Symptoms in Men: A Systematic Review and Meta-analysis

IMPORTANCE

Countering depressive disorders is a public health priority. Currently, antidepressants are the first-line treatment, although they show modest effects. In men, testosterone treatment is a controversial alternative or adjunct treatment option.

OBJECTIVES

To examine the association of testosterone treatment with alleviation of depressive symptoms in men and to clarify moderating effects of testosterone status, depression status, age, treatment duration, and dosage.

DATA SOURCES

English-language studies published in peer-reviewed journals identified from PubMed/Medline, Embase, Scopus, PsychINFO, and the Cochrane Controlled Trials Register from database inception to March 5, 2018, using the search terms testosterone, mood, administration, dosage, adverse effects, deficiency, standards, therapeutic use, therapy, treatment, and supplementation.

STUDY SELECTION

Randomized placebo-controlled clinical trials (RCTs) of testosterone treatment that together cover a broad age range and hypogonadal or eugonadal men reporting depressive symptoms on psychometrically validated depression scales.

DATA EXTRACTION AND SYNTHESIS

Of 7690 identified records, 469 were evaluated against full study inclusion criteria after removing duplicates, reviews, and studies that did not examine male patients or testosterone. Quality assessment and data extraction from the remaining 27 RCTs were performed.

MAIN OUTCOMES AND MEASURES

Primary outcomes were testosterone treatment effectiveness (standardized score difference after treatment), efficacy (proportion of patients who responded to testosterone treatment with a score reduction of 50% or greater), and acceptability (proportion of patients who withdrew for any reason).

RESULTS

Random-effects meta-analysis of 27 RCTs including 1890 men suggested that testosterone treatment is associated with a significant reduction in depressive symptoms compared with placebo (Hedges g, 0.21; 95% CI, 0.10-0.32), showing an efficacy of odds ratio (OR), 2.30 (95% CI, 1.30-4.06). There was no significant difference between acceptability of testosterone treatment and placebo (OR, 0.79; 95% CI, 0.61-1.01). Meta-regression models suggested significant interactions for testosterone treatment with dosage and symptom variability at baseline. In the most conservative bias scenario, testosterone treatment remained significant whenever dosages greater than 0.5 g/wk were administered and symptom variability was kept low.

CONCLUSIONS AND RELEVANCE

Testosterone treatment appears to be effective and efficacious in reducing depressive symptoms in men, particularly when higher-dosage regimens were applied in carefully selected samples. However, given the heterogeneity of the included RCTs, more preregistered trials are needed that explicitly examine depression as the primary end point and consider relevant moderators.

Saliva testosterone and cortisol in male depressive syndrome, a community study. The Sudurnesjamenn Study

INTRODUCTION

The association between testosterone levels and depression is unclear. The relationship has been described as complex, i.e. more U (J)-shaped than linear in some previous studies.

AIM

The primary aim of this study was to examine the relationship between saliva testosterone level variations and different levels of male depressive symptoms in a community sample. The secondary aim was to investigate whether simultaneous testing of evening cortisol and testosterone improved the detection of depression.

METHODS

In a community study, 534 males were screened, using the Beck Depression Inventory (BDI), the Gotland Male Depression Scale (GMDS) and the Montgomery-Åsberg Depression Rating Scale (MADRS). Those with signs of depression (n = 65) and randomly selected controls (n = 69) had psychiatric evaluation for depressive disorder. In a sub-sample (n = 51) saliva testosterone was measured twice on a single day.

RESULTS

Testosterone morning values were significantly higher than evening values (236 vs. 145 pg/ml, P = 0.009). Evening testosterone was significantly higher in depressive males, according to both MADRS (P = 0.028) and BDI (P = 0.036). Having depression increased the likelihood of being in the highest third of testosterone levels (BDI P = 0.021; MADRS P = 0.018). Positive correlation was between total BDI score and elevated evening testosterone with and without psychotropics (P = 0.017; P = 0.002). Correlation was between elevated evening cortisol and evening testosterone levels (P = 0.021) though simultaneous testing did not increase specificity of detecting depression.

CONCLUSION

Evening saliva testosterone measurements seem the most informative, as they correlate with male depressive syndrome. Simultaneous testing for evening cortisol and evening testosterone levels did not increase specificity for clinical diagnosis of depressive disorder.

Harmful effects of functional hypercortisolism: a working hypothesis

Functional hypercortisolism (FH) is caused by conditions able to chronically activate hypothalamic-pituitary-adrenal axis and usually occurs in cases of major depression, anorexia nervosa, bulimia nervosa, alcoholism, diabetes mellitus, simple obesity, polycystic ovary syndrome, obstructive sleep apnea syndrome, panic disorder, generalized anxiety disorder, shift work, and end-stage renal disease. Most of these states belong to pseudo-Cushing disease, a condition which is difficult to distinguish from Cushing's syndrome and characterized not only by biochemical findings but also by objective ones that can be attributed to hypercortisolism (e.g., striae rubrae, central obesity, skin atrophy, easy bruising, etc.). This hormonal imbalance, although reversible and generally mild, could mediate some systemic complications, mainly but not only of a metabolic/cardiovascular nature, which are present in these states and are largely the same as those present in Cushing's syndrome. In this review we aim to discuss the evidence suggesting the emerging negative role for FH.

