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Takasu K, Yawata Y, Tashima R, Aritomi H, Shimada S, Onodera T, Taishi T, Ogawa K. Distinct mechanisms of allopregnanolone and diazepam underlie neuronal oscillations and differential antidepressant effect. Front Cell Neurosci 2024; 17:1274459. [PMID: 38259500 PMCID: PMC10800935 DOI: 10.3389/fncel.2023.1274459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/29/2023] [Indexed: 01/24/2024] Open
Abstract
The rapid relief of depressive symptoms is a major medical requirement for effective treatments for major depressive disorder (MDD). A decrease in neuroactive steroids contributes to the pathophysiological mechanisms associated with the neurological symptoms of MDD. Zuranolone (SAGE-217), a neuroactive steroid that acts as a positive allosteric modulator of synaptic and extrasynaptic δ-subunit-containing GABAA receptors, has shown rapid-onset, clinically effective antidepressant action in patients with MDD or postpartum depression (PPD). Benzodiazepines, on the other hand, act as positive allosteric modulators of synaptic GABAA receptors but are not approved for the treatment of patients with MDD. It remains unclear how differences in molecular mechanisms contribute to the alleviation of depressive symptoms and the regulation of associated neuronal activity. Focusing on the antidepressant-like effects and neuronal activity of the basolateral amygdala (BLA) and medial prefrontal cortex (mPFC), we conducted a head-to-head comparison study of the neuroactive steroid allopregnanolone and the benzodiazepine diazepam using a mouse social defeat stress (SDS) model. Allopregnanolone but not diazepam exhibited antidepressant-like effects in a social interaction test in SDS mice. This antidepressant-like effect of allopregnanolone was abolished in extrasynaptic GABAA receptor δ-subunit knockout mice (δko mice) subjected to the same SDS protocol. Regarding the neurophysiological mechanism associated with these antidepressant-like effects, allopregnanolone but not diazepam increased theta oscillation in the BLA of SDS mice. This increase did not occur in δko mice. Consistent with this, allopregnanolone potentiated tonic inhibition in BLA interneurons via δ-subunit-containing extrasynaptic GABAA receptors. Theta oscillation in the mPFC of SDS mice was also increased by allopregnanolone but not by diazepam. Finally, allopregnanolone but not diazepam increased frontal theta activity in electroencephalography recordings in naïve and SDS mice. Neuronal network alterations associated with MDD showed decreased frontal theta and beta activity in depressed SDS mice. These results demonstrated that, unlike benzodiazepines, neuroactive steroids increased theta oscillation in the BLA and mPFC through the activation of δ-subunit-containing GABAA receptors, and this change was associated with antidepressant-like effects in the SDS model. Our findings support the notion that the distinctive mechanism of neuroactive steroids may contribute to the rapid antidepressant effects in MDD.
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Affiliation(s)
- Keiko Takasu
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Yosuke Yawata
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Ryoichi Tashima
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | | | | | - Tsukasa Onodera
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Teruhiko Taishi
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
| | - Koichi Ogawa
- Laboratory for Drug Discovery and Disease Research, Shionogi Pharmaceutical Research Center, Shionogi & Co., Ltd., Osaka, Japan
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Sonoyama T, Shimizu R, Kubota R, Matsuo Y, Okutsu D, Yamanaka H, Takasu K, Ogawa K, Motomiya T. Pharmacokinetics, safety, and tolerability of single and multiple doses of zuranolone in Japanese and White healthy subjects: A phase 1 clinical trial. Neuropsychopharmacol Rep 2023; 43:346-358. [PMID: 37366077 PMCID: PMC10496058 DOI: 10.1002/npr2.12359] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023] Open
Abstract
AIM This phase 1 study assessed the pharmacokinetics, safety, and tolerability of zuranolone in Japanese and White healthy adults, and Japanese healthy elderly subjects. METHODS This single-center study consisted of three parts. In Part A (randomized, double-blind), the safety, tolerability, and pharmacokinetics of single dose and 7-day consecutive multiple doses of zuranolone 10, 20, and 30 mg and placebo were assessed in 36 Japanese adults, 24 White adults, and 12 Japanese elderly (aged 65-75 years) subjects. In Part B (randomized, open-label, crossover), the effect of food intake on the pharmacokinetics and safety of single-dose zuranolone 30 mg was evaluated in 12 Japanese adults. In Part C (randomized, double-blind, crossover), the effects of single-dose zuranolone 10 and 30 mg and placebo on electroencephalography parameters were evaluated in eight Japanese adults. RESULTS Single and multiple doses of zuranolone were safe and well tolerated in all subjects. Linear pharmacokinetics were observed in the studied dose range. Time to steady-state plasma concentration was within 72 h for Japanese and White adults. Pharmacokinetic profiles were comparable between Japanese and White adults and between Japanese adults and Japanese elderly subjects. Plasma exposures of zuranolone were greater in the fed versus fasted state. Single-dose zuranolone 30 mg increased low-beta electroencephalography power. CONCLUSION In healthy Japanese subjects, zuranolone was well tolerated; pharmacokinetic profile was unaffected by ethnicity or age; plasma exposures were greater in the fed state. The increased low-beta electroencephalography power with the 30-mg dose is consistent with γ-aminobutyric acid receptor type A activation by zuranolone.
