Abnormalities of the HPA axis in affective disorders: clinical subtypes and potential treatments

Association between socioeconomic position of the household head, food insecurity and psychological health: an application of propensity score matching

BACKGROUND

Mental health outcomes can be influenced by various factors, one of which has recently gained attention, namely food security. Food security is paramount to maintaining not only physical, but also mental health. There is an increasing need to understand the interplay between food insecurity (FI) and mental health outcomes, especially among vulnerable populations. The objective of this study was to investigate the effect of FI on psychological health (anxiety and depression) as well as to examine the modifying effect of socioeconomic position on this relationship.

METHODS

A cross-sectional study was conducted in Maputo City, Mozambique, in 1,842 participants. Data were collected through structured interviews using a modified version of the US Department of Agriculture Household Food Security Module to measure FI, and the Hospital Anxiety and Depression Scale to measure anxiety and depression. A composite variable for psychological health was created. Propensity score matching and interaction effect analyses were employed to examine the effects of FI on psychological health and the moderating role of socioeconomic position.

RESULTS

Of the 1,174 participants randomly assigned to propensity score matching, 787 were exposed to FI while 387 were unexposed. The analysis revealed stark disparities in psychological health outcomes associated with FI. The risk of poor psychological health among those exposed to FI was 25.79%, which was significantly higher than the 0.26% in unexposed individuals. The risk difference was 25.54% points (95% CI: 22.44-28.63), with a risk ratio of 99.82. Our assessment of population attributable fractions indicated that nearly all the risk for poor psychological health in the exposed group could be ascribed to FI. The interaction effects analysis revealed that socioeconomic status modifies this relationship. Specifically, heads of food-insecure households with a lower socioeconomic position tended to report poor mental health compared to their food-secure counterparts with a higher position.

CONCLUSIONS

The findings underscore the profound impact of FI on the mental health of household heads in Maputo City, socioeconomic position being a significant modifier. Addressing household FI along with the socioeconomic position of household heads could be pivotal to mental health promotion, especially among vulnerable populations.

Epigenetic Genome Modifications during Pregnancy: The Impact of Essential Nutritional Supplements on DNA Methylation

Pregnancy is an extremely stressful period in a pregnant woman's life. Currently, women's awareness of the proper course of pregnancy and its possible complications is constantly growing. Therefore, a significant percentage of women increasingly reach for various dietary supplements during gestation. Some of the most popular substances included in multi-ingredient supplements are folic acid and choline. Those substances are associated with positive effects on fetal intrauterine development and fewer possible pregnancy-associated complications. Recently, more and more attention has been paid to the impacts of specific environmental factors, such as diet, stress, physical activity, etc., on epigenetic modifications, understood as changes occurring in gene expression without the direct alteration of DNA sequences. Substances such as folic acid and choline may participate in epigenetic modifications by acting via a one-carbon cycle, leading to the methyl-group donor formation. Those nutrients may indirectly impact genome phenotype by influencing the process of DNA methylation. This review article presents the current state of knowledge on the use of folic acid and choline supplementation during pregnancy, taking into account their impacts on the maternal-fetal unit and possible pregnancy outcomes, and determining possible mechanisms of action, with particular emphasis on their possible impacts on epigenetic modifications.

Association between childhood trauma, cognition, and psychosocial function in a large sample of partially or fully remitted patients with bipolar disorder and healthy participants

BACKGROUND

Childhood trauma (CT) are frequently reported by patients with bipolar disorder (BD), but it is unclear whether and how CT contribute to patients' cognitive and psychosocial impairments. We aimed to examine the impact of CT on cognition and psychosocial functioning in a large sample of 345 patients with BD and 183 healthy control participants (HC) using the Childhood Trauma Questionnaire, neurocognitive tests and ratings of mood symptoms and functioning.

RESULTS

Patients showed broad cognitive impairments across memory, attention and executive function and functional disability despite being in partial or full remission and had higher levels of CT than HC. Higher levels of CT correlated with impairments across almost all cognitive domains and lower psychosocial functioning across BD patients and HC. Of these, the associations between CT and poorer working memory and lower psychosocial functioning, respectively, prevailed after adjusting for clinical and demographical variables. Diagnosis of BD and estimated verbal intelligence did not moderate these associations. Analysis of CT sub-categories showed that working memory impairments were related particularly to childhood physical and emotional abuse, while psychosocial difficulties were related to physical and emotional neglect.

CONCLUSIONS

CT may have negative implications for working memory and psychosocial functioning across both BD and healthy populations. If the findings are replicated, this would suggest that early interventions that reduce the frequency of CT in vulnerable families may aid children's cognitive and psychosocial development.

