Changes on recovery in the concentrations of tryptophan and the biogenic amine metabolites in the cerebrospinal fluid of patients with affective illness

Neuroactive Kynurenines as Pharmacological Targets: New Experimental Tools and Exciting Therapeutic Opportunities

Both preclinical and clinical studies implicate functional impairments of several neuroactive metabolites of the kynurenine pathway (KP), the major degradative cascade of the essential amino acid tryptophan in mammals, in the pathophysiology of neurologic and psychiatric diseases. A number of KP enzymes, such as tryptophan 2,3-dioxygenase (TDO2), indoleamine 2,3-dioxygenases (IDO1 and IDO2), kynurenine aminotransferases (KATs), kynurenine 3-monooxygenase (KMO), 3-hydroxyanthranilic acid oxygenase (3-HAO), and quinolinic acid phosphoribosyltransferase (QPRT), control brain KP metabolism in health and disease and are therefore increasingly considered to be promising targets for the treatment of disorders of the nervous system. Understanding the distribution, cellular expression, and regulation of KP enzymes and KP metabolites in the brain is therefore critical for the conceptualization and implementation of successful therapeutic strategies. SIGNIFICANCE STATEMENT: Studies have implicated the kynurenine pathway of tryptophan in the pathophysiology of neurologic and psychiatric diseases. Key enzymes of the kynurenine pathway regulate brain metabolism in both health and disease, making them promising targets for treating these disorders. Therefore, understanding the distribution, cellular expression, and regulation of these enzymes and metabolites in the brain is critical for developing effective therapeutic strategies. This review endeavors to describe these processes in detail.

Tryptophan Catabolites in Bipolar Disorder: A Meta-Analysis

Objective

Tryptophan catabolites (TRYCATs) are implicated in the pathophysiology of mood disorders by mediating immune-inflammation and neurodegenerative processes. We performed a meta-analysis of TRYCAT levels in bipolar disorder (BD) patients compared to healthy controls.

Methods

A systematic literature search in seven electronic databases (PubMed, Embase, Web of Science, Cochrane, Emcare, PsycINFO, Academic Search Premier) was conducted on TRYCAT levels in cerebrospinal fluid or peripheral blood according to the PRISMA statement. A minimum of three studies per TRYCAT was required for inclusion. Standardized mean differences (SMD) were computed using random effect models. Subgroup analyses were performed for BD patients in a different mood state (depressed, manic). The methodological quality of the studies was rated using the modified Newcastle-Ottawa Quality assessment Scale.

Results

Twenty-one eligible studies were identified. Peripheral levels of tryptophan (SMD = -0.44; p < 0.001), kynurenine (SMD = - 0.3; p = 0.001) and kynurenic acid (SMD = -.45; p = < 0.001) were lower in BD patients versus healthy controls. In the only three eligible studies investigating TRP in cerebrospinal fluid, tryptophan was not significantly different between BD and healthy controls. The methodological quality of the studies was moderate. Subgroup analyses revealed no significant difference in TRP and KYN values between manic and depressed BD patients, but these results were based on a limited number of studies.

Conclusion

The TRYCAT pathway appears to be downregulated in BD patients. There is a need for more and high-quality studies of peripheral and central TRYCAT levels, preferably using longitudinal designs.

Depression: The predisposing influence of stress

Aversive experiences have been thought to provoke or exacerbate clinical depression. The present review provides a brief survey of the stress-depression literature and suggests that the effects of stressful experiences on affective state may be related to depletion of several neurotransmitters, including norepinephrine, dopamine, and serotonin. A major element in determining the neurochemical changes is the organism's ability to cope with the aversive stimuli through behavioral means. Aversive experiences give rise to behavioral attempts to cope with the stressor, coupled with increased utilization and synthesis of brain amines to contend with environmental demands. When behavioral coping is possible, neurochemical systems are not overly taxed, and behavioral pathology will not ensue. However, when there can be no behavioral control over the stressful stimuli, or when the aversive experience is perceived as uncontrollable, increased emphasis is placed on coping through endogenous neurochemical mechanisms. Amine utilization increases appreciably and may exceed synthesis, resulting in a net reduction of amine stores, which in turn promotes or exacerbates affective disorder. The processes governing the depletions may be subject to sensitization or conditioning, such that exposure to traumatic experiences may have long-term repercussions when the organism subsequently encounters related stressful stimuli. With continued uncontrollable stimulation, adaptation occurs in the form of increased activity of synthetic enzymes, and levels of amines approach basal values. It is suggested that either the initial amine depletion provoked by aversive experiences or a dysfunction of the adaptive processes, resulting in persistent amine depletion, contributes to behavioral depression. Aside from the contribution of behavioral coping, several organismic, experiential, and environmental variables will influence the effects of aversive experiences on neurochemical activity, and may thus influence vulnerability to depression.

