Testosterone and Depression in Aging Men

Gonads under stress: A systematic review and meta-analysis on the effects of acute psychosocial stress on gonadal steroids secretion in humans

Animal research has shown that the hypothalamus-pituitary-gonadal (HPG) axis is inhibited by (chronic and/or severe) stress, which can lead to impaired fertility and reproductive functioning, presumably caused by the inhibition of gonadal steroid secretion and in interactions with glucocorticoids. However, what has not been clarified is how acute psychosocial stress modulates gonadal steroid secretion in humans. Here we summarize the experimental research on the acute effects of stress on the secretion of gonadal steroids in humans. A systematic literature search revealed 21 studies (with N=881 individuals) measuring testosterone, progesterone or estradiol in response to a standardized acute laboratory stressor in healthy humans. Both our literature review and quantitative meta-analysis suggest that in humans, acute stress stimulates rather than inhibits HPG axis activity, although there is a considerable heterogeneity in the reported methods and results. Increased gonadal steroids in response to acute stress contrasts with many animal studies reporting the opposite pattern, at least regarding severe and/or chronic stressors. We discuss methodological issues and challenges for future research and hope to stimulate experimental studies within this area. A better understanding of these mechanisms is needed, and may have important implications for health and disease, as well as the modulation of various behaviors by acute stressors.

No evidence for relationship between paternal post-partum depressive symptoms and testosterone or cortisol in first-time fathers

Male life history strategies are regulated by the neuroendocrine system. Testosterone (T) and cortisol regulate male behaviors including parenting and facilitate managing tradeoffs at key transitions in development such as first-time fatherhood. Both hormones demonstrate marked fluctuations in the postnatal period, and this presents an opportunity to investigate the role of T and cortisol in postpartum depressive symptoms-comparably less studied in fathers than in mothers in the evolutionary literature. Prior work on depressive symptoms has yet to integrate insights from the "dual hormone hypothesis (DHH)" which has focused on how T and cortisol interact to jointly regulate traits associated with dominance and status-seeking (i.e., mating effort) but has yet to be included in models of parenting effort. In this research, we use secondary data to investigate the relationship between DHH and traits ostensibly opposed to status seeking (i.e., depressive symptoms). First-time fathers (n = 193) provided morning saliva samples 10 months following parturition and reported on the presence of depressive symptoms (BDI-II). Responses were decomposed into three factors: cognitive, affective, and somatic. Using hybrid latent variable structural equation modeling, we did not find evidence that T predicted variability in cognitive, affective, or somatic depressive symptom factors. We found a null effect for cortisol as well. Finally, we could not find evidence that the DHH variable (T × cortisol interaction) predicted any variability in cognitive, affective, or somatic depressive symptoms. While we did not find evidence to support our hypotheses using a secondary data set, this study contributes to research on the neuroendocrinology of depression in fathers. Discussion focuses on the limitations of sample demographics, timing of saliva and self-report collection, and the lack of extant theory specific to paternal postpartum depression.

The association of hypogonadism with depression and its treatments

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

Androgen deprivation therapy and depression in the prostate cancer patients: review of risk and pharmacological management

Purpose: Despite the effectiveness of androgen deprivation therapy in advanced prostate cancer, serious neuropsychiatric consequences in androgen deprivation therapy (ADT)-treated patients, mainly depression, have been concerning and gained more attention recently. This narrative review aims to shed light on the risk and pharmacological management of ADT-induced depression in PCa patients.Methods: We searched PubMed, Scopus and Google Scholar databases using MESH keywords "Prostate cancer OR prostate neoplasm" AND "Depression" AND "Androgen Deprivation Therapy" AND "antidepressants". Search was limited to English and studies conducted on humans. Studies' titles and abstracts were screened, and further information were obtained from the text, if necessary, to decide whether studies are to be included in this review.Results: Our review revealed 23 studies confirming the occurrence and worsening of depressive symptoms in ADT-treated patients, which frequently require pharmacological interventions; whereas 10 studies indicated otherwise. All studies were prospective, retrospective, cross-sectional or case reports. Based on the incidence of depression provided by the observational studies, the average among ADT-treated patients was 18.23% (range: 2.1-46.9%), while it was 8.42% (range: 1.4-23.3%) in the non-ADT patients. Although several treatments have been used for depression in cancer patients, current knowledge lacks observational and controlled studies as well as clinical guidelines that demonstrate efficacy and safety of antidepressants and guide clinicians to the appropriate treatment in these patients, respectively. On the other side, a few clinical studies have been published regarding the efficacy of selective serotonin reuptake inhibitors, selective serotonin and norepinephrine reuptake inhibitors and/or saftey on other ADT associated adverse effects.Conclusions: Our work supports the recent attention towards mood issues as an adverse effect of ADT, and that greater awareness of this is warranted among clinicians. Clinical studies published regarding the use of antidepressants for other ADT associated adverse effects established the foundation that can be adopted to examine these therapies on ADT-induced depression.

Psychometric properties of the Facial Disability Index in patients with facial palsy: a systematic review and meta-analysis

PURPOSE

The aim of the study was to present the systematic review and meta-analysis of the psychometrical analysis of Facial Disability Index (FDI) studies.

METHODS

A literature search was conducted in the relevant electronic databases "PubMed, Scopus, Web of Science (WoS), and Cochrane Library." A total of 621 articles were obtained by searching the relevant keywords (PubMed: 384, Cochrane Library: 14, Web of Science: 132, Scopus: 91). A total of 8 papers were included. The four-point classification and rating-based "COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)" tools were used to evaluate the bias risk and evidence levels.

RESULTS

Cronbach's alpha pooling of FDI total score was (ES): 0.803 (95% CI: 0.73-0.86). Heterogeneity for the Facial Disability Index-Physical Function (FDI-PF) and Facial Disability Index-Social Function (FDI-SF) subscore based on intraclass correlation coefficient (ICC) were I² = 84.2% (ICC: 0.88, 95% CI: 0.81-0.92) and I² = 73.7% (ICC: 0.87, 95% CI: 0.81-0.90), respectively. Correlational results between Sunnybrook Facial Grading System (SFGS) with FDI-PF and FDI-SF were 0.38 and 0.22, respectively. The correlations of FDI-PF with Short Form-12 Physical Component Summary (SF-12-PCS) and Short Form-12 Mental Health Component Summary (SF-12-MCS) were 0.43 and 0.28, respectively. Correlation results of FDI-SF with SF-12-PCS and SF-12-MCS were 0.23 and 0.57. The relationship results of Facial Clinimetric Evaluation with FDI-PF and FDI-SF were 0.71 and 0.57, respectively.

CONCLUSION

FDI is a psychometrically valuable questionnaire, especially for the internal consistency, reliability, and validity. In clinical practice, the use of FDI would be valuable, in addition to clinician-based grading, to see more of patients' social influences precisely.

Androgen Flare after LHRH Initiation Is the Side Effect That Makes Most of the Beneficial Effect When It Coincides with Radiation Therapy for Prostate Cancer

Simple Summary

Prostate cancer tumor growth is stimulated by androgens. Surgical castration or medical castration using long-acting luteinizing hormone-releasing hormone (LHRH) agonists or antagonists is the backbone of the treatments of metastatic disease. Treatment of locally advanced prostate cancer was accomplished with radiation therapy alone until multiple studies showed that combining radiation therapy with LHRH agonists results in significant survival benefit. While the goal of the use of LHRH agonists was to suppress testosterone levels during radiation, we show, through review of previous studies, that survival benefit was achieved only when LHRH was initiated during the course of radiation, and thus androgen flare during the first 1–3 weeks after the initiation of LHRH is most likely the reason for higher survival. Androgens drive tumor cells into mitosis, and mitotic death is the dominant mechanism of tumor cell kill by radiation.