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Affiliation(s)
- Takuhiro Sonoyama
- Medical Science Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Ryosuke Shimizu
- Clinical Pharmacology & Pharmacokinetics, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Ryuji Kubota
- Clinical Pharmacology & Pharmacokinetics, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Yumiko Matsuo
- Clinical Pharmacology & Pharmacokinetics, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Daiki Okutsu
- Clinical Research Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Hideki Yamanaka
- Clinical Research Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
| | - Keiko Takasu
- Laboratory for Drug Discovery and Disease Research, Pharmaceutical Research DivisionShionogi & Co., Ltd.OsakaJapan
| | - Koichi Ogawa
- Laboratory for Drug Discovery and Disease Research, Pharmaceutical Research DivisionShionogi & Co., Ltd.OsakaJapan
| | - Tomoko Motomiya
- Project Management Department, Drug Development and Regulatory Science DivisionShionogi & Co., Ltd.OsakaJapan
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Evaluating the evidence for sex differences: a scoping review of human neuroimaging in psychopharmacology research. Neuropsychopharmacology 2022; 47:430-443. [PMID: 34732844 PMCID: PMC8674314 DOI: 10.1038/s41386-021-01162-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/12/2021] [Accepted: 08/13/2021] [Indexed: 01/03/2023]
Abstract
Although sex differences in psychiatric disorders abound, few neuropsychopharmacology (NPP) studies consider sex as a biological variable (SABV). We conducted a scoping review of this literature in humans by systematically searching PubMed to identify peer-reviewed journal articles published before March 2020 that (1) studied FDA-approved medications used to treat psychiatric disorders (or related symptoms) and (2) adequately evaluated sex differences using in vivo neuroimaging methodologies. Of the 251 NPP studies that included both sexes and considered SABV in analyses, 80% used methodologies that eliminated the effect of sex (e.g., by including sex as a covariate to control for its effect). Only 20% (50 studies) adequately evaluated sex differences either by testing for an interaction involving sex or by stratifying analyses by sex. Of these 50 studies, 72% found statistically significant sex differences in at least one outcome. Sex differences in neural and behavioral outcomes were studied more often in drugs indicated for conditions with known sex differences. Likewise, the majority of studies conducted in those drug classes noted sex differences: antidepressants (13 of 16), antipsychotics (10 of 12), sedative-hypnotics (6 of 10), and stimulants (6 of 10). In contrast, only two studies of mood stabilizers evaluated SABV, with one noting a sex difference. By mapping this literature, we bring into sharp relief how few studies adequately evaluate sex differences in NPP studies. Currently, all NIH-funded studies are required to consider SABV. We urge scientific journals, peer reviewers, and regulatory agencies to require researchers to consider SABV in their research. Continuing to ignore SABV in NPP research has ramifications both in terms of rigor and reproducibility of research, potentially leading to costly consequences and unrealized benefits.
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Pharmacokinetics and Pharmacodynamics of Remimazolam (CNS 7056) after Continuous Infusion in Healthy Male Volunteers: Part II. Pharmacodynamics of Electroencephalogram Effects. Anesthesiology 2020; 132:652-666. [PMID: 31972657 DOI: 10.1097/aln.0000000000003102] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Remimazolam (CNS 7056) is a new ultra-short acting benzodiazepine for IV sedation. This study aimed to investigate the electroencephalogram (EEG) pharmacodynamics of remimazolam infusion. METHODS Twenty healthy male volunteers received remimazolam as continuous IV infusion of 5 mg/min for 5 min, 3 mg/min for the next 15 min, and 1 mg/min for further 15 min. Continuous EEG monitoring was performed by a neurophysiologic system with electrodes placed at F3, F4, C3, C4, O1, O2, Cz, and Fp1 (10/20 system) and using the Narcotrend Index. Sedation was assessed clinically by using the Modified Observer's Assessment of Alertness and Sedation scale. Pharmacodynamic models were developed for selected EEG variables and Narcotrend Index. RESULTS EEG changes during remimazolam infusion were characterized by an initial increase in beta frequency band and a late increase in delta frequency band. The EEG beta ratio showed a prediction probability of Modified Observer's Assessment of Alertness and Sedation score of 0.79, and could be modeled successfully using a standard sigmoid Emax model. Narcotrend Index showed a prediction probability of Modified Observer's Assessment of Alertness and Sedation score of 0.74. The time course of Narcotrend Index was described by an extended sigmoid Emax model with two sigmoid terms and different plasma-effect equilibration times. CONCLUSIONS Beta ratio was identified as a suitable EEG variable for monitoring remimazolam sedation. Narcotrend Index appeared less suitable than the beta ratio for monitoring the sedative effect if remimazolam is administered alone.