Serotonin-immune interactions in major depression: lower serum tryptophan as a marker of an immune-inflammatory response

Serum total tryptophan and the five competing amino acids (CAA), i.e., valine, leucine, tyrosine, phenylalanine, and isoleucine were determined in 35 major depressed subjects of whom 27 with treatment resistant depression (TRD), and 15 normal controls. Twenty-five of the depressed subjects had repeated measurements of the amino acids both before and after antidepressive treatment. The following immune-inflammatory variables were assayed in the above subjects: serum zinc (Zn), total serum protein (TSP), albumin (Alb), transferrin (Tf), iron (Fe), high-density lipoprotein cholesterol (HDL-C), number of peripheral blood leukocytes, and the CD4+/CD8+ T cell (T-helper/T-suppressor) ratio. Serum tryptophan and the tryptophan/CAA ratio were significantly lower in major depressed subjects than in normal controls. The tryptophan/CAA ratio was significantly lower in patients with TRD than in patients without TRD and normal controls. There were no significant alterations in any of the amino acids upon successful therapy. There were significant correlations between serum tryptophan and serum Zn, TSP, Alb, Tf, Fe, and HDL-C (all positive), and number of leukocytes and the CD4+/CD8+ T-cell ratio (all negative). The tryptophan/CAA ratio was significantly and negatively related to the number of leukocytes and the CD4+/CD8+ T-cell ratio. The results suggest that (a) TRD is characterized by lower availability of serum tryptophan; (b) the availability of tryptophan may remain decreased despite clinical recovery; and (c) the lower availability of tryptophan is probably a marker of the immune-inflammatory response during major depression.

Platelet serotonin levels in alcoholic patients: changes related to physiological and pathological factors

This study investigated platelet serotonin (5-hydroxytryptamine; 5-HT) levels and the effects of different physiological and pathological factors in 108 alcoholic patients (alcohol abuse, n = 49; alcohol dependence, n = 59) and 32 healthy control subjects. Platelet 5-HT levels were determined by a fluorescent-ortho-phthalaldehyde assay. In patients, platelet 5-HT levels during withdrawal from alcohol and after 2 weeks of abstinence were significantly lower than in control subjects. Among patients, this decrease was enhanced both in alcohol-dependent patients and in patients who were depressed during the withdrawal phase, whereas lifetime impulse control disorders (mostly found in alcohol abusers) were associated with comparatively high platelet 5-HT levels (i.e., close to control subjects' values). These results, which reflect the likely biphasic effect of alcohol ingestion upon 5-HT functioning, are consistent with the dimensional 5-HT hypothesis in psychiatric disorders.

Autoradiographic analysis of [3H]ketanserin binding in the human brain postmortem: effect of suicide

In vitro quantitative autoradiography of 5-HT2 receptors, using [3H]ketanserin as a ligand, was performed on 24 human brains postmortem. Twelve brains were donated by suicide victims and 12 by matched controls. We found a characteristic decline in 5-HT2 receptors with age in several brain regions of the control group. This age dependence of ketanserin binding was not present in some of these brain regions of the suicide group. We also found a significant but anatomically selective reduction in the density of ketanserin binding sites in the young suicide group, compared to age-matched controls. This reduction was evident in portions of the prefrontal cortex. Homogenate binding assays on prefrontal cortex samples from a large group of suicides (n = 20) and controls (n = 23) showed that the difference in age dependence of ketanserin binding and the reduced binding in the young suicide group were explained by differences in Bmax values. No differences were observed in Kd. Sex, presence of alcohol and time from death to autopsy did not affect ketanserin binding, in our sample, as measured by either autoradiography or homogenate binding assay.

Fluvoxamine and imipramine in the treatment of depressive patients: a double-blind controlled study

A double-blind, controlled study was carried out in 20 patients diagnosed as suffering from depressive disorder according to DSM-III criteria to compare the effectiveness and tolerability of fluvoxamine, a serotonin re-uptake inhibitor, with that of imipramine. Patients were allocated at random to receive one or other drug for a period of 4 weeks, dosage starting at 50 mg for the first 3 days and increasing to 100 mg daily for a further 3 days. Dosage was continued at this level for the remainder of the trial but was increased, if necessary, to 150 mg daily in two divided doses. Assessments of symptom severity were made on entry and response after 1, 2 and 4 weeks of treatment using the Hamilton Rating Scale for Depression, the Clinical Global Impression and a Visual Analogue Scale. Tolerability was assessed using the Dosage Record and Treatment Emergent Symptom Scale. The results showed that at the end of the trial there was a significant reduction in depressive symptoms severity in both groups and that fluvoxamine was significantly more effective than imipramine in reducing suicidal ideas and anxiety/somatic symptoms. Both drugs were relatively well tolerated but the side-effect profiles were different, being mainly of the anticholinergic type with the tricyclic and gastro-intestinal with fluvoxamine.