Abstract

Treatment of metastatic prostate cancer was historically performed via bilateral orchiectomy to achieve castration. An alternative to surgical castration is the administration of subcutaneous recombinant luteinizing hormone-releasing hormone (LHRH). LHRH causes the pituitary gland to produce luteinizing hormone (LH), which results in synthesis and secretion of testosterone from the testicles. When LHRH levels are continuously high, the pituitary gland stops producing LH, which results in reduced testosterone production by the testicles. Long-acting formulations of LHRH were developed, and its use replaced surgical orchiectomy in the vast majority of patients. Combining LHRH and radiation therapy was shown to increase survival of prostate cancer patients with locally advanced disease. Here, we present a hypothesis, and preliminary evidence based on previous randomized controlled trials, that androgen surge during radiation, rather than its suppression, could be responsible for the enhanced prostate cancer cell kill during radiation. Starting LHRH agonist on the first day of radiation therapy, as in the EORTC 22863 study, should be the standard of care when treating locally advanced prostate cancer. We are developing formulations of short-acting LHRH agonists that induce androgen flare, without subsequent androgen deprivation, which could open the door for an era in which locally advanced prostate cancer could be cured while patients maintain potency.

The effect of oral dexamethasone administration on testosterone levels in combat veterans with or without a history of suicide attempt

Combat exposure has been linked to increased risk of suicidal ideation, suicide attempts, and death by suicide, and suicidality has been linked with altered testosterone levels. In this study, we examined morning baseline free and total testosterone levels and the effect of dexamethasone administration on testosterone levels in male combat veterans with or without a history of suicide attempt. Demographic and clinical parameters of the study participants were assessed and recorded. Blood samples were collected between 8:00 and 8:30 a.m. on the day prior to and following dexamethasone (0.5 mg) ingestion. Suicide attempters had higher schedule for suicidal ideation (SSI) scores in comparison to non-attempters. Baseline free and total testosterone levels were lower in suicide attempters compared to non-attempters. In the whole sample, both baseline free and total testosterone levels negatively correlated with SSI scores. Free testosterone levels decreased after dexamethasone administration among non-attempters but not among attempters. Free testosterone post-dexamethasone levels positively correlated with aggression scores among non-attempters but not among suicide attempters. Our findings indicate that there are substantial differences in the testosterone regulation between combat veterans with or without a history of suicide attempt. Studies of the relation between the testosterone function and suicidal behavior among combat veterans may lead to improvement in detection of suicidality and finding new pharmacological targets for prevention of suicide among veterans.

Testosterone in Female Depression: A Meta-Analysis and Mendelian Randomization Study

Testosterone's role in female depression is not well understood, with studies reporting conflicting results. Here, we use meta-analytical and Mendelian randomization techniques to determine whether serum testosterone levels differ between depressed and healthy women and whether such a relationship is casual. Our meta-analysis shows a significant association between absolute serum testosterone levels and female depression, which remains true for the premenopausal group while achieving borderline significance in the postmenopausal group. The results from our Mendelian randomization analysis failed to show any causal relationship between testosterone and depression. Our results show that women with depression do indeed display significantly different serum levels of testosterone. However, the directions of the effect of this relationship are conflicting and may be due to menopausal status. Since our Mendelian randomization analysis was insignificant, the difference in testosterone levels between healthy and depressed women is most likely a manifestation of the disease itself. Further studies could be carried out to leverage this newfound insight into better diagnostic capabilities culminating in early intervention in female depression.

The effects of early life stress on motivated behaviors: A role for gonadal hormones

Motivated behaviors are controlled by the mesocorticolimbic dopamine (DA) system, consisting of projections from the ventral tegmental area (VTA) to the nucleus accumbens (NAc) and prefrontal cortex (PFC), with input from structures including the medial preoptic area (mPOA). Sex differences are present in this circuit, and gonadal hormones (e.g., estradiol and testosterone) are important for regulating DA transmission. Early life stress (ELS) also regulates the mesocorticolimbic DA system. ELS modifies motivated behaviors and the underlying DA circuitry, increasing risk for disorders such as substance use disorder, major depression, and schizophrenia. ELS has been shown to change gonadal hormone signaling in both sexes. Thus, one way that ELS could impact mesocorticolimbic DA is by altering the efficacy of gonadal hormones. This review provides evidence for this idea by integrating the gonadal hormone, motivation, and ELS literature to argue that ELS alters gonadal hormone signaling to impact motivated behavior. We also discuss the importance of these effects in the context of understanding risk and treatments for psychiatric disorders in men and women.

The Potential Effect of Aberrant Testosterone Levels on Common Diseases: A Mendelian Randomization Study

Testosterone has historically been linked to sexual dysfunction; however, it has recently been shown to affect other physical and mental attributes. We attempted to determine whether changes in serum testosterone could play a role in chronic or degenerative diseases. We used two separate genetic instruments comprising of variants from JMJD1C and SHBG regions and conducted a two-sample Mendelian randomization for type II diabetes (T2D), gout, rheumatoid arthritis (RA), schizophrenia, bipolar disorder, Alzheimer's disease and depression. For the JMJD1C locus, one unit increase in log transformed testosterone was significantly associated with RA (OR = 1.69, p = 0.02), gout (OR = 0.469, p = 0.001) and T2D (OR = 0.769, p = 0.048). Similarly, one unit increase in log transformed testosterone using variants from the SHBG locus was associated with depression (OR = 1.02, p < 0.0001), RA (OR = 1.254, p < 0.0001) and T2D (OR = 0.88, p < 0.0001). Our results show that low levels of serum testosterone levels may cause gout and T2D, while higher than normal levels of testosterone may result in RA and depression. Our findings suggest that fluctuations in testosterone levels may have severe consequences that warrant further investigation.

When Fathers Begin to Falter: A Comprehensive Review on Paternal Perinatal Depression

The transition to parenthood is considered to be a major life transition that can increase the vulnerability to parental depressive disorders, including paternal perinatal depression (PPND). Although it is known that many fathers experience anxiety and depression during the perinatal period, PPND is a recent diagnostic entity and there are not enough published studies on it. Accordingly, its prevalence and epidemiology are still not well defined, although the majority of studies agree that PPND is less frequent than maternal perinatal depression and postpartum depression. Nevertheless, PPND is different from maternal perinatal mental health disorders, usually, fathers have less severe symptoms, and mood alterations are often in comorbidity with other affective disorders. Despite the absence of DSM-5 diagnostic criteria and the fluctuation of prevalence rates, clinical symptoms have been defined. The main symptoms are mood alterations and anxiety, followed by behavioral disturbances and concerns about the progress of pregnancy and the child’s health. Moreover, PPND negatively impacts on family functioning, on couples’ relationships, and on family members’ well-being. The aim of this paper is to present an overview of the current understandings on PPND and the potential screening, prevention, and treatment options.