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Meng Z, Berro LF, Sawyer EK, Rüedi-Bettschen D, Cook JE, Li G, Platt DM, Cook JM, Rowlett JK. Evaluation of the anti-conflict, reinforcing, and sedative effects of YT-III-31, a ligand functionally selective for α3 subunit-containing GABA A receptors. J Psychopharmacol 2020; 34:348-357. [PMID: 31670615 PMCID: PMC8011597 DOI: 10.1177/0269881119882803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In recent years, pharmacological strategies have implicated α3 subunit-containing GABAA (α3GABAA) receptor subtypes in the anxiety-reducing effects of benzodiazepines, whereas transgenic mouse approaches have implicated α2 or α5 subunit-containing GABAA receptors. AIMS We investigated the role of α3GABAA subtypes in benzodiazepine-induced behaviors by evaluating the anti-conflict, reinforcing, and sedative-motor effects of the novel compound YT-III-31, which has functional selectivity for α3GABAA receptors. METHODS Female and male rhesus monkeys were trained under a conflict procedure (n = 3), and a progressive-ratio schedule of reinforcement with midazolam as the training drug (n = 4). Sedative-like behavior was assessed using a quantitative behavioral observation procedure (n = 4). A range of doses of YT-III-31 was administered in all tests using the i.v. route of administration. RESULTS In the conflict procedure, increasing doses of YT-III-31 resulted only in dose-dependent attenuation of non-suppressed responding. In the progressive-ratio model of self-administration, YT-III-31 maintained average injections/session above vehicle levels at 0.1 and 0.18 mg/kg/injection. In quantitative observation procedures, YT-III-31 engendered mild sedative effects ("rest/sleep posture"), and deep sedation at the highest dose tested (5.6 mg/kg, i.v.), along with a suppression of tactile/oral exploration and increased observable ataxia. In contrast to other benzodiazepine-like ligands, YT-III-31 uniquely engendered a biphasic dose-response function for locomotion and suppressed self-groom. CONCLUSIONS The finding that YT-III-31 lacked anti-conflict properties is in accordance with transgenic mouse research indicating no role for α3GABAA subtypes in benzodiazepine-mediated anxiety reduction. Instead, our results raise the possibility of a role for α3GABAA receptors in the abuse potential and sedative effects of benzodiazepine-type drugs.
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Affiliation(s)
- Zhiqiang Meng
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA,New England Primate Research Center, Harvard Medical School, Southborough, MA, USA,Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, CHINA
| | - Lais F Berro
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA
| | - Eileen K Sawyer
- New England Primate Research Center, Harvard Medical School, Southborough, MA, USA
| | - Daniela Rüedi-Bettschen
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jemma E Cook
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA
| | - Guanguan Li
- Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Donna M Platt
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA,New England Primate Research Center, Harvard Medical School, Southborough, MA, USA
| | - James M Cook
- Department of Chemistry and Biochemistry, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - James K Rowlett
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA,New England Primate Research Center, Harvard Medical School, Southborough, MA, USA
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Zhao Y, Bijlsma EY, Verdouw MP, Groenink L. No effect of sex and estrous cycle on the fear potentiated startle response in rats. Behav Brain Res 2018; 351:24-33. [DOI: 10.1016/j.bbr.2018.05.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/26/2018] [Accepted: 05/15/2018] [Indexed: 12/13/2022]
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Crouch B, Sommerlade L, Veselcic P, Riedel G, Schelter B, Platt B. Detection of time-, frequency- and direction-resolved communication within brain networks. Sci Rep 2018; 8:1825. [PMID: 29379037 PMCID: PMC5788985 DOI: 10.1038/s41598-018-19707-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/08/2018] [Indexed: 11/26/2022] Open
Abstract
Electroencephalography (EEG) records fast-changing neuronal signalling and communication and thus can offer a deep understanding of cognitive processes. However, traditional data analyses which employ the Fast-Fourier Transform (FFT) have been of limited use as they do not allow time- and frequency-resolved tracking of brain activity and detection of directional connectivity. Here, we applied advanced qEEG tools using autoregressive (AR) modelling, alongside traditional approaches, to murine data sets from common research scenarios: (a) the effect of age on resting EEG; (b) drug actions on non-rapid eye movement (NREM) sleep EEG (pharmaco-EEG); and (c) dynamic EEG profiles during correct vs incorrect spontaneous alternation responses in the Y-maze. AR analyses of short data strips reliably detected age- and drug-induced spectral EEG changes, while renormalized partial directed coherence (rPDC) reported direction- and time-resolved connectivity dynamics in mice. Our approach allows for the first time inference of behaviour- and stage-dependent data in a time- and frequency-resolved manner, and offers insights into brain networks that underlie working memory processing beyond what can be achieved with traditional methods.