Gender differences in serum testosterone and cortisol in patients with major depressive disorder compared with controls

OBJECTIVE

Testosterone may have a role distinct from cortisol in the pathophysiology of depression. The hypothalamus-pituitary-adrenal (HPA) axis affects the functions of sex steroid hormones through interaction with corticotropin-releasing hormone (CRH) and gonadotropin-releasing hormone (GnRH). The objective of this study was to investigate differences in serum levels of testosterone and cortisol in male and female patients with major depressive disorder (MDD).

METHODS

Participants included 87 inpatients with MDD at Juntendo University Koshigaya Hospital. Serum levels of testosterone and cortisol were assessed at admission. Matched controls included 128 healthy individuals. Data from MDD patients and controls were compared separately for men and women. Correlations between serum hormone levels and scores on the Hamilton Rating Scale for Depression (HAM-D) of patients were assessed by sex. Effects of various factors on testosterone and cortisol were analyzed using multiple regression analysis.

RESULTS

In male patients with MDD, a significant negative correlation was seen between testosterone levels and the "retardation" score of HAM-D. However, serum testosterone levels were not significantly different in either male or female MDD patients compared with controls. Serum testosterone was negatively associated with the number of depressive episodes in male patients with MDD. Serum cortisol levels in female patients were significantly increased compared with female controls with no significant correlations between cortisol levels and HAM-D scores.

CONCLUSIONS

The negative correlation between the sub-score of the HAM-D and testosterone may be associated with the biological pathophysiology of male depression. Findings of serum cortisol levels in women may suggest distinct characteristics of these hormones in men and women with MDD.

Disruption of fetal hormonal programming (prenatal stress) implicates shared risk for sex differences in depression and cardiovascular disease

Comorbidity of major depressive disorder (MDD) and cardiovascular disease (CVD) represents the fourth leading cause of morbidity and mortality worldwide, and women have a two times greater risk than men. Thus understanding the pathophysiology has widespread implications for attenuation and prevention of disease burden. We suggest that sex-dependent MDD-CVD comorbidity may result from alterations in fetal programming consequent to the prenatal maternal environments that produce excess glucocorticoids, which then drive sex-dependent developmental alterations of the fetal hypothalamic-pituitary-adrenal (HPA) axis circuitry impacting mood, stress regulation, autonomic nervous system (ANS), and the vasculature in adulthood. Evidence is consistent with the hypothesis that disruptions of pathways associated with gamma aminobutyric acid (GABA) in neuronal and vascular development and growth factors have critical roles in key developmental periods and adult responses to injury in heart and brain. Understanding the potential fetal origins of these sex differences will contribute to development of novel sex-dependent therapeutics.

Hormone replacement therapy and physical function in healthy older men. Time to talk hormones?

Improving physical function and mobility in a continuously expanding elderly population emerges as a high priority of medicine today. Muscle mass, strength/power, and maximal exercise capacity are major determinants of physical function, and all decline with aging. This contributes to the incidence of frailty and disability observed in older men. Furthermore, it facilitates the accumulation of body fat and development of insulin resistance. Muscle adaptation to exercise is strongly influenced by anabolic endocrine hormones and local load-sensitive autocrine/paracrine growth factors. GH, IGF-I, and testosterone (T) are directly involved in muscle adaptation to exercise because they promote muscle protein synthesis, whereas T and locally expressed IGF-I have been reported to activate muscle stem cells. Although exercise programs improve physical function, in the long-term most older men fail to comply. The GH/IGF-I axis and T levels decline markedly with aging, whereas accumulating evidence supports their indispensable role in maintaining physical function integrity. Several studies have reported that the administration of T improves lean body mass and maximal voluntary strength in healthy older men. On the other hand, most studies have shown that administration of GH alone failed to improve muscle strength despite amelioration of the detrimental somatic changes of aging. Both GH and T are anabolic agents that promote muscle protein synthesis and hypertrophy but work through separate mechanisms, and the combined administration of GH and T, albeit in only a few studies, has resulted in greater efficacy than either hormone alone. Although it is clear that this combined approach is effective, this review concludes that further studies are needed to assess the long-term efficacy and safety of combined hormone replacement therapy in older men before the medical rationale of prescribing hormone replacement therapy for combating the sarcopenia of aging can be established.

Testosterone prevents but not reverses anhedonia in middle-aged males and lacks an effect on stress vulnerability in young adults

Middle-aged male rats are more vulnerable than young adult ones to develop anhedonia when exposed to chronic mild stress (CMS). Clinical studies support the idea that in aged subjects the low testosterone (T) levels are related with their higher stress vulnerability and that this hormone possesses antidepressant-like actions. In this study we evaluated the role of gonadal hormones--mainly T--on the depressive-like behavior of middle-aged and young adult male rats submitted to CMS. In middle-aged rats we analyzed the effect of T restitution (at the levels of young adult animals) given 3 weeks before (experiment 1) or 3 weeks after (experiment 2) anhedonia development (indicated by a reduction in sucrose solution intake). T restitution before CMS effectively prevented anhedonia but failed to reverse it once installed. In young adult rats we studied if orchidectomy increased stress vulnerability and found that it failed to modify sucrose intake. These results indicate a stress-dependent differential effect of T in middle-aged rats an age differential role of gonadal hormones on the vulnerability to develop anhedonia. The results suggest that T is a resilience factor in middle-aged but not in young adult males.