Sexual motivation: problem solved and new problems introduced

Background During the past 50 years, motivational studies have evolved from the logical inference of logically required "intervening variables" to explain behavioral change, to electrophysiological and molecular analyses of the mechanisms causing such changes. Aim The purpose of this review article is two-fold: first to describe the logic of sexual motivation in a way that applies to laboratory animals as well as humans, and the second is to address some of the problems of sexual motivation experienced by men. Results When problems of motivational mechanisms are stripped down to their essentials, as performed in the laboratory animal models and are available for reductionistic studies, then the problems can be solved with certainty, as illustrated in the first part of this review. However, with respect to human sexual motivation, the various determinants which include so many behavioral routes and so many brain states come into play, that definite conclusions are harder to come by, as illustrated in the second part of this review. Conclusions This review highlights a number of key questions that merit further investigation. These include (a) What mechanisms do cultural and experiential influences interact with androgenic hormone influences on human sexual motivation? (b) How would epigenetic effects in the human brain related to changes in motivation be investigated? (c) What are the effects of unpredictable traumatic and stressful human experiences on sexual motivation; (d) How such mechanisms are activated upon unpredictable traumatic and stressful insults? (e) What are the outstanding differences between sexual motivational drive and motivations driven by homeostatic systems such as hunger and thirst?

The brain-adipocyte-gut network: Linking obesity and depression subtypes

Major depressive disorder (MDD) and obesity are dominant and inter-related health burdens. Obesity is a risk factor for MDD, and there is evidence MDD increases risk of obesity. However, description of a bidirectional relationship between obesity and MDD is misleading, as closer examination reveals distinct unidirectional relationships in MDD subtypes. MDD is frequently associated with weight loss, although obesity promotes MDD. In contrast, MDD with atypical features (MDD-AF) is characterised by subsequent weight gain and obesity. The bases of these distinct associations remain to be detailed, with conflicting findings clouding interpretation. These associations can be viewed within a systems biology framework-the psycho-immune neuroendocrine (PINE) network shared between MDD and metabolic disorders. Shared PINE subsystem perturbations may underlie increased MDD in overweight and obese people (obesity-associated depression), while obesity in MDD-AF (depression-associated obesity) involves more complex interactions between behavioural and biomolecular changes. In the former, the chronic PINE dysfunction triggering MDD is augmented by obesity-dependent dysregulation in shared networks, including inflammatory, leptin-ghrelin, neuroendocrine, and gut microbiome systems, influenced by chronic image-associated psychological stress (particularly in younger or female patients). In MDD-AF, behavioural dysregulation, including hypersensitivity to interpersonal rejection, fundamentally underpins energy imbalance (involving hyperphagia, lethargy, hypersomnia), with evolving obesity exaggerating these drivers via positive feedback (and potentially augmenting PINE disruption). In both settings, sex and age are important determinants of outcome, associated with differences in emotional versus cognitive dysregulation. A systems biology approach is recommended for further research into the pathophysiological networks underlying MDD and linking depression and obesity.

Testosterone imbalance may link depression and increased body weight in premenopausal women

Accumulating evidence supports a link between depression and being overweight in women. Given previously reported sex differences in fat accumulation and depression prevalence, as well as the likely role of sex hormones in both overweight and mood disorders, we hypothesised that the depression-overweight association may be mediated by sex hormones. To this end, we investigated the association of being overweight with depression, and then considered the role of sex hormones in relation to being overweight and depression in a large population-based cohort. We included a total of 3124 women, 970 premenopausal and 2154 postmenopausal from the LIFE-Adult cohort study in our analyses. We evaluated associations between being overweight (BMI >25 kg/m²), sex hormone levels, and depressive symptomatology according to Centre for Epidemiologic Studies Depression (CES-D) scores, and explored mediation of depression in a mediation model. Being overweight was significantly associated with depressive symptoms in premenopausal but not postmenopausal women. Both premenopausal and postmenopausal overweight women had higher free testosterone levels compared with normal weight women. Premenopausal women with depressive symptomatology had higher free testosterone levels compared to women without. We found a significant mediation effect of depressive symptomatology in overweight premenopausal women through free testosterone level. These findings highlight the association between being overweight and depressed, and suggest that high free testosterone levels may play a significant role in depression of overweight premenopausal women. Based on this, pharmacological approaches targeting androgen levels in overweight depressed females, in particular when standard anti-depressive treatments fail, could be of specific clinical relevance.

Targeting hypothalamic-pituitary-adrenal axis hormones and sex steroids for improving cognition in major mood disorders and schizophrenia: a systematic review and narrative synthesis

Cognitive deficits are a core feature of serious mental illnesses such as schizophrenia, major depressive disorder (MDD) and bipolar disorder (BD) and are a common cause of functional disability. There is limited efficacy of pharmacological interventions for improving the cognitive deficits in these disorders. As pro-cognitive pharmacological treatments are lacking, hormones or drugs that target the endocrine system may become potential candidates for 'repurposing' trials aiming to improve cognition. We aimed to study whether treatment with drugs targeting the hypothalamic-pituitary-adrenal (HPA) axis and sex steroids can improve cognition in patients with schizophrenia, MDD or BD. A systematic search was performed using PubMed (Medline), PsychInfo and clinicaltrials.gov, and a narrative synthesis was included. The systematic review identified 12 studies dealing with HPA-related drugs (mifepristone [n = 3], cortisol synthesis inhibitors [ketoconazole, n = 2], dehydroepiandrosterone [n = 5], fludrocortisone [n = 2]) and 14 studies dealing with sex steroids (oestradiol [n = 2], selective oestrogen receptor modulators [raloxifene, n = 7], pregnenolone [n = 5]). Positive trials were found for BD (mifepristone), MDD (dehydroepiandrosterone and fludrocortisone) and schizophrenia (dehydroepiandrosterone, raloxifene and pregnenolone). A replication of positive findings by at least two clinical trials was found for mifepristone in BD and raloxifene and pregnenolone in schizophrenia. The use of drugs targeting hormones related to the HPA axis and sex steroids is a promising field of research that might help to improve the cognitive outcome of patients with schizophrenia, bipolar disorder and major depressive disorder in the near future.

Debate position: cognition and mood are not improved in men administered exogenous testosterone therapy

PURPOSE OF REVIEW

The purpose of this article is to provide an overview of the increasing evidence suggesting that exogenous testosterone therapy is not associated with improvements in cognition or mood. This article is part of a series, in this issue, in which authors are assigned opinion pieces on controversial topics pertaining to testosterone replacement.

RECENT FINDINGS

Testosterone is increasingly being prescribed. Particularly in the setting of recent data suggestive of possible cardiovascular risk associated with its use; a clear understanding of the domains of health that improve with exogenous testosterone use is important. Data on endogenous and exogenous testosterone with cognition and mood are mixed, likely partly related to methodological differences of type of testosterone, patient population, and dosing.

SUMMARY

Overall, available data are not suggestive of a clear benefit of testosterone supplementation in multiple domains of cognition and in mood. Supraphysiologic testosterone has been associated with adverse psychological outcomes, albeit not uniformly in studies.

Sexual dysfunction in old age

The sexual behaviour of older people is more often the target of jocularity or ridicule than the subject of serious scientific research. As a consequence, relatively little is known about the sexual behaviour of the over-65s and such information as is available shows a polarisation according to gender, male sexual behaviour and dysfunction being viewed very much in the light of physical problems, whereas women's sexual behaviour revolves around attitudes towards sexuality and the psychological effects of ageing. This review will address the biological changes associated with ageing, the psychological and social concomitants, the prevalence of sexual dysfunction, its aetiological factors, and the management of common sexual problems including those found in an institutional setting.