Biogenic amines and their metabolites in body fluids of normal, psychiatric and neurological subjects

The biogenic monoamines and their metabolites have been isolated, identified and quantified in human body fluids over the past forty years using a wide variety of chromatographic separation and detection techniques. This review summarizes the results of those studies on normal, psychiatric and neurological subjects. Tables of normal values and the methods used to obtain them should prove to be useful as a reference source for benchmark amine and metabolite concentrations and for successful analytical procedures for their chromatographic separation, detection and quantification. Summaries of the often contradictory results of the application of these methods to psychiatric and neurological problems are presented and may assist in the assessment of the validity of the results of experiments in this field. Finally, the individual, environmental and the methodological factors affecting the concentrations of the amines and their metabolites are discussed.

Biology of depression

Research over the past three decades has led to a greater understanding of the biologic basis of depression. Observations that certain medications could improve or worsen mood led to the development of hypotheses describing the possible role of specific neurotransmitters in the brain in depression. Modifications of these original hypotheses focused on altered receptor function, failures in the regulation of neurotransmitter systems, and interactions of the monoamines with cholinergic systems. Strategies using endocrinologic measurements in the evaluation of the depressed patient have provided researchers with new clues regarding disordered neuroendocrine function in depression and clinicians with new tests to aid in diagnosis and management. Moreover, the development of standardized sleep EEG methodology has proven useful for the identification of characteristic sleep abnormalities in depression. Although there are many methodologic and clinical problems still to be resolved, the use of biological markers in the assessment of the depressed patient is increasing, and is likely to be of significant importance in the future. Finally, recent advances in molecular genetics hold promise for further advances in our understanding of the inheritance and biochemistry of depression.

Ventricular size and CSF transmitter metabolite concentrations in severe endogenous depression

The relationship between neurotransmitter metabolite concentrations and measurements of ventricular size on CAT scans and pneumoencephalographs was investigated in 15 patients with severe affective disorder. An association was identified between reduced levels of plasma free tryptophan and ventricular enlargement, and also between raised ventricular CSF levels of 5 HIAA and ventricular enlargement.

Clinical and neuroendocrine features of endogenous unipolar and bipolar depression

A group of 19 patients suffering from endogenous unipolar depression was compared with another group of eight patients with bipolar depression. Comparisons were based on psychopathological features together with results of the dexamethasone suppression test and the thyrotropin releasing hormone stimulation test. Unipolar patients showed more frequent loss of weight, reduced appetite, autonomic disturbances, muscular tension, sadness, and reduced sexual interest, whereas bipolar patients showed more frequent hostile feelings. Each neuroendocrine test identified at least 50% of the patients in each group. The combined use of both tests identified about 75% of the patients. The bipolar depressives obtained slightly but not significantly higher rates of positive results in each test and a more frequent association of abnormality in both tests.

5-hydroxytryptamine and depression: a model for the interaction of normal variance with pathology

1 Theories linking 5-hydroxytryptamine (5-HT) with depression are briefly reviewed. The various experimental strategies adopted to investigate this relationship, examination of autopsy data, CSF metabolite data, 5-HT re-uptake patterns in human blood platelets and imipramine binding studies in human platelets, are discussed. 2 Recent studies of 5-hydroxyindole acetic acid (5-HIAA) levels in cerebrospinal fluid have revealed a linkage between low 5-HIAA levels and suicide, aggression and impulsivity. Decreases in the number of imipramine binding sites have also been found in brains of suicide victims. 3 The available data lead to the conclusion that decreased 5-hydroxytryptaminergic function may be associated with an increased risk of depression, suicide, and some types of aggression.

Statistical power in biological psychiatry

The use of statistical power and power analysis in both the design and evaluation of experiments in biological psychiatry is described. The possible consequences of low power investigations are discussed, and guidelines are provided to facilitate the application of power analysis. Power curves are provided for sample sizes ranging from 10 to 100 for the Student's t test, and for testing the significance of an obtained Pearson correlation coefficient at both the 0.01 and 0.05 alpha levels. Additionally, difference scales are provided for plasma cortisol and for several neurotransmitter metabolites that are frequently measured in cerebrospinal fluid (CSF). Power evaluation of selected CSF studies measuring neurotransmitter metabolites in depressives and controls suggests the majority had less than a 50% chance of detecting a medium size difference before the experiment was actually performed.