The effect of testosterone supplementation on depression symptoms in hypogonadal men from the Testim Registry in the US (TRiUS)

OBJECTIVE

To determine the effect of long-term testosterone replacement therapy (TRT) on depression symptoms in hypogonadal men.

METHODS

Data were from TRiUS, a multicenter, 12-month observational registry (N = 849) of hypogonadal men prescribed 1% testosterone gel. Measures including total testosterone (TT) were assessed at baseline and months 3, 6, and 12. Depression symptoms were measured with Patient Health Questionnaire-9 (PHQ-9), a validated self-report questionnaire. A PHQ-9 score decrease of ≥5 represents clinical improvement.

RESULTS

PHQ-9 scores were available for 762/849 TRiUS participants at baseline. Overall, 92.4% (704/762) demonstrated some level of depressive symptoms, with 17.3% (132/762) having moderately severe (score 15-19) to severe (score 20-27) symptoms. Subcohorts with significantly (p ≤ 0.03) more moderately severe to severe symptoms were: <60 years old, TT levels <250 ng/dl (<8.68 nmol/l), HIV/AIDS-positive, or used antidepressants or opioids. TT levels and PHQ-9 scores improved significantly (p < 0.01) by 3 months of TRT. At 12 months PHQ-9 scores showed a clinically meaningful mean improvement of 5.62 points, patients with moderately severe to severe symptoms decreased from 17.3% to 2.1% (5/233), and subcohorts, including those defined by age (<60 years) and antidepressant use, had improved PHQ-9 scores ≥5.

CONCLUSION

TRT may reduce depression symptoms in hypogonadal men, including middle-aged men and those using antidepressants.

Men's health: sexual dysfunction, physical, and psychological health--is there a link?

INTRODUCTION

Sexual dysfunction in men, such as erectile dysfunction, hypogonadism, and premature ejaculation, generates considerable attention. Its association with physical and psychological health is an issue which should be addressed seriously.

AIM

A review of the literature pertaining to the correlation between sexual dysfunction and physical and psychological health.

METHODS

PubMed search for relevant publications on the association between sexual dysfunction in men and physical and psychological health.

MAIN OUTCOME MEASURE

Clinical and epidemiological evidence that demonstrates the association between sexual dysfunction in men and physical and psychological health.

RESULTS

Sexual dysfunction, i.e., erectile dysfunction, hypogonadism, and premature ejaculation, has been shown to be associated with physical and psychological health. There is a strong correlation between sexual dysfunction and cardiovascular disease, metabolic syndrome, quality of life, and depression.

CONCLUSION

The association between men's sexual dysfunction and physical and psychological health is real and proven. Therefore, it should not be taken lightly but instead treated as a life-threatening medical problem.

Is there a neuroendocrinological rationale for testosterone as a therapeutic option in depression?

Depression is a disease of growing incidence and economic burden worldwide. In view of increasing treatment resistance, new therapeutic approaches are urgently needed. In addition to its gonadal functions, testosterone has many effects on the central nervous system. An association between testosterone levels and depressive symptoms has been proposed. Many hormones and neurotransmitters are involved in the aetiology and the course of depression including serotonin, dopamine, noradrenaline, vasopressin and cortisol. Testosterone is known to interact with them. Preclinical data suggest that testosterone has antidepressant potential. However, the data from clinical studies have been inconsistent. This review provides a critical overview on the currently available preclinical and clinical literature and concludes with clinical recommendations.

Testosterone and depression: systematic review and meta-analysis

BACKGROUND

Studies suggest that testosterone (TT) replacement may have an antidepressant effect in depressed patients.

OBJECTIVE

The objective of this study was to explore the effect of TT administration on depression using both a systematic review of the literature and a meta-analysis.

METHODOLOGY

A search was conducted of MEDLINE, the Clinical Trials Registry, and Cochrane Central for English-language publications concerning randomized, placebo-controlled trials involving use of TT therapy in depressed patients. We searched for additional trials in the individual reference lists of the articles identified in the search. A study was judged to be relevant for inclusion in this review and meta-analysis if it reported original data from a controlled trial comparing use of TT and placebo in patients diagnosed with a depressive disorder according to DSM criteria, and the treatment response was evaluated according to changes on the Hamilton Rating Scale for Depression (HAM-D). We extracted the following data from the identified studies: study source, total number of participants in the study and in each treatment group, participants' ages, number of participants with a diagnosis of hypogonadism or HIV/AIDS, study duration, type of intervention, and change in HAM-D scores in the groups receiving TT versus placebo. The meta-analysis evaluated the effect of TT replacement on response in depressed patients as measured by change in HAM-D scores in the available placebo-controlled, randomized clinical trails.