Quality of sleep in patients receiving androgen deprivation therapy for prostate cancer

Androgen deprivation is a therapeutic option for patients with prostate cancer (PC). However, it has negative effects on sleep quality and psychological condition. Here, we evaluated the appearance of sleep disturbances in patients on androgen deprivation therapy (ADT). We administered Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), Epworth Sleepiness Scale (ESS), and Fatigue Severity Scale (FSS) to consecutive prostate cancer patients who had undergone radical prostatectomy and are presently either under adjuvant ADT or followed in an unmedicated program (non-ADT). The results of the tests in ADT and non-ADT groups in addition to the demographic data and the features of the malignancy were statistically compared. Of the 106 patients enrolled, 48 (45.3%) were receiving adjuvant ADT and 58 (54.7%) were not. Age, disease duration, and education levels showed no difference between the two groups. Compared with the non-ADT group, the patients receiving ADT showed higher levels of depression, worse quality of sleep, and more severe fatigue (p < 0.001, for each). There was no significant difference among the two groups regarding excessive daytime sleepiness (p = 0.856). The mean PSQI scores showed a positive correlation with BDI and FSS scores (r = 0.710, p < 0.001; r = 0.528, p < 0.001, respectively). Additionally, ADT was strongly associated with PSQI and FSS scores at multivariate analysis (p = 0.037, p = 0.043, respectively). We conclude that PC patients receiving ADT are likely to be fatigued, more depressed, and had poorer sleep quality. Our study showed that receiving ADT therapy is strongly associated with poor sleep quality and fatigue.

Patients receiving androgen deprivation therapy for prostate cancer have an increased risk of depressive disorder

Androgen deprivation therapy (ADT) results in testosterone suppression, a hypothesized mechanism linking ADT to depressive symptoms. This study investigated the relationship between ADT and the risk of subsequently being diagnosed with depressive disorder (DD) during a 3-year follow-up period. The patient sample for this population-based, retrospective cohort study was retrieved from the Taiwan Longitudinal Health Insurance Database 2005. We included all 1714 patients aged over 40 years with a first-time diagnosis of prostate cancer (PC) during 2001 to 2010 who did not have an orchiectomy. Among them, we defined 868 patients who received ADT during the 3-year follow-up period as the study group, and 846 patients who did not receive ADT as the comparison group. The incidence rates of DD per 1000 person-years were 13.9 (95% confidence interval (CI): 9.5~19.6) and 6.7 (95% CI: 3.7~11.0), respectively. Cox proportional hazard regressions showed that the adjusted hazard ratio for DD for ADT recipients was 1.93 (95% CI: 1.03~3.62) relative to the comparison group. This study presents epidemiological evidence of an association between ADT and a subsequent DD diagnosis.

Prospective longitudinal study of testosterone and incident depression in older men: The Health In Men Study

BACKGROUND

Depression in older men has been associated with low circulating testosterone concentration but data from prospective studies are limited.

METHODS

We conducted a prospective longitudinal study in a community representative cohort of 3179 older men free of clinically significant depressive symptoms at baseline. The main objective of this study was to determine if low serum testosterone, dihydrotestosterone and estradiol concentrations are associated with the development of depressive symptoms. Incident depression was assessed with the Patient Health Questionnaire and via an electronic health record database (The West Australian Data Linkage System). The main exposures of interest were serum testosterone, dihydrotestosterone and estradiol measured by liquid chromatography-mass spectrometry and calculated free testosterone in baseline blood samples (collected between 2001 and 2004).

RESULTS

One hundred and thirty five men (4.2%) developed depression over a median follow up time of 9.4 years (range 8.4-10.9). Men with incident depression were older (median age 77.7 vs 76.1 years, z=-3.82, p=0<0.001) and were more likely to have cardiovascular disease (43.0% vs 32.6%, χ(2)=6.32, p=0.012) and diabetes (22.2% vs 13.2%, χ(2)=8.95, p=0.003). Low serum total testosterone (<6.4 nmol/L) was associated with incident depression (HR 2.07, 95%CI 1.17-3.68) and this remained significant after adjustment for relevant potential confounding factors (HR 1.86, 95%CI 1.05-3.31). Low serum dihydrotestosterone, estradiol and calculated free testosterone were not associated with risk of depression.

CONCLUSIONS

Low serum total testosterone, but not calculated free testosterone, was associated with incident depression in this sample of older men.

Are andropause symptoms related to depression?

BACKGROUND

Andropause is a middle-age condition in which men experience changes in their physical, spiritual and emotional health. The association between andropause and psychological symptoms such as depression are not very clear yet.

AIMS

The objective of this study was therefore to determine the association between the 'Aging Males Symptoms Scale' (AMS) and depression.

METHODS

A cross sectional study was conducted among 521 old men. To collect data, the AMS and the Patient Health Questionnaires 2 and 9 were used to screen depression, in addition to questions on background and fertility. Multiple linear regression analysis was used to assess the association between andropause symptoms and depression.

RESULTS

Based on our results and the AMS score, 51.5% of the study population had clinical symptoms of androgen disorder, 3.7% of which had severe symptoms. There was a strong correlation between the AMS score and depression. Depression, diabetes, cigarette smoking and spousal age retained their significant associations even after entering the relevant demographic, anthropometric, smoking and disease variables in the multivariable model. As a positive predictive factor, depression had the strongest association with AMS.

CONCLUSIONS

Based on our results, there is a direct association between andropause symptoms and depression, where the increasing AMS score corresponds with the severity of depression.

DISCUSSION

Our results show the need of screening for depression when evaluating andropause symptoms.

The effect of testosterone levels on mood in men: a review

BACKGROUND

The effects of both high and low levels of testosterone are wide ranging and can include changes in mood, often overlapping with symptoms of mood disorders.

OBJECTIVE

We sought to review the literature on the correlation of high and low levels of testosterone on mood disorders in men.

RESULTS

Based on limited studies, high levels of testosterone are related to increased rates of depression as well as hypomania, whereas low levels of testosterone are related to depressive disorders in certain subpopulations of patients. There is insufficient evidence to conclude that low testosterone level routinely leads to major depressive disorder in men.

CONCLUSIONS

Physicians should consider screening for low testosterone levels in certain subgroups of depressed men.

Olfactory Sensitivity and Sexual Desire in Young Adult and Elderly Men: An Introductory Investigation

Background

It has been suggested that olfaction could influence human sexual behavior. Age is negatively associated with many aspects of sexuality and, with increasing age, people tend to show a declining sexual desire. The present pilot study investigated the relationship between sexual desire and olfactory sensitivity in healthy men of two age groups, young adult and elderly (≥65 years old), to ascertain whether their sense of smell could determine sexual desire and whether an age-related weaker olfactory sensitivity could correlate with the decline in sexual appetite in elderly patients.

Methods

Sixty-three volunteers were recruited and divided into two groups, one consisting of 48 healthy young adult men, the other of 15 healthy elderly men. All participants were tested to ascertain their odor threshold for n-butanol (Sniffin’ Sticks) and their sexual desire using the International Index of Erectile Function (IIEF), presenting only the questions relating to frequency (IIEF1) and level (IIEF2) of sexual desire.

Results

Sexual desire and mean olfactory thresholds were higher in the younger adults than in the elderly men (p = 0.001 and p = 0.02, respectively). There was a significant association between butanol threshold and sexual desire for the young adult group (p = 0.02), but not for the elderly group (p = 0.35).