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Affiliation(s)
- Barry Crouch
- Institute of Medical Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, United Kingdom
| | - Linda Sommerlade
- Institute for Complex Systems and Mathematical Biology, University of Aberdeen, King's College, Old Aberdeen, AB24 3UE, United Kingdom
- Institute for Pure and Applied Mathematics, University of Aberdeen, King's College, Old Aberdeen, AB24 3UE, United Kingdom
| | - Peter Veselcic
- Institute of Medical Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, United Kingdom
- AbbVie Deutschland GmbH & Co. KG; Knollstr, 67061, Ludwigshafen, Germany
| | - Gernot Riedel
- Institute of Medical Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, United Kingdom
| | - Björn Schelter
- Institute for Complex Systems and Mathematical Biology, University of Aberdeen, King's College, Old Aberdeen, AB24 3UE, United Kingdom
- Institute for Pure and Applied Mathematics, University of Aberdeen, King's College, Old Aberdeen, AB24 3UE, United Kingdom
- TauRx Therapeutics Ltd, King Street, Aberdeen, United Kingdom
| | - Bettina Platt
- Institute of Medical Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, United Kingdom.
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Bifidobacterium longum 1714 as a translational psychobiotic: modulation of stress, electrophysiology and neurocognition in healthy volunteers. Transl Psychiatry 2016; 6:e939. [PMID: 27801892 PMCID: PMC5314114 DOI: 10.1038/tp.2016.191] [Citation(s) in RCA: 301] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/04/2016] [Accepted: 08/03/2016] [Indexed: 01/01/2023] Open
Abstract
The emerging concept of psychobiotics-live microorganisms with a potential mental health benefit-represents a novel approach for the management of stress-related conditions. The majority of studies have focused on animal models. Recent preclinical studies have identified the B. longum 1714 strain as a putative psychobiotic with an impact on stress-related behaviors, physiology and cognitive performance. Whether such preclinical effects could be translated to healthy human volunteers remains unknown. We tested whether psychobiotic consumption could affect the stress response, cognition and brain activity patterns. In a within-participants design, healthy volunteers (N=22) completed cognitive assessments, resting electroencephalography and were exposed to a socially evaluated cold pressor test at baseline, post-placebo and post-psychobiotic. Increases in cortisol output and subjective anxiety in response to the socially evaluated cold pressor test were attenuated. Furthermore, daily reported stress was reduced by psychobiotic consumption. We also observed subtle improvements in hippocampus-dependent visuospatial memory performance, as well as enhanced frontal midline electroencephalographic mobility following psychobiotic consumption. These subtle but clear benefits are in line with the predicted impact from preclinical screening platforms. Our results indicate that consumption of B. longum 1714 is associated with reduced stress and improved memory. Further studies are warranted to evaluate the benefits of this putative psychobiotic in relevant stress-related conditions and to unravel the mechanisms underlying such effects.
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Prefrontal activity decline in women under a single dose of diazepam during rule-guided responses: an fMRI study. Exp Brain Res 2016; 234:3483-3495. [PMID: 27491682 DOI: 10.1007/s00221-016-4746-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
Abstract
Daily life events confront us with new situations demanding responses to usual and unusual rules. Diazepam (DZ), a clinically important drug, facilitates the inhibitory activity of the GABAergic system. Prefrontal cortex, rich in DZ receptors, coordinates necessary resources to direct actions according to rules. The balance between excitatory and inhibitory activity is critical to achieve optimal function of brain systems leading to complex functions. Major sex differences in the physiological mechanisms of the GABAergic system have been reported. However, the differential influence of DZ on men and women in neural activity during behavior directed by frontal lobes remains unexplored. The ability of healthy volunteers to select responses following usual/congruent and novel/incongruent rules, and brain correlates were measured with fMRI under the administration of DZ and a placebo. 10 mg of DZ was enough to decrease the performance in a different manner between men and women. While reaction times increased in both men and women, women committed more errors selecting responses than men under DZ. Men demonstrated increased activity, while women demonstrated decreased activity in frontal regions involved in response selection of rules. These findings could have important consequences in understanding the differential influences of DZ between the sexes in complex daily life situations. More importantly, this study emphasizes the importance of understanding the differential effects on men and women of drugs widely employed by society, thereby achieves better therapeutic results and avoids side effects that the present study revealed to be different between sexes.