RESULTS

Seven studies (N=364) were identified that included a placebo-control group in a double-blind design. Eligibility criteria were clearly reported in all trials. Meta-analysis of the data from these seven studies showed a significant positive effect of TT therapy on HAM-D response in depressed patients when compared with placebo (z=4.04, P<0.0001). Subgroup analysis also showed a significant response in the subpopulations with hypogonadism (z=3.84, P=0.0001) and HIV/AIDS (z=3.33, P=0.0009) as well as in patients treated with TT gel (z=2.32, P=0.02).

CONCLUSIONS

TT may have an antidepressant effect in depressed patients, especially those with hypogonadism or HIV/AIDS and elderly subpopulations. The route by which TT is administered may play a role in treatment response.

Effects of testosterone replacement in middle-aged men with dysthymia: a randomized, placebo-controlled clinical trial

Mid-life onset male dysthymic disorder (DD) seems to be a distinct clinical condition with limited therapeutic options. Testosterone replacement is mood-enhancing and has been proposed as an antidepressant therapy, though this strategy has received limited systematic study. We therefore conducted a six-week double-blind placebo-controlled clinical trial in 23 men with DD and with low or low-normal testosterone (T) level (i.e, screening total serum testosterone <350 ng/dL). Enrolled men were randomized to receive intramuscular injections of 200 mg of testosterone cypionate or placebo every 10 days. The primary outcome measures were the Clinical Global Impression (CGI) improvement score and the 21-item Hamilton Depression Rating Scale (HDRS) score.Twenty-three patients were randomized. The mean (SD) age of the enrolled patients was 50.6 (7.0) years and that of total testosterone level was 339 (93) ng/dL. The median duration of the current dysthymic episode was 3.6 (2.3) years, and the mean (SD) HDRS was 14.0 (2.9). After the intervention, the mean HDRS score decreased significantly more in the testosterone group (7.46 [4.56]) than in the placebo group (1.8 [4.13], t21 = -3.07, P = 0.006). Remission, defined as a CGI improvement score of 1 or 2 and a final HDRS score lower than 8, was achieved by 7 (53.8%) of 13 in the testosterone group and 1 (10%) of 10 in the placebo group (P = 0.03). Testosterone replacement may be an effective antidepressant strategy for late-onset male dysthymia.

Testosterone and depression in men

PURPOSE OF REVIEW

The purpose of the review is to update the current literature regarding the role, if any, that testosterone plays in depressive illness. We have considered the influences on depression of endogenous testosterone, that is, hypogonadism and depression; and exogenous testosterone, that is, as a potential antidepressant.

RECENT FINDINGS

Studies do not support a consistent relationship between testosterone level and mood. There may be vulnerable subpopulations in whom hypogonadism contributes to depression; and chronic depressive illness may lead to hypogonadism in some men. Results from multiple randomized, controlled clinical trials are conflicting. Most do not support testosterone as a broadly effective antidepressant, but it may be effective in carefully selected populations, such as hypogonadal men, antidepressant-resistant men, men with early onset depression, and/or HIV-infected men.

SUMMARY

There is little support for a pervasive influence of testosterone on mood.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The decline of androgen levels in elderly men and its clinical and therapeutic implications

Aging in men is accompanied by a progressive, but individually variable decline of serum testosterone production, more than 20% of healthy men over 60 yr of age presenting with serum levels below the range for young men. Albeit the clinical picture of aging in men is reminiscent of that of hypogonadism in young men and decreased testosterone production appears to play a role in part of these clinical changes in at least some elderly men, the clinical relevancy of the age-related decline in sex steroid levels in men has not been unequivocally established. In fact, minimal androgen requirements for elderly men remain poorly defined and are likely to vary between individuals. Consequently, borderline androgen deficiency cannot be reliably diagnosed in the elderly, and strict differentiation between "substitutive" and "pharmacological" androgen administration is not possible. To date, only a few hundred elderly men have received androgen therapy in the setting of a randomized, controlled study, and many of these men were not androgen deficient. Most consistent effects of treatment have been on body composition, but to date there is no evidence-based documentation of clinical benefits of androgen administration to elderly men with normal or moderately low serum testosterone in terms of diminished morbidity or of improved survival or quality of life. Until the long-term risk-benefit ratio for androgen administration to elderly is established in adequately powered trials of longer duration, androgen administration to elderly men should be reserved for the minority of elderly men who have both clear clinical symptoms of hypogonadism and frankly low serum testosterone levels.

The combined T3/TRH test in depressed patients and healthy controls

It is well established that depressed patients show a blunted TSH response in the TRH-stimulation test. However, it has not been investigated so far whether pre-treatment with 3,5,3'-triiodothyronine (T3) is able to further suppress the TRH-induced TSH response in depressed patients or whether it may cause an escape-phenomenon with paradoxically enhanced TSH stimulation in a subsequent TRH test. In 20 drug-free depressed patients (eight men, 12 women) suffering from a major depressive episode according to DSM-IV criteria and in 20 age- and sex-matched healthy controls, the single TRH-stimulation test (administration of 200 microg TRH at 09:00 h) was carried out followed by a combined T3/TRH test (pre-treatment with 40 microg T3 at 23:00 h the night before; administration of 200 microg TRH at 09:00 h the next day). Compared to the controls, the depressed patients showed a significantly blunted TSH response in the single TRH test. However, the percentage suppression of TRH-induced TSH stimulation after pre-treatment with 40 microg T3 was comparable in the depressive patients (61.07%) and the healthy volunteers (64.20%). Prolactin secretion did not differ between patients and controls either in the single TRH test or in the combined T3/TRH test. Apparently, in contrast to the hypothalamo-pituitary-adrenocortical (HPA) system, no disturbance of feedback control in regulation of the hypothalamo-pituitary-thyroid (HPT) axis secretion can be demonstrated in depressed patients when using the combined T3/TRH test.