Conclusion

This study found a preliminary association between olfaction and sexual behavior, in young adults at least. More studies are needed to improve our knowledge in this intriguing field, possibly using electrophysiological olfactory methods.

Interactions of sexual activity, gender, and depression with immunity

INTRODUCTION

Depression can suppress immune function, leading to lower resistance against infection and longer healing times in depressed individuals. Sexuality may also influence immune function, with evidence that sexual activity is associated with lowered immune function in women and mixed results in men. Immune mediators like immunoglobulin A (IgA) are immediately relevant to sexual health, since they are the first line of defense against pathogens at mucous membranes like the vagina.

AIM

This study aims to determine if and how depression, sexual activity, and their interaction impact salivary IgA (SIgA) in men and women.

METHODS

In Study 1, a community-based sample of 84 women and 88 men provided saliva samples and completed questionnaires on their demographic background, level of depression, and frequency of partnered and solitary sexual activity. Study 2, conducted separately in an undergraduate student sample of 54 women and 52 men, had similar methods.

MAIN OUTCOME MEASURES

The main outcome measures were scores on the General Well-Being Schedule depression subscale, reported frequency of sexual activity, and SIgA levels as measured by enzyme immunoassay.

RESULTS

Across studies, higher levels of partnered sexual activity were associated with lower SIgA for women with high depression scores, but not for women with low depression scores. In contrast, higher levels of partnered sexual activity were associated with higher SIgA for men with high depression scores, but not for men with low depression scores.

CONCLUSION

Our results show that partnered sexual activity is a risk factor for lowered immunity in women with depressive symptoms but a possible resilience factor for men with depressive symptoms. This suggests a role for sexual activity in determining the impact of depression on physical health parameters.

Depression in late life

Despite its prevalence and seriousness, depression in late life remains underappreciated as a source of disability and suffering for older people and their families. Despite a solid and substantial body of research, recognition of depression remains problematic and is often attributed to normal developmental changes in aging. Treatment efficacy data notwithstanding, the adequacy and appropriateness of treatment is highly variable. This paper contains a broad overview of new research developments in depression in late life and the disabilities associated with it Serving as an introduction to the specific papers that follow in this issue of Dialogues in Clinical Neuroscience, this article scans the knowledge base in basic, clinical, and health services research, identifying the highlights of current work in the area and proposing areas of needed expansion of research efforts.

Postpartum depression is a family affair: addressing the impact on mothers, fathers, and children

The purpose of this paper is to present research on the effects of postpartum depression (PPD) on mothers, fathers, and children that point to a re-conceptualization of PPD as a mental health condition that affects the whole family. As such, the objectives of this paper are to discuss: (1) the incidence and effects of PPD on mothers and fathers; (2) common predictors of PPD in mothers and fathers, and (3) the effects of PPD on parenting and parent-child relationships, and (4) the effects of PPD on children's health, and their cognitive and social-emotional development. Finally, the implications for screening and intervention if depression is re-conceptualized as a condition of the family are discussed.

Characterization of the "sporadically lurking HAP1-immunoreactive (SLH) cells" in the hippocampus, with special reference to the expression of steroid receptors, GABA, and progenitor cell markers

Huntingtin-associated protein 1 (HAP1) is a neural huntingtin interactor that is widely expressed as a core molecule of the stigmoid body (a neurocytoplasmic inclusion) in the limbic and hypothalamic regions and has putative protective functions against some neurodegenerative diseases (HAP1 protection hypothesis). Although HAP1 has been reported to be intimately associated with several steroid receptors, HAP1-immunoreactive (HAP1-ir) cells remain to be identified in the hippocampus, which is one of the major steroidal targets. In this study, we determined the distribution of hippocampal HAP1-ir cells in light and fluorescence microscopy and characterized their morphological relationships with steroid receptors, markers of adult neurogenesis, and the GABAergic system in adult male and female Wistar rats. HAP1-ir cells, which were sporadically distributed particularly in the subgranular zone (SGZ) of the dentate gyrus and in the interface between the stratum lacunosum-moleculare and stratum radiatum of Ammon's horn, were identified as the "sporadically lurking HAP1-ir (SLH)" cells. The SLH cells showed no clear association with neural progenitor/proliferating or migrating cell markers of adult neurogenesis, such as Ki-67, proliferating cell nuclear antigen, doublecortin, and glial fibrillary acidic protein in the SGZ, whereas all the SLH cells expressed a neuronal specific nuclear protein (NeuN). More than 90% of the SLH cells expressed nuclear estrogen receptor (ER) α but neither ERβ nor the androgen receptor, whereas glucocorticoid receptor was differently stained in the SLH cells depending on the antibodies. More than 60% of them exhibited GABA immunoreactivity in the SGZ, suggestive of basket cells, but they were distinct from the ones expressing cholecystokinin or parvalbumin. We conclude that SLH cells, which should be stable against apoptosis due to putative HAP1 protectivity, might be involved in estrogen-dependent maturation, remodeling and activation of hippocampal memory and learning functions via ERα and partly through GABAergic regulation.

Partial androgen deficiency, depression, and testosterone supplementation in aging men

The aim of this review was to summarize current knowledge on the correlation between depressive symptoms with a syndrome called partial androgen deficiency of the aging male (PADAM) and on the potential benefits of testosterone (T) treatment on mood. Despite, the causative nature of the relationship between low T levels and depression is uncertain, many hypogonadal men suffer from depression and vice versa several depressed patients are affected by hypogonadism. Supplementation with testosterone failed to show sound evidence of effectiveness in the treatment of depression. Nevertheless, testosterone supplementation has proved to be effective on some domains significant for the quality of life of aged patients with PADAM (sexual function and cognitive functions, muscular strengths).

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

INTRODUCTION

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

AIM

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

METHODS

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSION

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

Low free testosterone levels are associated with prevalence and incidence of depressive symptoms in older men

OBJECTIVE

The prevalence of both low testosterone levels and depression increases with age. Currently, there is no consensus regarding the existence of an association. Our study analyses the cross-sectional association of testosterone levels with depressive symptoms and its prospective association with the development of incident depressive symptoms.

DESIGN

Longitudinal population-based study; based on the data of the Longitudinal Aging Study Amsterdam (LASA) including 608 men aged >or=65 years (median age 75.6 years).

MEASUREMENTS

Linear and logistic regression between total and free testosterone levels and depressive symptoms as measured by the Center of Epidemiologic Studies Depression (CES-D) scale, taking into account medical and lifestyle factors. Cox Proportional Hazards model was used to assess incident depressive symptoms.

RESULTS

Unadjusted linear regression between square-root transformed CES-D scores and free testosterone levels showed a significant inverse association as a continuous variable (beta = -0.10, P < 0.05), lowest quartile compared to highest (beta = 0.12, P < 0.05) and with a threshold value of 170 pmol/l (beta = 0.13, P < 0.05). The results remained significant for the group below threshold after adjustment for all confounders (beta = 0.09, P < 0.05). Cox Proportional Hazards Model showed a decreased risk for incident depressive symptoms for men with higher free testosterone levels [HR = 0.997 CI (0.995-1.000)]. Men with the threshold value below 220 pmol/l were at increased risk of incident depressive symptoms [HR = 1.989 CI (1.173-3.374)].

CONCLUSIONS

Free testosterone levels below 170 pmol/l are associated with depressive symptoms, while free testosterone levels below 220 pmol/l (lowest quintile of our population) predict the onset of depressive symptoms.