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Cross-conditional entropy and coherence analysis of pharmaco-EEG changes induced by alprazolam. Psychopharmacology (Berl) 2012; 221:397-406. [PMID: 22127555 DOI: 10.1007/s00213-011-2587-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 11/09/2011] [Indexed: 10/15/2022]
Abstract
RATIONALE Quantitative analysis of electroencephalographic signals (EEG) and their interpretation constitute a helpful tool in the assessment of the bioavailability of psychoactive drugs in the brain. Furthermore, psychotropic drug groups have typical signatures which relate biochemical mechanisms with specific EEG changes. OBJECTIVES To analyze the pharmacological effect of a dose of alprazolam on the connectivity of the brain during wakefulness by means of linear and nonlinear approaches. METHODS EEG signals were recorded after alprazolam administration in a placebo-controlled crossover clinical trial. Nonlinear couplings assessed by means of corrected cross-conditional entropy were compared to linear couplings measured with the classical magnitude squared coherence. RESULTS Linear variables evidenced a statistically significant drug-induced decrease, whereas nonlinear variables showed significant increases. All changes were highly correlated to drug plasma concentrations. The spatial distribution of the observed connectivity changes clearly differed from a previous study: changes before and after the maximum drug effect were mainly observed over the anterior half of the scalp. Additionally, a new variable with very low computational cost was defined to evaluate nonlinear coupling. This is particularly interesting when all pairs of EEG channels are assessed as in this study. CONCLUSIONS Results showed that alprazolam induced changes in terms of uncoupling between regions of the scalp, with opposite trends depending on the variables: decrease in linear ones and increase in nonlinear features. Maps provided consistent information about the way brain changed in terms of connectivity being definitely necessary to evaluate separately linear and nonlinear interactions.
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Diazepam-Induced Changes in EEG Oscillations During Performance of a Sustained Attention Task. J Clin Neurophysiol 2011; 28:394-9. [DOI: 10.1097/wnp.0b013e318227323a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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12
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Behavioural and neural effects of diazepam on a rule-guided response selection task. Neurosci Res 2011; 70:260-8. [DOI: 10.1016/j.neures.2011.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 03/06/2011] [Accepted: 03/20/2011] [Indexed: 11/22/2022]
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13
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Vogel conflict test: Sex differences and pharmacological validation of the model. Behav Brain Res 2011; 218:174-83. [DOI: 10.1016/j.bbr.2010.11.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 11/12/2010] [Accepted: 11/20/2010] [Indexed: 11/22/2022]
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Hall SD, Barnes GR, Furlong PL, Seri S, Hillebrand A. Neuronal network pharmacodynamics of GABAergic modulation in the human cortex determined using pharmaco-magnetoencephalography. Hum Brain Mapp 2010; 31:581-94. [PMID: 19937723 PMCID: PMC3179593 DOI: 10.1002/hbm.20889] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Neuronal network oscillations are a unifying phenomenon in neuroscience research, with comparable measurements across scales and species. Cortical oscillations are of central importance in the characterization of neuronal network function in health and disease and are influential in effective drug development. Whilst animal in vitro and in vivo electrophysiology is able to characterize pharmacologically induced modulations in neuronal activity, present human counterparts have spatial and temporal limitations. Consequently, the potential applications for a human equivalent are extensive. Here, we demonstrate a novel implementation of contemporary neuroimaging methods called pharmaco‐magnetoencephalography. This approach determines the spatial profile of neuronal network oscillatory power change across the cortex following drug administration and reconstructs the time course of these modulations at focal regions of interest. As a proof of concept, we characterize the nonspecific GABAergic modulator diazepam, which has a broad range of therapeutic applications. We demonstrate that diazepam variously modulates θ (4–7 Hz), α (7–14 Hz), β (15–25 Hz), and γ (30–80 Hz) frequency oscillations in specific regions of the cortex, with a pharmacodynamic profile consistent with that of drug uptake. We examine the relevance of these results with regard to the spatial and temporal observations from other modalities and the various therapeutic consequences of diazepam and discuss the potential applications of such an approach in terms of drug development and translational neuroscience. Hum Brain Mapp, 2010. © 2009 Wiley‐Liss, Inc.
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Affiliation(s)
- Stephen D Hall
- Biomedical Sciences, School of Life and Health Sciences, Aston University, Birmingham.
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Alonso JF, Mañanas MA, Romero S, Hoyer D, Riba J, Barbanoj MJ. Drug effect on EEG connectivity assessed by linear and nonlinear couplings. Hum Brain Mapp 2010; 31:487-97. [PMID: 19894215 PMCID: PMC6870649 DOI: 10.1002/hbm.20881] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 07/03/2009] [Accepted: 07/20/2009] [Indexed: 11/07/2022] Open
Abstract
Quantitative analysis of human electroencephalogram (EEG) is a valuable method for evaluating psychopharmacological agents. Although the effects of different drug classes on EEG spectra are already known, interactions between brain locations remain unclear. In this work, cross mutual information function and appropriate surrogate data were applied to assess linear and nonlinear couplings between EEG signals. The main goal was to evaluate the pharmacological effects of alprazolam on brain connectivity during wakefulness in healthy volunteers using a cross-over, placebo-controlled design. Eighty-five pairs of EEG leads were selected for the analysis, and connectivity was evaluated inside anterior, central, and posterior zones of the scalp. Connectivity between these zones and interhemispheric connectivity were also measured. Results showed that alprazolam induced significant changes in EEG connectivity in terms of information transfer in comparison with placebo. Trends were opposite depending on the statistical characteristics: decreases in linear connectivity and increases in nonlinear couplings. These effects were generally spread over the entire scalp. Linear changes were negatively correlated, and nonlinear changes were positively correlated with drug plasma concentrations; the latter showed higher correlation coefficients. The use of both linear and nonlinear approaches revealed the importance of assessing changes in EEG connectivity as this can provide interesting information about psychopharmacological effects.