Safety and efficacy of testosterone gel 1% augmentation in depressed men with partial response to antidepressant therapy

The current study evaluates the efficacy and safety of testosterone (T) gel 1% augmentation on depressive symptoms and quality of life in treatment-resistant, depressed, hypogonadal men older than 50 years of age who are receiving antidepressants. The authors hypothesized that T augmentation would improve depressive symptoms and quality of life. Eighteen hypogonadal men entered the study who had had an adequate trial of antidepressant therapy and had significant depressive symptoms. Participants were continued on their antidepressant and were randomized to receive either placebo or active T gel (5 g) to be applied once a day. Participants were tested on 6 occasions: screening visit, an initial session (pretreatment), at 6 and 12 weeks during the first treatment condition, and at 18 and 24 weeks during the crossover condition. The authors found a significant improvement in depressive symptoms from baseline to 12 weeks of testosterone treatment. However, a statistical difference between placebo and testosterone treatment phases was not demonstrated. The limitations of the study, including the chronicity and severity of patients' depression, variability in T levels, and a small sample size, probably influenced the ability to detect a discernable difference. Nevertheless, the study shows that T gel augmentation may be helpful in hypogonadal males with depression.

Andropause and psychopathology: minor symptoms rather than pathological ones

This study examined the psychological symptomatology of men diagnosed with andropause and the association between calculated free testosterone (T) and depressed mood, anxiety and quality of life. Subjects were 153 men, aged 50-70 years, who participated in a screening of andropause. Total testosterone, FSH, LH and SHBG levels were measured. Depressed mood was assessed with the Carroll Rating Scale, anxiety with the "anxiety-insomnia" dimension of the General Health Questionnaire, and quality of life with the World Health Organisation Quality of Life questionnaire. The results showed that levels of free T decreased with age, whereas FSH and LH increased. Carroll Rating Scale scores were higher among hypogonadal subjects, but the mean score was low and not pathological. A negative correlation was observed between severity of depression as assessed by the Carroll Rating Scale and free T levels. However, subjects with a significant score on this scale did not exhibit different free T levels compared to subjects with a non-significant depressive score. Anxiety and quality of life did not differ between hypogonadal and eugonadal subjects. The present study therefore suggests that andropause is not characterised by specific psychological symptoms, but may be associated with "depressive symptoms" that are not considered as pathological.

No relationship between testosterone levels and depressive symptoms in aging men

We investigated the associations between depression and serum testosterone levels in the elderly. There was no significant difference in the mean levels of the serum testosterone between the groups of patients and normals. For both groups, there was no significant correlation between testosterone and total depression scores or age.

The hypothalamic-pituitary-gonadal axis in mood disorders

This article has demonstrated that stress and HPA axis activation affect the reproductive axis. Despite similarities in the HPA axis picture between women with major depression and those with hypothalamic amenorrhea and exercise or nutritional amenorrhea, no abnormalities in LH secretion have been documented in major depression. Lower estradiol in the follicular phase in depressed women and lower testosterone in depressed men however, have been observed [81, 92]. Although PMS would appear to be the best candidate for a mood disorder associated with abnormalities in reproductive hormones, no abnormalities in LH, estradiol or progesterone have been documented in PMS either [62]. Similarly, blockade of progesterone appears to be ineffective as a treatment for PMS [79]. Complete elimination of monthly cycling with leuprolide improves mood, however. No published studies have examined women with major depression to determine whether leuprolide will exacerbate or improve depressive symptoms. Some studies suggest beneficial effects of estrogen on mood in postmenopausal women, but no placebo controlled studies have explored estrogen augmentation in the treatment of major depression in either post- or premenopausal women, although estrogen is beneficial in women with perimenopause-related mood disorders [78].

