The challenges of psychopharmacogenetics

Pathophysiology of depression and mechanisms of treatment

Major depression is a serious disorder of enormous sociological and clinical relevance. The discovery of antidepressant drugs in the 1950s led to the first biochemical hypothesis of depression, which suggested that an impairment in central monoaminergic function was the major lesion underlying the disorder. Basic research in all fields of neuroscience (including genetics) and the discovery of new antidepressant drugs have revolutionized our understanding of the mechanisms underlying depression and drug action. There is no doubt that the monoaminergic system is one of the cornerstones of these mechanisms, but multiple interactions with other brain systems and the regulation of central nervous system function must also be taken into account In spite of all the progress achieved so far, we must be aware that many open questions remain to be resolved in the future.

Pharmacogenetics of the serotonin transporter

Response to psychopharmacologic drugs is genetically complex, results from an interplay of multiple genomic variations with environmental influences, and depends on the structure or functional expression of gene products, which are direct drug targets or indirectly modify the development and synaptic plasticity of neural networks critically involved in their effects. During brain development, the serotonin (5HT) system, which is commonly targeted by antidepressant, anxiolytic, and antipsychotic drugs, controls neuronal specification, differentiation, and phenotype maintenance. While formation and integration of these neural networks is dependent on the action of multiple proteins, converging lines of evidence indicate that genetically controlled variability in the expression of the 5HT transporter (5HTT) is critical to the development and plasticity of distinct neurocircuits. The most promising finding to date indicate an association between the response time as well as overall response to serotonin reuptake inhibitors (SSRIs) and a common polymorphism (5HTTLPR) within the transcriptional control region of the 5HTT gene (SLC6A4) in patients with depressive disorders. The formation and maturation of serotonergic and associated systems, in turn, are influencing the efficacy of serotonergic compounds in a variety of psychiatric conditions. Based on the notion that complex gene x gene and gene x environment interactions in the regulation of brain plasticity are presumed to contribute to individual differences in psychopharmacologic drug response, the concept of developmental psychopharmacogenetics is emerging.

Candidate genes for antidepressant response to selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) can safely and successfully treat major depression, although a substantial number of patients benefit only partially or not at all from treatment. Genetic polymorphisms may play a major role in determining the response to SSRI treatment. Nonetheless, it is likely that efficacy is determined by multiple genes, with individual genetic polymorphisms having a limited effect size. Initial studies have identified the promoter polymorphism in the gene coding for the serotonin reuptake transporter as moderating efficacy for several SSRIs. The goal of this review is to suggest additional plausible polymorphisms that may be involved in antidepressant efficacy. These include genes affecting intracellular transductional cascades; neuronal growth factors; stress-related hormones, such as corticotropin-releasing hormone and glucocorticoid receptors; ion channels and synaptic efficacy; and adaptations of monoaminergic pathways. Association analyses to examine these candidate genes may facilitate identification of patients for targeted alternative therapies. Determining which genes are involved may also assist in identifying future, novel treatments.

Determination of serotonin, noradrenaline, dopamine and their metabolites in rat brain extracts and microdialysis samples by column liquid chromatography with fluorescence detection following derivatization with benzylamine and 1,2-diphenylethylenediamine