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

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

Testosterone and depression: systematic review and meta-analysis

BACKGROUND

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

OBJECTIVE

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Partial androgen deficiency, depression and testosterone treatment in aging men

This study provides a critical review of the literature on depressive symptoms of partial androgen deficiency (PADAM) and their treatment with Testosterone (T). PADAM in aging males is responsible for a variety of behavioral symptoms, such as weakness, decreased libido and erectile dysfunction, lower psychological vitality, depressive mood, anxiety, insomnia, difficulty in concentrating, and memory impairment. The psychological and behavioural aspects of PADAM may overlap with signs and symptoms of major depression. Evidence of the relationship between androgen deficiency and male depression comes from studies that have assessed depression in hypogonadal subjects, the association between low T level and male depressive illness, and the antidepressant action of androgen replacement. The etiology of depressive symptoms of PADAM is multifactorial, and results from the interaction of the biological and psychosocial changes that take place during the mid-life transition. Although data derived from androgen treatment trials and androgen replacement do not support T treatment or replacement as more efficacious than placebo for major depressive disorder (MDD), the clinical impression is that, in some sub-threshold depressive syndromes, T may lead to antidepressant benefits.

Short-term testosterone augmentation in male schizophrenics: a randomized, double-blind, placebo-controlled trial

Although there are few studies on the treatment of schizophrenia with testosterone, several indirect findings have suggested testosterone as a possible treatment modality for schizophrenia. To explore the therapeutic effect of testosterone augmentation of antipsychotic medication on symptoms in male patients with schizophrenia, the authors performed a placebo-controlled, double-blind trial on 30 schizophrenic men, using either 5 g of 1% testosterone gel (Testogel; Besins Iscovesco, Paris, France) or a placebo added to a fixed dosage of antipsychotic medication over a period of 4 weeks with a 2-week washout period. In addition, to get additional information about the involvement of these reproductive hormones after testosterone augmentation, the authors evaluated several hormones such as total testosterone, free testosterone, dehydroepiandrosterone sulfate, estradiol, and prolactin. Results indicated a significant improvement of negative symptoms in both the last observation carried forward and the completer analyses and a nonsignificant trend for the improvement of depressive symptoms in completers. There were no significant changes in serum hormone levels except total and free testosterone. The findings of this study suggest that testosterone augmentation may be a potential therapeutic strategy in patients with schizophrenia.

Testosterone and behavior: involvement of the hormone in psychotropic effects of baclofen

We studied the effect of baclofen (GABA(B) receptor agonist) on the behavior of male mice with different levels of anxiety in tests for social and sexual contact and on blood testosterone levels. The drug reduced testosterone level and behavioral reaction to an unknown male in intact animals and did not modulate the hormone level and social contacts in anxious mice. In the test with receptive female, baclofen reduced testosterone level and sexual motivation in intact males and did not modulate the hormone level and initial sexual interest in anxious mice. Parallelism in the development of behavioral and endocrine components of the reaction to social and sexual stimuli confirms possible involvement of testosterone in psychotropic effects of baclofen.

Cortisol and testosterone levels on a weekend and a work day in three mountain villages in the Selska Valley of northwest Slovenia

BACKGROUND

In contemporary western populations, a week commonly involves 5 days of paid work (work days) and two non-working days (weekend). Work days are usually perceived as being more stressful than non-work days and this hypothesis has been tested in several studies, most of which selected subjects with jobs that are perceived to have high stress.

AIM

The study measured salivary cortisol and testosterone on a work day and a weekend in a community-based sample of people going about their everyday lives and tested the hypothesis that hormone levels will be higher on a work day.

SUBJECTS AND METHODS

Slovenian alpine villagers (30 females and 25 males) were sampled without reference to their occupation. Each individual was measured on two occasions, a day on a weekend and a work day as they went about their usual activities in the afternoon.

RESULTS

Cortisol (mean = 3.32 ng ml(-1), range 0.4-27.9) and testosterone (mean = 121 pg ml(-1), range 17-424) values were similar to other populations. Neither the age of subjects nor the time in the afternoon of sample collection were associated with hormone concentrations. On each day of collection, cortisol and testosterone values were correlated for each sex, with the estimate of the correlation coefficient ranging from 0.57 to 0.88. For females, testosterone values were higher on the weekend than the work day (102 pg ml(-1) and 60 pg ml(-1), respectively) but not for males (mean across both days 134 pg ml(-1)). Independent of this effect, the presence of a spouse or other adult in the house was significantly associated with lower testosterone levels in both sexes. Husband and wife testosterone values are correlated on the weekend (r = 0.67, p = 0.02) but not on the work day. Mean cortisol values for the weekend and work day were not different and there was no correlation between levels on these two days.

CONCLUSIONS

These results, although based upon a small sample size, reveal potential relationships between testosterone, work-rest activities, and the presence-absence of a social partner that warrant further investigation.

Association between serum testosterone levels and the severity of negative symptoms in male patients with chronic schizophrenia

OBJECTIVES

Dysfunction of the hypothalamic-pituitary-gonadal axis may contribute to the pathophysiology of schizophrenia. Recent neuroendocrinological studies have suggested that gonadal sex hormones, including androgens and estrogen, play a significant role in the pathophysiology of schizophrenia. The purpose of this study was to determine any correlation between negative symptoms and the plasma levels of free testosterone, total testosterone, dehydroepiandrosterone sulfate, estradiol, and prolactin with consideration to depressive symptoms, extrapyramidal symptoms (EPS), and other factors including differences in age, diurnal variation of the serum hormone levels, and body fat composition.

METHODS

The subjects were 35 male inpatients with chronic schizophrenia aged 20-39 years. The patients' psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS). The Calgary Depression Scale for Schizophrenia (CDSS) and the Drug-induced EPS scale (DIEPSS) were also used to exclude the effects of depression or drug-induced movement disorders.

RESULTS

The PANSS negative scores had a significant inverse correlation with the serum total and free testosterone levels. The other hormone levels were not correlated with the PANSS negative scores. Moreover, a partial correlation analysis showed an inverse correlation between the PANSS negative subscores and the serum total and free testosterone levels after controlling for the DIEPSS and/or CDSS scores and age.

CONCLUSIONS

This study indicates that total and free testosterone may play an important role in the severity of negative symptoms in male patients with schizophrenia.