Cushing’s disease and melancholia

Striking similarities exist in the endocrinology of Cushing's disease and melancholic depression.Laboratory abnormalities, which have been found in both, include raised urinary,plasma and salivary cortisol, non-suppression of cortisol in the dexamethasone suppression test and adrenocorticotrophin (ACTH) hypersecretion. The hypercortisolism can be so severe in melancholic depression that it is difficult to distinguish from Cushing's disease and has been described as a "pseudo-Cushing's" state. Cerebrospinal fluid corticotrophin-releasing hormone (CRH) levels have been found to be lower in patients with Cushing's disease than in depressed subjects. Dynamic endocrine tests may help to distinguish between the two disorders.An exaggerated response to synacthen has been found in both but a reduced ACTH response to CRH occurs in depression, unlike those with Cushing's disease who show ACTH hyper-responsiveness. Other tests, which may help to distinguish between the two disorders,include the dexamethasone-CRH test, the naloxone test, the insulin-induced hypoglycemia test and the desmopressin stimulation test. Similarities in psychiatric symptoms have been recognised for many years. More recently, the physical complications of melancholic depression have been noted. These include osteoporosis, an increased risk of death from cardiovascular disease, hypertension, a redistribution of fat to intra abdominal sites and insulin resistance. Cushing's disease shares these physical complications and we propose that the common underlying factor is excessive plasma glucocorticoids. The increasing recognition of the physical complications and the increased morbidity and mortality in those who suffer from depression underscores the necessity for early detection and treatment of this illness and screening for undetected physical complications.

The male menopause and mood: testosterone decline and depression in the aging male--is there a link?

The objective of this study was to review the literature on the hormonal changes that occur in aging males in order to determine if testosterone declines in relation to depressed mood and if testosterone might prove useful in treatment of depression. Pertinent articles were identified through a MEDLINE search from 1966 to 1999 and by careful review of the bibliographies of articles most relevant to the topic. There is a moderate decline of total testosterone and more significant decline of bioavailable testosterone in aging males. Elderly males who are depressed appear to have the lowest testosterone levels. In eugonadal males, testosterone replacement does not have a significant effect on mood; in hypogonadal males, some studies show an effect whereas others do not. In several small studies of depressed hypogonadal males, testosterone was effective in alleviating depression. Major side effects of testosterone include increased hematocrit and potential effects on the prostate and lipid metabolism. Testosterone replacement as primary or adjuvant treatment of depression may prove useful in elderly, hypogonadal males who fail to respond to conventional antidepressants. Further studies are needed to confirm these initial impressions.

Sexual dysfunction in depression

Sexual dysfunction is a well-known symptom of depression. However, it has received little, if any, attention from clinicians and researchers. A review of published literature suggests that sexual dysfunction occurs in the majority of depressed patients. It has a major impact on the quality of life of the patients. The pathophysiology of sexual dysfunction in depression involves a complex interplay of various neurotransmitters and hormones. Clinicians need to be more proactive in enquiring about sexual dysfunction in depressed patients. More information is needed about the nature, prevalence and pathophysiology of sexual dysfunction in depression. Copyright 2000 John Wiley & Sons, Ltd.

Antidepressant medications, mood and male fertility

By modulating the activity of central neurotransmitters, psychotropic agents may affect reproductive functioning in men and women. Many neurotransmitters influence the hypothalamic-pituitary-gonadal (HPG) axis and can consequently affect menstrual cycling in women and spermatogenesis in men. Emotional state similarly may disrupt reproductive functioning through the effects of stress hormones on the HPG axis. While some data exist on the relationship between stress and menstrual cyclicity in women of reproductive age, little is known regarding the potential effect of emotional state on reproductive function in men. This paper will review: (1) aspects of male reproductive function that may be vulnerable to medication-induced influences; (2) the impact of emotional state on male reproductive function; and (3) the literature on the possible effects of antidepressant medications on male fertility.

Fluoxetine efficacy in menopausal women with and without estrogen replacement

A gradual decline in estrogen levels after the age of 40 may contribute to a higher rate of depression in women over 45 years of age. Estrogen replacement therapy (ERT) has been shown to produce cognitive and mood-enhancing effects in women and may facilitate antidepressant activity.

METHODS

We examined the efficacy rates in women on ERT > or = 45 years (n = 40) compared to women > or = 45 years not on ERT (n = 132) and to women < 45 years (n = 396) and to men (n = 262) with major depression during fluoxetine 20 mg daily up to 8 weeks. Remitters with a HAM-D17 score < or = 7 from week 9 to 12 were then treated up to 1-year in a placebo-controlled, relapse-prevention trial.

RESULTS

Efficacy rates were similar in women > or = 45 years on ERT when compared to women > or = 45 years taking fluoxetine alone, and when compared to women < 45 years and men taking fluoxetine. A Kaplan-Meier survival analysis in fluoxetine responders treated up to 26 weeks showed a somewhat greater relapse rate in women > or = 45 years taking ERT compared to other treatment groups (P < 0.06).

LIMITATIONS

This study was retrospective nature and ERT was given in an uncontrolled fashion: 63% of women received estrogen alone while 37% also took intermittent progesterone. Other variables include the absence of hormonal documentation of menopausal status, no direct assessment of ERT compliance and the use of fixed-dose fluoxetine 20 mg daily.

CONCLUSION

In contrast to prior reports suggesting that ERT may facilitate antidepressant activity, we observed similar efficacy in depressed women > or = 45 years taking fluoxetine plus ERT compared to those taking fluoxetine alone.