A highly selective and sensitive column liquid chromatographic method for fluorescence determination of serotonin (5-HT), dopamine (DA), noradrenaline (NA) and their related metabolites 5-hydroxyindole-3-acetic acid (5-HIAA) and 3,4-dihydroxyphenylacetic acid (DOPAC) following derivatization with benzylamine and 1,2-diphenylethylenediamine (DPE) is described. The monoamines and the metabolites (20 microl samples) were derivatized in a two-step reaction, initiated with 20 microl of 0.3M benzylamine in 0.3M 3-cyclohexylaminopropanesulfonic acid (CAPS) buffer (pH 10.0), (for 5-HT, 5-HIAA, 2 min, 24 degrees C) and followed by 20 microl of 0.1M DPE in 0.3M glycine buffer (pH 10.0), (for DA, NA, DOPAC, 20 min, 50 degrees C). Both reagents contained 0.02 M potassium hexacyanoferrate(III) and 50% (v/v) methanol. The resulting highly fluorescent and stable benzoxazole derivatives were isocratically separated on a reversed-phase column (150 mm x 1.5 mm i.d., packed with C18 silica, 5 microm) within 45 min. Using fluorescence detection at ex. and em. wavelengths of 345 and 480 nm, respectively, the detection limit (signal-to-noise ratio of 3) for 5-HT, DA, NA, 5-HIAA, L-DOPA and DOPAC ranged between 0.08 and 5.65 fmol per 20-microl injection (12-847.5 pM in standard solution). The concentrations of monoamines (expressed in microg/g wet weight, mean +/- S.E.M., n=5) in tissue extracts from the rat striatum were: 0.45+/-0.05 (5-HT), 4.27+/-0.08 (DA), 0.27+/-0.04 (NA), 0.55+/-0.06 (5-HIAA), 1.26+/-0.16 (L-DOPA) and 1.62+/-0.11 (DOPAC). Microdialysis samples were collected in 20 min intervals from the probes implanted in the striatum of awake rats. The basal monoamine levels (in fmol/20 microl, mean +/- S.E.M., n=5) in the dialysates were: 4.0+/-0.7 (5-HT), 78.4+/-9.1 (DA), 6.4+/-0.8 (NA), 785.5+/-64.5 (5-HIAA) and 5504.5+/-136.5 (DOPAC). It is concluded that the new fluorescence derivatization protocol provides an excellent means for simultaneous determination of all three monoamines both in the complex samples (e.g. brain homogenates) and also at trace levels, such as those found in the microdialysis samples.

Using pharmacogenetics and pharmacogenomics in the treatment of psychiatric disorders: some ethical and economic considerations

Current pharmacotherapies for psychiatric disorders are generally incompletely effective. Many patients do not respond well or suffer adverse reactions to these drugs, which can result in poor patient compliance and poor treatment outcome. Adverse drug reactions and non-response are likely to be influenced by genetic polymorphisms. Pharmacogenetics holds some promise for improving the treatment of mood disorders by utilising information about genetic polymorphisms to match patients to the drug therapy that is the most effective with the fewest side effects. Pharmacogenomics promises to facilitate the development of new drugs for treatment. However, these technologies raise many ethical, economic and regulatory issues that need to be addressed before they can be integrated into psychiatry, and medicine more generally. We discuss ethical and policy issues arising from pharmacogenetic testing and pharmacogenomics research, such as informed consent, privacy and confidentiality, research on vulnerable persons and discrimination; and economic viability of pharmacogenetics and pharmacogenomics. We conclude with recommendations for the regulation and distribution of pharmacogenetic testing services and pharmacogenomic drugs.

Genetic animal models of anxiety

The focus of this review is on progress achieved in identifying specific genes conferring risk for anxiety disorders through the use of genetic animal models. We discuss gene-finding studies as well as those manipulating a candidate gene. Both human and animal studies thus far support the genetic complexity of anxiety. Clinical manifestations of these diseases are likely related to multiple genes. While different anxiety disorders and anxiety-related traits all appear to be genetically influenced, it has been difficult to ascertain genetic influences in common. Mouse studies have provisionally mapped several loci harboring genes that affect anxiety-related behavior. The growing array of mutant mice is providing valuable information about how genes and environment interact to affect anxious behavior via multiple neuropharmacological pathways. Classical genetic methods such as artificial selection of rodents for high or low anxiety are being employed. Expression array technologies have as yet not been employed, but can be expected to implicate novel candidates and neurobiological pathways.