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Affiliation(s)
- Joan F Alonso
- Biomedical Engineering Research Center, Department of Automatic Control, Universitat Politècnica de Catalunya, Barcelona, Spain.
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Galanopoulou AS. Sexually dimorphic expression of KCC2 and GABA function. Epilepsy Res 2008; 80:99-113. [PMID: 18524541 PMCID: PMC2613346 DOI: 10.1016/j.eplepsyres.2008.04.013] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Revised: 04/06/2008] [Accepted: 04/07/2008] [Indexed: 12/13/2022]
Abstract
GABA(A) receptors have an age-adapted function in the brain. During early development, they mediate depolarizing effects, which result in activation of calcium-sensitive signaling processes that are important for the differentiation of the brain. In more mature stages of development and in adults, GABA(A) receptors acquire their classical hyperpolarizing signaling. The switch from depolarizing to hyperpolarizing GABA(A)-ergic signaling is triggered through the developmental shift in the balance of chloride cotransporters that either increase (i.e. NKCC1) or decrease (i.e. KCC2) intracellular chloride. The maturation of GABA(A) signaling follows sex-specific patterns, which correlate with the developmental expression profiles of chloride cotransporters. This has first been demonstrated in the substantia nigra, where the switch occurs earlier in females than in males. As a result, there are sensitive periods during development when drugs or conditions that activate GABA(A) receptors mediate different transcriptional effects in males and females. Furthermore, neurons with depolarizing or hyperpolarizing GABA(A)-ergic signaling respond differently to neurotrophic factors like estrogens. Consequently, during sensitive developmental periods, GABA(A) receptors may act as broadcasters of sexually differentiating signals, promoting gender-appropriate brain development. This has particular implications in epilepsy, where both the pathophysiology and treatment of epileptic seizures involve GABA(A) receptor activation. It is important therefore to study separately the effects of these factors not only on the course of epilepsy but also design new treatments that may not necessarily disturb the gender-appropriate brain development.
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Affiliation(s)
- Aristea S Galanopoulou
- Albert Einstein College of Medicine, Saul R Korey Department of Neurology, Bronx, NY, USA.
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Cantello R, Varrasi C, Tarletti R, Cecchin M, D'Andrea F, Veggiotti P, Bellomo G, Monaco F. Ketogenic diet: electrophysiological effects on the normal human cortex. Epilepsia 2007; 48:1756-1763. [PMID: 17561954 DOI: 10.1111/j.1528-1167.2007.01156.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To explore the cortical electrophysiology of the ketogenic diet (KD) in the normal human. KD is effective against refractory epilepsy, but its precise mechanism is obscure. At the transmitter level, an enhancement of GABA inhibition has often been proposed. METHODS We studied eight healthy volunteers undergoing a "classic" KD for 2 weeks. We measured several biochemical variables at baseline (T0), after 1 week (T1) and 2 weeks (T2) of KD, then 3 months after the KD conclusion (T3). Ketosis was quantified as 24-h ketonuria. At the same time, we studied the motor cortical excitability by means of transcranial magnetic stimulation (TMS). We also quantitatively evaluated the EEG signal in search of frequency shifts over the rolandic areas. RESULTS Significant (p < 0.05) neurophysiological changes appeared at T2. These consisted of a strengthening of short-latency cortical inhibition (SICI), a TMS index which is thought to reflect GABA-A inhibition in the cortex. Then, there was an enhancement of the beta EEG band over the perirolandic region, similar to that following administration of GABA-A agonists. All changes disappeared at T3. CONCLUSIONS A standard, short-term KD affected the cortical physiology of the normal human. The main changes were an augmented SICI and an increased perirolandic beta EEG activity, which are compatible with a lower level of neural excitation within the cortex.