Sex playing with the mind. Effects of oestrogen and testosterone on mood and cognition

Women now spend more than 1/3 of their lives in a state of oestrogen deprivation as a result of increased life expectancy. A similar, but milder, hypogonadal state has been described for elderly men. This paper aims to review the available literature on the effects of both oestrogen and testosterone on mood and cognition. Oestrogen replacement therapy of postmenopausal women is associated with improvements in measures of well being and decline in depression scores. In addition, oestrogen seems to augment the response of postmenopausal women with major depression to antidepressant treatment. Most studies designed to investigate the impact of oestrogen on cognition indicate that replacement therapy is associated with better performance on neuropsychological tests, particularly in measures of verbal memory and fluency. The data also supports claims that oestrogen replacement therapy reduces the risk of Alzheimer's disease in later life and improves response of patients to anticholinesterase treatment. Data on the effects of testosterone is sparser. Preliminary findings suggest that testosterone therapy may improve mood when used in isolation or in association with oestrogen. The effects of testosterone on cognitive functioning are less clear--some studies indicate that the administration of testosterone to non-demented subjects is associated with better visuospatial functioning and deterioration of verbal skills. In summary, gonadal hormones seem to modulate various aspects of mental functioning. If future studies prove this to be true, hormone replacement therapy should have a major impact on the physical and mental health of older people in the years to come.

Melancholic depression and abdominal fat distribution: a mini-review

Fat is stored around the abdomen in both subcutaneous and intra abdominal (visceral) sites. Visceral fat is associated in its own right with a set of metabolic abnormalities, including non insulin dependent diabetes, hypertension and dyslipidaemias. States of marked hypercortisolaemia, for example Cushing's syndrome, lead to the preferential accumulation of visceral fat. Since melancholic depression is known to be associated with elevated plasma Cortisol levels, this review explores whether depressed patients are prone to excess visceral fat storage, with the subsequent risk of developing the associated metabolic disturbances. Though the literature is limited, there is evidence that intra abdominal fat is increased in major depression. There is also evidence that depression is associated with increased risk of death from cardiovascular disease. Is visceral fat and its association with metabolic abnormalities the link between depression and physical illness?

Testosterone, gonadotropin, and cortisol secretion in male patients with major depression

OBJECTIVE

Previous studies of sex hormone concentrations in depression yielded inconsistent results. However, the activation of the hypothalamic-pituitary-adrenal system seen in depression may negatively affect gonadal function at every level of regulation. The objective of this study was to explore whether major depressive episodes are indeed associated with an alteration of gonadal function.

METHODS

Testosterone, pulsatile LH secretion, FSH, and cortisol were assessed using frequent sampling during a 24-hour period in 15 male inpatients with major depression of moderate to high severity and in 22 healthy comparison subjects (age range 22-85 years).

RESULTS

An analysis of covariance model showed that after adjustment for age only, daytime testosterone (p < .01), nighttime testosterone (p < .05), and 24-hour mean testosterone secretion (p < .01) were significantly lower in the depressed male inpatients. There was also a trend for a decreased LH pulse frequency in the depressed patients (p < .08).

CONCLUSIONS

Gonadal function may be disturbed in men with a depressive episode of moderate to high severity.

Psychoneuroendocrinology of depression. Hypothalamic-pituitary-gonadal axis

Women are more susceptible than men to depression, particularly during periods of rapid fluctuation of gonadal hormones, such as premenstrually, postpartum, and during the climacteric. This review summarizes the evidence for the association of depression with abnormalities in reproductive hormones. Although there are similarities in stress hormones changes between depressed women and women with stress-related amenorrhea, no abnormalities in LH activity have been documented in depression. Similarly no abnormalities in LH, estradiol, or progesterone have been documented in premenstrual syndrome (PMS), although complete elimination of monthly cycling with leuprolide improves mood. Some studies have suggested beneficial effects of estrogen on mood in postmenopausal women but as yet there have been no adequately controlled studies of estrogen treatment of either premenopausal or postmenopausal women.

Neuroendocrine aspects of primary endogenous depression--XIV. Gonadotropin secretion in female patients and their matched controls

To determine the extent of dysregulation of gonadotropin secretion in depressed women, we measured nocturnal and diurnal serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) concentrations and the responses of these hormones to gonadotropin releasing hormone (LHRH) in 20 Research Diagnostic Criteria primary, definite endogenous female depressives and in 20 individually matched female normal controls. Fourteen patients and 14 controls were premenopausal, and six patients and six controls were peri/postmenopausal or panhysterectomized. None of the latter was receiving estrogen replacement therapy. The premenopausal patients showed no significant differences in basal nocturnal or diurnal gonadotropin concentrations and no significant differences in hormone concentrations post-LHRH compared to their premenopausal matched controls. In contrast, in the postmenopausal subjects there were (1) significantly increased diurnal vs. nocturnal serum FSH concentrations in the depressives; (2) marginally increased nocturnal, diurnal, and LHRH-stimulated LH concentrations and highly significantly increased LHRH-stimulated FSH concentrations in the depressives compared to their controls; and (3) positive correlations between the LH measures and ratings of depression severity in the patients. These results suggest a dysregulation of the HPG axis in peri/postmenopausal and panhysterectomized female endogenous depressives.