Obsessive-Compulsive Disorder, 5-HTTLPR polymorphism and treatment response

Recently, a role for a functional polymorphism within the promoter region of the serotonin transporter gene (5-HTTLPR) in conferring susceptibility to Obsessive Compulsive Disorder (OCD) has been suggested. The aim of this study was to test the hypothesis that allelic variation of the 5-HTTLPR could be associated with OCD susceptibility or influence the drug response in OCD. One hundred and eighty-one OCD patients were recruited; 92 patients underwent a standardized treatment with fluvoxamine. No significant differences in allele/genotype distribution of the 5-HTTLPR were found between 191 controls and OCD. No differences in fluvoxamine response in the three genotypes groups in OCD were found, considering Yale-Brown Obsessive Compulsive Scale (YBOCS) total scores. Nevertheless, a significant time per genotype interaction was found for the YBOCS subtotal compulsion scores. Considering patients without tic disorder co-diagnosis, a significant time per genotype interaction for both YBOCS total scores and compulsion scores was found.

Polymorphism of the serotonin transporter: implications for the use of selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are used to treat a number of psychiatric disorders related to mood and anxiety, and variations in the serotonin transporter (5-HTT) gene may be involved in a number of these. A polymorphic site in the promoter region is associated with differences in 5-HTT gene expression. Studies suggest that the short allele of the 5-HTT promoter (5-HTTPR) site can adversely influence the antidepressant response to SSRIs, and is associated with anxiety-related traits, depression, and impulsive disorders such as alcohol abuse. Several studies do not replicate these findings; potential confounding factors include age, gender, and population stratification. Other 5-HTT polymorphisms also exist. For example, individuals with the short allele of a variable number of tandem repeats (VNTR) polymorphism, located in the second intron, may have reduced responsiveness to SSRIs, and the STin2.12 allele at this site has been associated with bipolar disorder. Findings both supporting and inconsistent with these conclusions are reviewed. The clinical effects of the polymorphisms may be associated with effects on platelets, neural 5-HTT levels, and indices of serotonergic function.

Serotonin transporter gene polymorphism in irritable bowel syndrome

OBJECTIVES

Serotonin is a key mediator of intestinal peristalsis, and after it is secreted, it is effectively cleansed from the neuronal gap by means of a high affinity substance called serotonin transporter (SERT), which depends on the Na+ and Cl- ions localized in the presynaptic neuronal membranes. The aim of this study was to investigate SERT polymorphism in patients with irritable bowel syndrome (IBS).

METHODS

SERT gene polymorphism was assessed by polymerase chain reaction on DNA chains obtained from leukocytes in serum samples from 54 patients diagnosed with IBS and 91 healthy subjects. The polymorphism of two regions (variable number tandem repeats and the SERT gene-linked polymorphic region [5-HTTLPR]) of SERT was assessed.

RESULTS

SERT polymorphisms were found to be similar in healthy subjects and IBS patients (p > 0.05). IBS patients were divided into three groups: diarrhea predominant (n = 18), constipation predominant (n = 26), and alternating diarrhea and constipation (n = 10). These groups were compared with respect to gene polymorphism, and it was found that the 5-HTTLPR allele S/S genotype occurred with greater frequency in the constipation predominant group than in the other two subgroups (p < 0.05), and L/S genotype frequency in the diarrhea predominant group was higher than those in the constipation and control groups.

CONCLUSIONS

No relationship was found between IBS and SERT gene polymorphism. It is conceivable that the presence of the S/S genotype in IBS patients carries an increased risk of the constipation predominant type of IBS, whereas the presence of the 5-HTTLPR allele L/S genotype carries an increased risk of the diarrhea predominant type.

Pharmacogenetics of bipolar disorder

To review the pharmacogenetics of bipolar disorders, the authors searched databases for genetic association and linkage studies involving response to long-term prophylactic lithium treatment, as well as treatment with antidepressants or clozapine. Significant ethnic variations in the metabolism and efficacy of antidepressants, as well as clozapine, have been reported by several groups. Systematic studies suggest that that genetic factors affect the response to prophylactic lithium treatment. Numerous associations between the three traits of interest and candidate gene polymorphisms have been proposed. Among these, an association between the serotonin transporter gene and response to serotonin reuptake inhibitors appears robust. Considerable interest has also focused on serotonergic gene polymorphisms and response to clozapine. Response to pharmacotherapy in bipolar disorders may be mediated by genetic factors, but the role played by heritability is unknown.