Serotonin and dopamine disturbances in patients with unipolar depression and Parkinsonism

Probenecid was administered to 7 unipolar depressed patients, 7 parkinsonians and 7 extrapyramidal patients with senile dementia matched for age and sex. Before and after the administration of probenecid, the levels of 5 hydroxyindoleacetic acid (5HIAA) and homovanillic acid (HVA) were determined in the cerebrospinal fluid (CSF) of all patients in order to study the central turnover rate of serotonin and dopamine. Unipolar depressed patients showed a significantly lower increase in CSF 5HIAA levels after probenecid than parkinsonians. Patients with Parkinsonism had a reduced increment of CSF HVA levels following probenecid administration when compared to unipolar depressed and extrapyramidal patients with senile dementia.

Reassessing the bipolar-unipolar dichotomy

This paper is a critical review of the literature on the dichotomous classification of affective disorders into unipolar and bipolar types. The majority of genetic studies show significant overlap in the liability to develop two forms of illness, and the majority of lithium studies show a similar clinical responsiveness of both groups to both acute and maintenance treatment. Biological studies comparing the two groups are difficult to interpret as most have compared manics to depressives without controlling for motor activity, excitement, and other state-dependent clinical variables. Viewed in light of our research findings in a recent genetic study of affective states, we believe these data suggest that the separation of affective disorders by polarity may have been premature, and that the search for heterogeneity should now be carried out using alternative strategies.

Tryptophan, 5-hydroxyindoleacetic acid and indoleacetic acid in human cerebrospinal fluid: interrelationships and the influence of age, sex, epilepsy and anticonvulsant drugs

Tryptophan, 5-hydroxyindoleacetic acid and indoleacetic acid were measured in cerebrospinal fluid, taken during pneumoencephalography, from a large series of patients, the majority of whom were epileptics, most of them receiving anticonvulsants. CSF indoleacetic acid reflects CNS tyrptamine metabolism in the same way that CSF 5-hydroxyindoleacetic acid reflects CNS 5-hydroxytryptamine metabolism. Our data suggest that (i) the brain tryptophan content is an important factor in the control of both 5-hydroxytryptamine and tryptamine synthesis (ii) brain 5-hydroxytryptamine metabolism exhibits a U-shaped relationship with age (iii) the mean brain tryptophan content and rate of 5-hydroxytryptamine metabolism are greater for women than men (iv) indoleamine metabolism is unaffected in untreated epileptics compared with non-epileptics, but anticonvulsant drugs decrease the rate of 5-hydrosytryptamine metabolism.

Tryptophan disposition in psychiatric patients before and after stress

Non-esterified fatty acid and total and free tryptophan were determined in the plasma of psychiatric patients unselected with respect to psychiatric diagnosis and in the plasma of normal subjects before and after physiological and psychiatric tests. Retarded patients had significantly low total and free tryptophan values which correlated negatively with agitation. Total tryptophan fell significantly after testing in the non-retarded subjects. The only biochemical abnormality significantly associated with a diagnosis of primary depression was the rise of plasma non-esterified fatty acid after testing. Thus, tryptophan abnormalities were associated more with psychiatric rating scores than with diagnoses.

Tryptophan-nicotinamide, imipramine and their combination in depression. A controlled study

In a double-blind controlled study lasting 4 weeks 25 newly admitted severely depressed patients were randomly assigned to tryptophan-nicotinamide or imipramine or tryptophan-nicotinamide-imipramine combination. Nicotinamide was given to reduce peripheral breakdown of tryptophan. Although there were no substantial differences between the three treatments, the efficacy of tryptophan-nicotinamide tended to diminish after 2 weeks when the dose of tryptophan was increased from 4 g/day to 6 g/day and that of nicotinamide from 1.0 g/day to 1.5 g/day. The therapeutic response of patients treated with tryptophan-nicotinamide was significantly correlated with the rise in plasma tryptophan. For the tryptophan-nicotinamide-imipramine group, however, therapeutic response and rise in plasma tryptophan were negatively correlated, implying that tryptophan levels were too high in some patients. The data suggest that tryptophan-nicotamide may be as effective as imipramine in unipolar patients providing the dose is kept within the therapeutic window, and that at low doses it could also potentiate the action of tricyclic antidepressants. Bipolar patients seem to require higher doses of tryptophan than unipolar patients.