The stress system in depression and neurodegeneration: focus on the human hypothalamus

The stress response is mediated by the hypothalamo-pituitary-adrenal (HPA) system. Activity of the corticotropin-releasing hormone (CRH) neurons in the hypothalamic paraventricular nucleus (PVN) forms the basis of the activity of the HPA-axis. The CRH neurons induce adrenocorticotropin (ACTH) release from the pituitary, which subsequently causes cortisol release from the adrenal cortex. The CRH neurons co-express vasopressin (AVP) which potentiates the CRH effects. CRH neurons project not only to the median eminence but also into brain areas where they, e.g., regulate the adrenal innervation of the autonomic system and affect mood. The hypothalamo-neurohypophysial system is also involved in stress response. It releases AVP from the PVN and the supraoptic nucleus (SON) and oxytocin (OXT) from the PVN via the neurohypophysis into the bloodstream. The suprachiasmatic nucleus (SCN), the hypothalamic clock, is responsible for the rhythmic changes of the stress system. Both centrally released CRH and increased levels of cortisol contribute to the signs and symptoms of depression. Symptoms of depression can be induced in experimental animals by intracerebroventricular injection of CRH. Depression is also a frequent side effect of glucocorticoid treatment and of the symptoms of Cushing's syndrome. The AVP neurons in the hypothalamic PVN and SON are also activated in depression, which contributes to the increased release of ACTH from the pituitary. Increased levels of circulating AVP are also associated with the risk for suicide. The prevalence, incidence and morbidity risk for depression are higher in females than in males and fluctuations in sex hormone levels are considered to be involved in the etiology. About 40% of the activated CRH neurons in mood disorders co-express nuclear estrogen receptor (ER)-alpha in the PVN, while estrogen-responsive elements have been found in the CRH gene promoter region, and estrogens stimulate CRH production. An androgen-responsive element in the CRH gene promoter region initiates a suppressing effect on CRH expression. The decreased activity of the SCN is the basis for the disturbances of circadian and circannual fluctuations in mood, sleep and hormonal rhythms found in depression. Neuronal loss was also reported in the hippocampus of stressed or corticosteroid-treated rodents and primates. Because of the inhibitory control of the hippocampus on the HPA-axis, damage to this structure was expected to disinhibit the HPA-axis, and to cause a positive feedforward cascade of increasing glucocorticoid levels over time. This 'glucocorticoid cascade hypothesis' of stress and hippocampal damage was proposed to be causally involved in age-related accumulation of hippocampal damage in disorders like Alzheimer's disease and depression. However, in postmortem studies we could not find the presumed hippocampal damage of steroid overexposure in either depressed patients or in patients treated with synthetic steroids.

Total testosterone, androgen receptor polymorphism, and depressive symptoms in young black and white men: the CARDIA Male Hormone Study

Androgen receptor (AR) CAG repeat length (RL) might modify the relationship between endogenous testosterone (T) and depressive symptoms in men on average over age 50 years. We hypothesized that CAG RL modifies the association between T and depressive symptoms in 525 black and 721 white men under age 40 years participating in the CARDIA Male Hormone Study. We assessed cross-sectional associations of quartiles of total and bioavailable T and tertiles of CAG RL with depressive symptoms, defined as Center for Epidemiologic Studies Depression Scale (CES-D) score > or=16, in 1995-1996. The interaction of CAG RL and total T on depressive symptoms was statistically significant for blacks, whites, and both groups combined. In the combined analysis, the odds ratios (OR) (95% confidence intervals (CI)) across the quartiles of total T were 1.00, 0.17 (95% CI=0.07-0.43), 0.31 (95% CI=0.14-0.70), and 0.49 (95% CI=0.22-1.09) for the shortest RL group. The interaction of CAG RL and bioavailable T on depressive symptoms was statistically significant for black men only, and nonsignificant in a combined analysis. For black men in the shortest RL group, the ORs for the quartiles of bioavailable T were 1.00, 0.41 (95% CI=0.16-1.05), 0.10 (95% CI=0.03-0.38), and 0.35 (95% CI=0.14-0.90). In other CAG groups, there were no relationships of total or bioavailable T with depressive symptoms. CAG RL might modify the association between endogenous total and bioavailable T and depressive symptoms in younger black men. Clinical trials assessing the effects of T replacement therapy on depressive symptoms in hypogonadal men should consider including CAG RL in their design and/or analysis.

Testosterone and the brain

Gender differences in spatial recognition, and age-related declines in cognition and mood, point towards testosterone as an important modulator of cerebral functions. Testosterone appears to activate a distributed cortical network, the ventral processing stream, during spatial cognition tasks, and addition of testosterone improves spatial cognition in younger and older hypogonadal men. In addition, reduced testosterone is associated with depressive disorders. The relationship between depression and testosterone appears to partly depend upon the androgen receptor genotype of the patient, and in appropriate patients with low testosterone levels, testosterone substitution can increase positive mood and decrease negative mood. The much publicized link between testosterone and aggression is probably only of importance in athletes who supplement their testosterone levels to excessively high levels, whereas in hypogonadal men, testosterone supplementation only enhances the positive aspects of aggression such as vigour and energy. Current data suggest that testosterone supplementation in hypogonadal men of all ages will enhance many aspects of mood and cognition.

Association of hypogonadism and type II diabetes in men attending an outpatient erectile dysfunction clinic

Patients with diabetes mellitus (DM) were more often hypogonadal than normal fasting glucose subjects. The aim of this investigation is the assessment of characteristics and psychobiological correlates of DM associated with hypogonadism (DMAH). The Structured Interview SIEDY was used along with several biochemical, psychological and instrumental investigations in a series of more than 1200 patients with erectile dysfunction (ED); 16% of whom with type II DM. Hypogonadism was defined as circulating total testosterone (T) below 10.4 nmol/l. The prevalence of hypogonadism was 24.5% in DM versus 12.6% in the rest of the sample (P < 0.0001); differences in the prevalence of hypogonadism retained significance after adjustment for age and BMI. DMAH was associated with typical hypogonadism-related symptoms, such as reduction in sexual desire, leading to a decreased number of sexual attempts, and with higher depressive symptomatology. In DMAH, testis size and LH concentrations were significantly reduced, suggesting a central origin of the disease. At penile Duplex ultrasound examination, diabetic patients and in particular hypogonadal type II diabetic patients showed lower levels of basal and dynamic (after PGE1 injection) peak systolic velocity and acceleration, when compared to the rest of the sample, even after adjustment for age and BMI. Our results show that hypogonadism is frequently associated with type II DM, at least in the 6th decade. DMAH might exacerbate sexual dysfunction by reducing libido and mood and further compromising penile vascular reactivity.

Normative hypogonadism and depression: does ‘andropause’ exist?

The progressive decline in testosterone level has been demonstrated in both cross-sectional and longitudinal studies, and overall at least 25% of men over the age of 70 years meet laboratory criteria for hypogonadism (i.e., testosterone deficiency). Such age-associated HPG hypofunctioning, which has been termed 'andropause', is thought to be responsible for a variety of symptoms experienced by elderly men, including sexual dysfunction and depression. Although, it has been difficult to establish correlations between 'andropausal' symptoms and plasma testosterone levels, there is some evidence that testosterone replacement leads to improvement in muscle strength, bone mineral density, and erectile dysfunction. There is little evidence of a link between HPG-axis dysfunction and depressive illness, and exogenous androgens have not been consistently shown to be antidepressant. This article reviews the relationship between androgens and depression in aging men.