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Affiliation(s)
- Roberto Cantello
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
| | - Claudia Varrasi
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
| | - Roberto Tarletti
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
| | - Michela Cecchin
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
| | - Federico D'Andrea
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
| | - Pierangelo Veggiotti
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
| | - Giorgio Bellomo
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
| | - Francesco Monaco
- Department of Clinical and Experimental Medicine, Section of NeurologySection of Clinical Chemistry, "A. Avogadro" University, Novara, ItalyDepartment of Diet and Nutrition, "Maggiore della Carità" Hospital, Novara, ItalyDepartment of Child Neurology and Psychiatry, IRCCS Fondazione, Istituto Neurologico Casimiro Mondino, University of Pavia, Italy
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van Broekhoven F, Bäckström T, van Luijtelaar G, Buitelaar JK, Smits P, Verkes RJ. Effects of allopregnanolone on sedation in men, and in women on oral contraceptives. Psychoneuroendocrinology 2007; 32:555-64. [PMID: 17470385 DOI: 10.1016/j.psyneuen.2007.03.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2006] [Revised: 03/18/2007] [Accepted: 03/19/2007] [Indexed: 10/23/2022]
Abstract
Allopregnanolone is a known GABA(A) receptor agonist not previously given to men, or to women using oral contraceptives (OC). The effects of metabolites of sex hormones on the GABA(A) receptor are different between men and women. OC are known to change GABA(A) receptor subunit composition. These factors might play a role in the differential effect of allopregnanolone in men and women, and in women with or without OC. To study the sedative effect of and sensitivity to allopregnanolone in men and in women with OC, nine healthy men (mean age 24.6 years) and nine healthy women on OC (mean age 21.8 years) were given three, increasing, intravenous dosages (0.015, 0.03, and 0.045 mg/kg) of allopregnanolone. Saccadic eye velocity (SEV), subjective ratings, and electroencephalography (EEG) were used to evaluate the response to allopregnanolone. Repeated blood samples for analyses of serum allopregnanolone levels were drawn throughout the study day. Allopregnanolone decreased SEV more in women than in men, and increased subjective ratings of 'sedation'. The results in women on OC are similar to earlier results in women without OC. Subjective ratings of 'contentedness' decreased in men but increased in women. Serum levels of allopregnanolone were more highly increased in men compared to women. Other pharmacokinetic parameters were not different between sexes. On the EEG, beta power increased in men. In conclusion, men and women on OC reacted differently to allopregnanolone.
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Affiliation(s)
- F van Broekhoven
- Department of Psychiatry, Unit for Clinical Psychopharmacology and Neuropsychiatry, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Corsi-Cabrera M, Ondarza R, Martínez-Gutiérrez V, del Río-Portilla Y, Guevara MA, Ramos-Loyo J. Role of corpus callosum in interhemispheric coherent activity during sleep. Clin Neurophysiol 2006; 117:1826-35. [PMID: 16807092 DOI: 10.1016/j.clinph.2006.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 05/09/2006] [Accepted: 05/21/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate to what extent the increase in interhemispheric coherent activity observed from wakefulness to sleep depends on the integrity of the corpus callosum (CC). METHODS Interhemispheric coherent activity was analyzed in two epileptic patients selected for callosotomy because of multifocal refractory epilepsy, before and 4 months after callosotomy. One patient underwent complete callosotomy and another was subjected to callosotomy of the anterior 2/3, which offered the possibility of comparing the role of the CC in the coherent activity increase from wakefulness to sleep, between anterior regions with interrupted CC communication (in the two patients) and posterior regions with intact communication (in one of them). Results were compared with a group of normal subjects. RESULTS Both patients showed increased coherent activity from wakefulness to sleep after surgery. CONCLUSIONS Results demonstrate that interhemispheric coherent activity, despite an attenuation after surgery, is higher during SWS than during wakefulness after sectioning the CC; however, they have to be taken with caution because they come from two patients only. SIGNIFICANCE Present results show that the increase in coherent activity during sleep does not depend exclusively on callosal integrity but also on state-dependent influences from sleep-promoting mechanisms, probably spread throughout the thalamo-cortical network.
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Affiliation(s)
- M Corsi-Cabrera
- Facultad de Psicología, Posgrado, Universidad Nacional Autónoma de México, México City, Mexico.
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Abstract
In spite of its origins deeply rooted in the discipline, pharmaco-EEG applications in psychiatry remain limited to its achievements in the field of psychotropic drugs classification and, in few instances, discovery. In the present paper two attempts to transfer pharmaco-EEG methods to psychiatric clinical routine will be described: 1) monitoring of psychotropic drug toxicity at the central nervous system level, and 2) prediction of clinical response to treatment with psychotropic drugs. Both applications have been the object of several investigations providing promising and sometimes consistent findings which, however, had no impact on clinical practice. For the first topic, the review is limited to antipsychotics, lithium and recreational drugs, as for other psychotropic drugs mostly case studies are available, while for the response prediction it will include antipsychotics, antidepressants, anxiolytics, psychostimulants and nootropics. In spite of several methodological limitations, pharmaco-EEG studies dealing with monitoring of antipsychotic- and lithium-induced EEG abnormalities went close to, but never became, a clinical routine. EEG studies of recreational drugs are flawed by several limitations, and failed, so far, to identify reliable indices of CNS toxicity to be used in clinical settings. Several QEEG studies on early predictors of treatment response to first generation antipsychotics have produced consistent findings, but had no clinical impact. For other psychotropic drug classes few and inconsistent reports have appeared. Pharmaco-EEG had the potential for important clinical applications, but so far none of them entered clinical routine. The ability to upgrade theories and methods and promote large scale studies represent the future challenge.
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Affiliation(s)
- Armida Mucci
- Department of Psychiatry, University of Naples SUN, Naples, Italy.