Visible burrow system as a model of chronic social stress: behavioral and neuroendocrine correlates

In mixed-sex rat groups maintained in visible burrow systems (VBS), consistent asymmetries in offensive and defensive behaviors of male dyads are associated with the development of dominance hierarchies. Subordinate males are characterized by particular wound patterns, severe weight loss, and a variety of behavioral changes, many of them isomorphic to target symptoms of clinical depression. In two VBS studies, subordinate males showed increased basal levels of plasma corticosterone (CORT), and increased adjusted adrenal and spleen weights compared to controls, and often, to dominants as well. Thymus weights and testosterone levels of subordinates were not reliably different in one study using highly aggressive males, but were reduced, along with testes weights, in a second study using unselected males. Glucocorticoid receptor binding levels in hippocampus, hypothalamus, and pituitary were not different, nor were aldosterone levels. When tested in a restraint stress procedure, subordinates had higher basal CORT levels, but about 40% of these animals showed a reduced, or absent, CORT response to restraint. These findings indicate that subordination may be reflected in high magnitude changes consistent with physiological indices of prolonged stress. Dominant rats of such groups may also show physiological changes suggesting stress, particularly when the groups are comprised of highly aggressive males only. The VBS colony model thus appears to enable rat groups to produce natural, stress-engendering, social interactions that constitute a particularly relevant model for investigating the behavioral, neural, and endocrine correlates of chronic stress.

Gonadotropin (LH and FSH) response after submaximal GnRH stimulation in depressed premenopausal women and healthy controls

Although hormonal response abnormalities in depression have been demonstrated in several hypothalamic-pituitary-target organ axes after a variety of neuroendocrine challenge tests, studies of hypothalamic-pituitary-gonadal (HPG) axis function have been inconsistent in their findings. The use of maximal or supramaximal doses of gonadotropin-releasing hormone (GnRH) in early studies (150-600 micrograms) may have masked the presence of more subtle disturbances in luteinizing hormone (LH) and follicle-stimulating hormone (FSH) responsiveness in depression. We hypothesized that submaximal doses of GnRH might reveal a more subtle dysregulation in gonadotropin responsiveness in depression, and therefore measured LH and FSH responses after GnRH 10 micrograms and 90 micrograms doses in nine premenopausal depressed women and six healthy controls. There were no statistically significant differences between subject groups for mean basal LH, FSH, and estradiol concentrations, nor for any of the LH and FSH response values after either GnRH stimulation dose. The present observations of an intact HPG axis in depression contrast with findings of disturbances in most other hypothalamic-pituitary axes, and suggest that neuroendocrine dysregulation in depression might not represent a generalized limbic system-hypothalamic-pituitary abnormality, but rather a more restricted lesion sparing the medial preoptic and/or arcuate region of the hypothalamus which regulates gonadotropin secretion.

Hypothalamic-pituitary-gonadal axis in depressed premenopausal women: elevated blood testosterone concentrations compared to normal controls

To assess the function of the hypothalamic-pituitary-gonadal (HPG) axis in major depression, a multihormonal study was carried out in 20 depressed premenopausal women. Serum concentrations of LH, FSH, estradiol, progesterone, testosterone, and GnRH-stimulated LH and FSH were measured before initiation of treatment (on the first day after menstruation) and during clomipramine treatment (same time one menstrual cycle later). Significantly higher blood concentrations of testosterone were found in untreated patients compared to normal controls. Furthermore, there was a significant negative correlation between Hamilton depression scores and estradiol concentrations of patients. The efficacy of clomipramine treatment was not related to hormonal parameters.

Salivary testosterone levels and major depressive illness in men

Studies of testosterone levels in patients with major depressive illness have produced varying results, plasma levels usually being reported. Saliva levels reflect 'free' plasma testosterone, and a pilot study of 11 men with major depression with melancholia, who underwent a standard dexamethasone suppression test, is described. There were no significant differences in testosterone levels compared with an age-matched control group. In the patient group, pre-dexamethasone levels correlated significantly and negatively with depression ratings on the 21-item Hamilton and the Montgomery and Asberg depression scales, and also with state anxiety measured on the Spielberger scale.

Steroids and depression

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

Neuroendocrine aspects of primary endogenous depression. X: Serum growth hormone measures in patients and matched control subjects

To determine the extent of dysregulation of growth hormone (GH) secretion in endogenous depression, we measured nocturnal serum GH concentrations and GH responses to thyrotropin-releasing hormone (TRH, gonadotropin-releasing hormone (LHRH), and dexamethasone administration in 40 Research Diagnostic Criteria primary, definite endogenous depressives and 40 individually matched normal control subjects. Compared with their controls, the patients showed no difference in basal nocturnal GH concentrations or in GH responses to TRH or LHRH. The GH measures were not significantly related to the other endocrine measures reported previously, including dexamethasone suppression test status. None of the diagnostic schemes for endogenous/melancholic depression which we studied was significantly related to the GH measures in the patients. Of the other subject and symptom variables, the mood depression factor of the Hamilton depression scale and the performance difficulty factor of the Beck depression inventory were moderately negatively correlated with the nocturnal GH measures. These findings suggest that, in contrast to the previously reported hypothalamopituitary-adrenal cortical and thyroid axis abnormalities in our patients, GH secretion was relatively normal. Patients with more severe depressed mood and greater difficulty accomplishing tasks did have moderately lower nocturnal GH values.