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

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

The stress system in the human brain in depression and neurodegeneration

Corticotropin-releasing hormone (CRH) plays a central role in the regulation of the hypothalamic-pituitary-adrenal (HPA)-axis, i.e., the final common pathway in the stress response. The action of CRH on ACTH release is strongly potentiated by vasopressin, that is co-produced in increasing amounts when the hypothalamic paraventricular neurons are chronically activated. Whereas vasopressin stimulates ACTH release in humans, oxytocin inhibits it. ACTH release results in the release of corticosteroids from the adrenal that, subsequently, through mineralocorticoid and glucocorticoid receptors, exert negative feedback on, among other things, the hippocampus, the pituitary and the hypothalamus. The most important glucocorticoid in humans is cortisol, present in higher levels in women than in men. During aging, the activation of the CRH neurons is modest compared to the extra activation observed in Alzheimer's disease (AD) and the even stronger increase in major depression. The HPA-axis is hyperactive in depression, due to genetic factors or due to aversive stimuli that may occur during early development or adult life. At least five interacting hypothalamic peptidergic systems are involved in the symptoms of major depression. Increased production of vasopressin in depression does not only occur in neurons that colocalize CRH, but also in neurons of the supraoptic nucleus (SON), which may lead to increased plasma levels of vasopressin, that have been related to an enhanced suicide risk. The increased activity of oxytocin neurons in the paraventricular nucleus (PVN) may be related to the eating disorders in depression. The suprachiasmatic nucleus (SCN), i.e., the biological clock of the brain, shows lower vasopressin production and a smaller circadian amplitude in depression, which may explain the sleeping problems in this disorder and may contribute to the strong CRH activation. The hypothalamo-pituitary thyroid (HPT)-axis is inhibited in depression. These hypothalamic peptidergic systems, i.e., the HPA-axis, the SCN, the SON and the HPT-axis, have many interactions with aminergic systems that are also implicated in depression. CRH neurons are strongly activated in depressed patients, and so is their HPA-axis, at all levels, but the individual variability is large. It is hypothesized that particularly a subgroup of CRH neurons that projects into the brain is activated in depression and induces the symptoms of this disorder. On the other hand, there is also a lot of evidence for a direct involvement of glucocorticoids in the etiology and symptoms of depression. Although there is a close association between cerebrospinal fluid (CSF) levels of CRH and alterations in the HPA-axis in depression, much of the CRH in CSF is likely to be derived from sources other than the PVN. Furthermore, a close interaction between the HPA-axis and the hypothalamic-pituitary-gonadal (HPG)-axis exists. Organizing effects during fetal life as well as activating effects of sex hormones on the HPA-axis have been reported. Such mechanisms may be a basis for the higher prevalence of mood disorders in women as compared to men. In addition, the stress system is affected by changing levels of sex hormones, as found, e.g., in the premenstrual period, ante- and postpartum, during the transition phase to the menopause and during the use of oral contraceptives. In depressed women, plasma levels of estrogen are usually lower and plasma levels of androgens are increased, while testosterone levels are decreased in depressed men. This is explained by the fact that both in depressed males and females the HPA-axis is increased in activity, parallel to a diminished HPG-axis, while the major source of androgens in women is the adrenal, whereas in men it is the testes. It is speculated, however, that in the etiology of depression the relative levels of sex hormones play a more important role than their absolute levels. Sex hormone replacement therapy indeed seems to improve mood in elderly people and AD patients. Studies of rats have shown that high levels of cumulative corticosteroid exposure and rather extreme chronic stress induce neuronal damage that selectively affects hippocampal structure. Studies performed under less extreme circumstances have so far provided conflicting data. The corticosteroid neurotoxicity hypothesis that evolved as a result of these initial observations is, however, not supported by clinical and experimental observations. In a few recent postmortem studies in patients treated with corticosteroids and patients who had been seriously and chronically depressed no indications for AD neuropathology, massive cell loss, or loss of plasticity could be found, while the incidence of apoptosis was extremely rare and only seen outside regions expected to be at risk for steroid overexposure. In addition, various recent experimental studies using good stereological methods failed to find massive cell loss in the hippocampus following exposure to stress or steroids, but rather showed adaptive and reversible changes in structural parameters after stress. Thus, the HPA-axis in AD is only moderately activated, possibly due to the initial (primary) hippocampal degeneration in this condition. There are no convincing arguments to presume a causal, primary role for cortisol in the pathogenesis of AD. Although cortisol and CRH may well be causally involved in the signs and symptoms of depression, there is so far no evidence for any major irreversible damage in the human hippocampus in this disorder.

Sex Steroid Level, Androgen Receptor Polymorphism, and Depressive Symptoms in Healthy Elderly Men

OBJECTIVES

To determine the prevalence of depression in a cohort of elderly men as assessed using a 30-item Geriatric Depression Scale (GDS) score and to describe the association between this score and sex steroids, androgen receptor (AR) polymorphism, and general health status.

DESIGN

Observational study on the relationship between sex steroid status and health-related parameters.

SETTING

Community-based.

PARTICIPANTS

Ambulatory men (n=236 in 1997, n=192 in 2000) aged 70 and older at inclusion in 1996, interviewed in 1997 and 2000.

MEASUREMENTS

Serum levels of testosterone, estradiol, sex hormone binding globulin (SHBG), dehydroepiandrosterone-sulfate (DHEAS), cortisol, and the AR gene cytosine, adenine, guanine (CAG)-repeat length polymorphism were determined. Free testosterone and free estradiol were calculated. Questionnaires included GDS, 36-item Short Form, and Rapid Disability Rating Scale-2.

RESULTS

Median age was 75.3 years (interquartile range=73.5-78.5). A GDS score of 11 or greater was found in 30 (12.7%) men. Age and GDS score were significantly interrelated (P<.01), as were all health-assessment scores. GDS scores were not related to (free) testosterone or AR polymorphism in 1997 or 2000. In 1997 only (n=236), higher GDS scores were related to higher estradiol, free estradiol, and DHEAS levels.

CONCLUSION

The data did not support a role for testosterone in depression in elderly community-based men as assessed using the GDS.

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

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

Androgen Replacement Therapy

The major goal of androgen substitution is to replace testosterone at levels as close to physiological levels as is possible. For some androgen-dependent functions testosterone is a pro-hormone, peripherally converted to 5alpha-dihydrotestosterone (DHT) and 17beta-estradiol (E2), of which the levels preferably should be within normal physiological ranges. Furthermore, androgens should have a good safety profile without adverse effects on the prostate, serum lipids, liver or respiratory function, and they must be convenient to use and patient-friendly, with a relative independence from medical services. Natural testosterone is viewed as the best androgen for substitution in hypogonadal men. The reason behind the selection is that testosterone can be converted to DHT and E2, thus developing the full spectrum of testosterone activities in long-term substitution. The mainstays of testosterone substitution are parenteral testosterone esters (testosterone enantate and testosterone cipionate) administered every 2-3 weeks. A major disadvantage is the strongly fluctuating levels of plasma testosterone, which are not in the physiological range at least 50% of the time. Also, the generated plasma E2 is usually supraphysiological. A major improvement is parenteral testosterone undecanoate producing normal plasma levels of testosterone for 12 weeks, with normal plasma levels of DHT and E2 also. Subcutaneous testosterone implants provide the patient, depending on the dose of implants, with normal plasma testosterone for 3-6 months. However, their use is not widespread. Oral testosterone undecanoate dissolved in castor oil bypasses the liver via its lymphatic absorption. At a dosage of 80 mg twice daily, plasma testosterone levels are largely in the normal range, but plasma DHT tends to be elevated. For two decades transdermal testosterone preparations have been available and have an attractive pharmacokinetic profile. Scrotal testosterone patches generate supraphysiological plasma DHT levels, which is not the case with the nonscrotal testosterone patches. Transdermal testosterone gel produces fewer skin irritations than the patches and offers greater flexibility in dosage. Oromucosal testosterone preparations have recently become available. Testosterone replacement is usually of long duration and so patient compliance is of utmost importance. Therefore, the patient must be involved in the selection of type of testosterone preparation. Administration of testosterone to young individuals has almost no adverse effects. With increasing age the risk of adverse effects on the prostate, the cardiovascular system and erythropoiesis increases. Consequently, short-acting testosterone preparations are better suited for aging androgen-deficient men.