Pharmacogenetics in affective disorders

Pharmacogenetics will be of substantial help in the field of affective disorders pharmacotherapy. The possible definition of a genetic liability profile for drug side-effects and efficacy will be of great help in treatments that need weeks to months to be effective. During the last few years, a number of groups have reported possible liability genes. The efficacy and time of onset of selective serotonin reuptake inhibitors have been associated with a polymorphism in the promoter region of the transporter (SERTPR) in many independent studies, while variants at the tryptophan hydroxylase gene, 5-HT2a receptor and G-protein beta3 have been associated with them in pilot studies. Lithium long-term prophylactic efficacy has been associated with SERTPR, TPH and inositol polyphosphate 1-phosphatase variants, though in unreplicated samples. A number of further candidate genes were not associated with these treatments. In conclusion, both acute and long-term treatments appear to be, at least to some extent, under genetic influence and preliminary data have identified possible liability genes.

Variation of serotonergic gene expression: neurodevelopment and the complexity of response to psychopharmacologic drugs

Individual differences in drug effects and treatment response are relatively enduring, continuously distributed, as well as substantially heritable, and are therefore likely to result from an interplay of multiple genomic variations with environmental influences. As the etiology and pathogenesis of behavioral and psychiatric disorders is genetically complex, so is the response to drug treatment. Psychopharmacologic drug response depends on the structure and functional expression of gene products, which may be direct drug targets or may indirectly modify the development and synaptic plasticity of neural networks critically involved in drug response. While formation and integration of these neural networks is dependent on the action of manifold proteins, converging lines of evidence indicate that genetically controlled variability in the expression of genes critical to the development and plasticity of distinct neurocircuits influences a wide spectrum of quantitative traits including treatment response. During brain development, neurotransmitter systems (e.g. serotonergic system), which are frequently targeted by psychotropic drugs, control neuronal specification, differentiation, and phenotype maintenance. The formation and maturation of these neurotransmitter systems, in turn, is directed by an intrinsic genetic program. Based on the notion that complex gene-gene and gene environment interactions in the regulation of brain plasticity are presumed to contribute to interindividual differences in drug response, the concept of developmental psychopharmacogenetics is emerging. This review appraises prototypical genomic variation with impact on gene expression and complementary studies of genetic and environmental effects on brain development and synaptic plasticity in the mouse model. Although special emphasis is given to molecular mechanisms of neurodevelopmental genetics, relevant conceptual and methodological issues pertinent to the dissection of the psychopharmacogenetic-neurodevelopmental interface are also considered.

Psychopharmacogenetics--a challenge for pharmacotherapy in psychiatry

Differences in response to treatment or the incidence of adverse drug effects are quite common in clinical psychopharmacotherapy. Although several factors may account for these discrepancies, there is increasing knowledge that genetic factors play a major role. The aim of pharmacogenetics, a new and rapidly growing field in research, is to elucidate the variability in drug response and metabolism due to hereditary differences. According to the hypotheses on the mechanisms of drug action, several mutations in genes coding for neurotransmitter receptors, degrading enzymes, transport proteins or enzymes of the drug metabolizing system (P-450 isoenzymes) have been identified and investigated in psychiatric disorders over the last years. Although some controversy exists among the results, many studies are supportive of the hypothesis that psychopharmacogenetics will be helpful in predicting an individual patient's drug response while minimising the rate of side effects.