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Gordon JA, Lacefield CO, Kentros CG, Hen R. State-dependent alterations in hippocampal oscillations in serotonin 1A receptor-deficient mice. J Neurosci 2006; 25:6509-19. [PMID: 16014712 PMCID: PMC6725436 DOI: 10.1523/jneurosci.1211-05.2005] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Mice lacking the serotonin 1A receptor (5-HT(1A)R) show increased levels of anxiety-related behavior across multiple tests and background strains. Tissue-specific rescue experiments, lesion studies, and neurophysiological findings all point toward the hippocampus as a potential mediator of the phenotype. Serotonin, acting through 5-HT(1A)Rs, can suppress hippocampal theta-frequency oscillations, suggesting that theta oscillations might be increased in the knock-outs. To test this hypothesis, local field potential recordings were obtained from the hippocampus of awake, behaving knock-outs and wild-type littermates. The magnitude of theta oscillations was increased in the knock-outs, specifically in the anxiety-provoking elevated plus maze and not in a familiar environment or during rapid eye movement sleep. Theta power correlated with the fraction of time spent in the open arms, an anxiety-related behavioral variable. These results suggest a possible role for the hippocampus, and theta oscillations in particular, in the expression of anxiety in 5-HT(1A)R-deficient mice.
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Affiliation(s)
- Joshua A Gordon
- Center for Neurobiology and Behavior, Department of Psychiatry, Columbia University, New York, New York 10032, USA.
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Solis-Ortiz S, Guevara MA, Corsi-Cabrera M. Performance in a test demanding prefrontal functions is favored by early luteal phase progesterone: an electroencephalographic study. Psychoneuroendocrinology 2004; 29:1047-57. [PMID: 15219656 DOI: 10.1016/j.psyneuen.2003.10.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2003] [Revised: 10/08/2003] [Accepted: 10/24/2003] [Indexed: 10/26/2022]
Abstract
There are some psychological studies showing changes in intellectual efficiency before and during menstruation. Many women report that they experience a feeling of difficulty to initiate activities, confront challenging situations and lack of concentration suggesting transient changes in frontal lobe functions related with gonadal hormone levels. Therefore, performance of a task demanding prefrontal functions, the Wisconsin Card Sorting Test, with simultaneous recording of electroencephalographic (EEG) activity was assessed in 9 healthy women, in a repeated measure study, during ovulation (OVU), early luteal (EL), late luteal (LL) and menstrual (MEN) phases. Spectral power of base line and task EEG, and number of responses to reach successful and unsuccessful outcomes in the task were evaluated. Performance was impaired to a certain degree during the OVU phase and was associated with an attenuated alpha1 power and with an increase of the theta and beta2 power. Performance was better during EL phase, when progesterone level is at its highest, no significant changes were observed from BL to task. Performance was worse during LL phase when hormone levels are at its lowest and was associated with a decrease in beta1 and beta2 power together with a significant attenuation of alpha1 and alpha2 power. During MEN phase performance was also improved and was associated with a significant decrease of alpha1 and alpha2 power and no changes in beta power were observed. These findings show that performance of a task demanding internal attention and planning is modulated by physiological progesterone and estrogen levels during menstrual cycle and is associated with specific EEG profiles.
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Affiliation(s)
- S Solis-Ortiz
- Instituto de Investigaciones Medicas, Universidad de Guanajuato, 20 de Enero 929, Leon, Guanajuato, CP 37320, Mexico.
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Wilson MA, Burghardt PR, Ford KA, Wilkinson MB, Primeaux SD. Anxiolytic effects of diazepam and ethanol in two behavioral models: comparison of males and females. Pharmacol Biochem Behav 2004; 78:445-58. [PMID: 15251253 DOI: 10.1016/j.pbb.2004.04.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Revised: 04/14/2004] [Accepted: 04/19/2004] [Indexed: 11/21/2022]
Abstract
The present study compared the anxiolytic effects of the benzodiazepine agonist diazepam and ethanol in adult male and female rats. Varying doses of diazepam (1-3 mg/kg) or ethanol (0.5-2.0 g/kg) were tested using both the elevated plus maze and defensive prod-burying models. Two time points following ethanol administration (10 and 30 min) were tested in the plus maze. Sex differences were seen in some anxiety-related behaviors, with females showing greater open arm time and reduced burying behavior than males. Although this suggests females displayed less anxiety-like behavior than males, the differences in the plus maze were not observed in all testing situations. Both diazepam and ethanol dose-dependently increased open arm times in the plus maze and reduced burying behavior in the defensive prod-burying task. The parallel nature of the dose-response curves suggests that both diazepam and ethanol have similar anxiolytic effects in males and females. No sex differences were seen in the brain levels of diazepam-like activity or blood alcohol levels with these treatments. A greater corticosterone response was observed in females than males with these two behavioral tests, but neither diazepam nor ethanol decreased this response. These results suggest a dissociation between the anxiety-reducing influences of these compounds and the changes in stress-related endocrine responses.
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Affiliation(s)
- Marlene A Wilson
- Department of Pharmacology, Physiology and Neuroscience, University of South Carolina School of Medicine, Building 1, D26 Columbia, SC 29208, USA.
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