Food insufficiency, adverse childhood experiences and mental health: results of the Singapore Mental Health Study 2016

OBJECTIVE

This study aimed to investigate the prevalence and correlates of food insufficiency and its association with mental disorders and adverse childhood experiences (ACE) in Singapore.

DESIGN

This analysis utilised data from the Singapore Mental Health Study (SMHS 2016).

SETTING

SMHS 2016 was a population-based, psychiatric epidemiological study conducted among Singapore residents.

PARTICIPANTS

Interviews were conducted with 6126 respondents. Respondents were included if they were aged 18 years and above, Singapore citizens or permanent residents and able to speak in English, Chinese or Malay.

RESULTS

The prevalence of food insufficiency was 2·0 % (95 % CI (1·6, 2·5)) among adult Singapore residents. Relative to respondents who did not endorse any ACE, those with ACE (OR: 2·9, 95 % CI (1·2, 6·6)) had higher odds of food insufficiency. In addition, there were significant associations between lifetime mental disorders and food insufficiency. Bipolar disorder (OR: 2·7, 95 % CI (1·2, 6·0)), generalised anxiety disorder (OR: 4·5, 95 % CI (1·5, 13·5)) and suicidal behaviour (OR: 2·37, 95 % CI (1·04, 5·41)) were shown to be significantly associated with higher odds of food insufficiency.

CONCLUSIONS

The prevalence of food insufficiency is low in Singapore. However, this study identifies a vulnerable group of food-insufficient adults that is significantly associated with mental disorders, including suicidality. Government-funded food assistance programmes and multi-agency efforts to deal with the social determinants of food insufficiency, such as income sufficiency and early detection and intervention of mental distress, are key to ensuring a sustainable and equitable food system.

Methyl Donors, Epigenetic Alterations, and Brain Health: Understanding the Connection

Methyl donors such as choline, betaine, folic acid, methionine, and vitamins B6 and B12 are critical players in the one-carbon metabolism and have neuroprotective functions. The one-carbon metabolism comprises a series of interconnected chemical pathways that are important for normal cellular functions. Among these pathways are those of the methionine and folate cycles, which contribute to the formation of S-adenosylmethionine (SAM). SAM is the universal methyl donor of methylation reactions such as histone and DNA methylation, two epigenetic mechanisms that regulate gene expression and play roles in human health and disease. Epigenetic mechanisms have been considered a bridge between the effects of environmental factors, such as nutrition, and phenotype. Studies in human and animal models have indicated the importance of the optimal levels of methyl donors on brain health and behavior across the lifespan. Imbalances in the levels of these micronutrients during critical periods of brain development have been linked to epigenetic alterations in the expression of genes that regulate normal brain function. We present studies that support the link between imbalances in the levels of methyl donors, epigenetic alterations, and stress-related disorders. Appropriate levels of these micronutrients should then be monitored at all stages of development for a healthier brain.

Shielding children from food insecurity and its association with mental health and well-being in Canadian households

OBJECTIVE

Adults in food-insecure households will often sacrifice their own nutritional needs so that children are fed first. This shielding may protect children from malnutrition, but its links to mental health and well-being have not been closely examined. The aim of this study is to explore these links.

METHODS

We used data from three cycles of the Canadian Community Health Survey (n = 28,871 youth, 74,416 adults) to identify shielded children (those who reported not being food insecure but lived in food-insecure households). Using Poisson regression, we examined youth and adult mental health and well-being (mood disorder, anxiety disorder, fair/poor mental health, fair/poor health, and low life satisfaction) in shielding households compared to food-secure households and food-insecure households where children were not shielded.

RESULTS

About one in six (15.3%) households with children was food insecure. One third of these (6.3%) included children who were shielded from experiencing food insecurity. Shielded youth did not differ significantly from food-secure youth in three of the five outcomes examined. However, unshielded youth, compared to food-secure youth, showed increased risks of every health outcome we investigated. Adults in food-insecure households also reported worse mental health than food-secure adults but better mental health if children were shielded.

CONCLUSION

Shielding is associated with reduced risk of common psychiatric outcomes and poor mental health in youth and adults, possibly because it is associated with milder forms of food insecurity. The inability to protect children from having inadequate access to food may compound the psychological strain of food insecurity on mental health and well-being among adults.