Genetic mechanisms of behavior--don't forget about the transcription factors

Major changes in psychiatric phenotypes due to genetic factors are seldom the result of single gene polymorphisms, but more often the result of several genetic mechanisms. In this millennium article we discuss the notion that the expression of numerous candidate genes could be regulated by the same transcription factors, and that polymorphisms in transcription factor genes might explain some phenotypes. We describe recent results of studies on the biological marker thrombocyte monoamine oxidase (trbc MAO) and the transcription factor AP-2beta. Low levels of trbc MAO is associated with temperamental characteristics such as sensation seeking and impulsiveness, and the enzyme is genetically regulated by specific transcriptional mechanisms. Transcription factor AP-2beta is important for the development of midbrain structures and AP-2beta has several binding sites in the regulatory regions of genes encoding key proteins in the monoamine transmitter systems. We have recently shown AP-2beta to be linked to personality, binge-eating disorder, treatment with antidepressant drugs, and also to trbc MAO. Regardless of whether transcriptions factors, such as AP-2beta, regulate the expression of eg, the number of monoamine neurons or a variety of candidate genes within the monoamine systems, or both, we would like to emphasize the role of transcription factors, besides polymorphisms in monoaminergic candidate genes, when explaining inter-individual differences in temperament and psychiatric vulnerability.

Pharmacogenomics of psychiatric disorders

Pharmacogenomics, the utilization of genetic information to predict outcome of drug treatment (therapeutic and side-effects), holds great promise for clinical medicine. The pharmacotherapy of psychiatric disorders exhibits wide variability in therapeutic response with little scientific guidance for treatment on a patient-by-patient basis. The emerging field of pharmacogenomics holds great potential for refining and optimizing psychopharmacology. Key components for future development of the pharmacogenomics of psychiatric disorders include understanding the mechanism of drug action, identification of candidate genes and their variants, and well-conducted clinical trials. In this article, data from recent studies are examined with particular emphasis on methodological requirements and direction for future research.

Quantitative trait loci for the monoamine-related traits heart rate and headless behavior in Drosophila melanogaster

Drosophila melanogaster appears to be well suited as a model organism for quantitative pharmacogenetic analysis. A genome-wide deficiency screen for haploinsufficient effects on prepupal heart rate identified nine regions of the genome that significantly reduce (five deficiencies) or increase (four deficiencies) heart rate across a range of genetic backgrounds. Candidate genes include several neurotransmitter receptor loci, particularly monoamine receptors, consistent with results of prior pharmacological manipulations of heart rate, as well as genes associated with paralytic phenotypes. Significant genetic variation is also shown to exist for a suite of four autonomic behaviors that are exhibited spontaneously upon decapitation, namely, grooming, grasping, righting, and quivering. Overall activity levels are increased by application of particular concentrations of the drugs octopamine and nicotine, but due to high environmental variance both within and among replicate vials, the significance of genetic variation among wild-type lines for response to the drugs is difficult to establish. An interval mapping design was also used to map two or three QTL for each behavioral trait in a set of recombinant inbred lines derived from the laboratory stocks Oregon-R and 2b.

Serotonergic gene expression and depression: implications for developing novel antidepressants

The development and configuration of several neural networks is dependent on the actions of serotonin (5-HT) acting through multiple hetero- and autoreceptor subtypes. During early brain development 5-HT modulates morphogenetic activities, such as neural differentiation, axon outgrowth, and synaptic modeling. In the adult brain, midbrain raphe serotonergic neurons project to a variety of brain regions and modulate a wide range of physiological functions. Several lines of evidence indicate that genetically determined variability in serotonergic gene expression, as it has been documented for the 5-HT transporter, influences temperamental traits and may lead to psychopathological conditions with increased anxiety, depression, and aggression. Investigation of the regulation of serotonergic gene transcription and its impact on neuronal development, synaptic plasticity, and neurogenesis spur interest to identify serotonergic gene-related molecular factors underlying disease states and to develop more effective antidepressant treatment strategies. Gene targeting strategies have increasingly been integrated into investigations of brain function and along with the fading dogma of a limited capacity of neurons for regeneration and reproducibility, it is realized that gene transfer techniques using efficient viral vectors in conjunction with neuron-selective transcriptional control systems may also be applicable to complex disorders of the brain. Given the fact that the 5-HT system continues to be an important target for drug development and production, novel strategies aiming toward the modification of 5-HT function at the level of gene expression are likely to be exploited by enterprises participating actively in the introduction of alternative therapeutic approaches.