HIV-1 Tat Protein Promotes Neuroendocrine Dysfunction Concurrent with the Potentiation of Oxycodone's Psychomotor Effects in Female Mice

Human immunodeficiency virus (HIV) is associated with neuroendocrine dysfunction which may contribute to co-morbid stress-sensitive disorders. The hypothalamic-pituitary-adrenal (HPA) or -gonadal (HPG) axes are perturbed in up to 50% of HIV patients. The mechanisms are not known, but we have found the HIV-1 trans-activator of transcription (Tat) protein to recapitulate the clinical phenotype in male mice. We hypothesized that HPA and/or HPG dysregulation contributes to Tat-mediated interactions with oxycodone, an opioid often prescribed to HIV patients, in females. Female mice that conditionally-expressed the Tat_1-86 protein [Tat(+) mice] or their counterparts that did not [Tat(-) control mice] were exposed to forced swim stress (or not) and behaviorally-assessed for motor and anxiety-like behavior. Some mice had glucocorticoid receptors (GR) or corticotropin-releasing factor receptors (CRF-R) pharmacologically inhibited. Some mice were ovariectomized (OVX). As seen previously in males, Tat elevated basal corticosterone levels and potentiated oxycodone's psychomotor activity in females. Unlike males, females did not demonstrate adrenal insufficiency and oxycodone potentiation was not regulated by GRs or CRF-Rs. Rather OVX attenuated Tat/oxycodone interactions. Either Tat or oxycodone increased anxiety-like behavior and their combination increased hypothalamic allopregnanolone. OVX increased basal hypothalamic allopregnanolone and obviated Tat or oxycodone-mediated fluctuations. Together, these data provide further evidence for Tat-mediated dysregulation of the HPA axis and reveal the importance of HPG axis regulation in females. HPA/HPG disruption may contribute vulnerability to affective and substance use disorders.

Reducing Allostatic Load in Depression and Anxiety Disorders: Physical Activity and Yoga Practice as Add-On Therapies

The allostatic load (AL) index constitutes a useful tool to objectively assess the biological aspects of chronic stress in clinical practice. AL index has been positively correlated with cumulative chronic stress (physical and psychosocial stressors) and with a high risk to develop pathological conditions (e.g., metabolic syndrome, cardiovascular pathology, inflammatory disorders) and the so-called stress-related psychiatric disorders, including anxiety and depressive disorders. Chronic stress has negative effects on brain neuroplasticity, especially on hippocampal neurogenesis and these effects may be reversed by antidepressant treatments. Several evidences indicate that non-pharmacological interventions based on physical activity and yoga practice may add synergizing benefits to classical treatments (antidepressant and benzodiazepines) for depression and anxiety, reducing the negative effects of chronic stress. The aim of this review is to provide a general overview of current knowledge on AL and chronic stress in relation to depression and anxiety, physical activity and yoga practice.

Food Insecurity Is Associated With Poorer Mental Health and Sleep Outcomes in Young Adults

PURPOSE

The aim of the study was to determine the association between food insecurity, mental health, and sleep outcomes among young adults. Young adulthood represents an important developmental period when educational and economic transitions may increase the risk for food insecurity; however, little is known about associations between food insecurity and health outcomes in this period.

METHODS

Cross-sectional nationally representative data of U.S. young adults aged 24-32 years from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health were analyzed in 2018. Multiple logistic regression analysis was conducted with food insecurity as the independent variable and self-reported mental health (depression, anxiety, and suicidality) and sleep (trouble falling and staying asleep) outcomes as the dependent variables.

RESULTS

Of the 14,786 young adults in the sample, 11% were food insecure. Food-insecure young adults had greater odds of mental health problems including a depression diagnosis (1.67, 95% confidence interval [CI] 1.39-2.01), anxiety or panic disorder diagnosis (1.47, 95% CI 1.16-1.87), and suicidal ideation in the past 12 months (2.76, 95% CI 2.14-3.55). Food insecurity was also associated with poorer sleep outcomes including trouble falling (adjusted odds ratio 1.78, 95% CI 1.52-2.08) and staying (adjusted odds ratio 1.67, 95% CI 1.42-1.97) asleep.

CONCLUSIONS

Food insecurity is associated with poorer mental and sleep health in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate. Future research should test interventions to simultaneously combat food insecurity and mental health problems in young adulthood.

Atypical depression and non-atypical depression: Is HPA axis function a biomarker? A systematic review

BACKGROUND

The link between the abnormalities of the Hypothalamic-pituitary-adrenal (HPA) axis and depression has been one of the most consistently reported findings in psychiatry. At the same time, multiple studies have demonstrated a stronger association between the increased activation of HPA-axis and melancholic, or endogenous depression subtype. This association has not been confirmed for the atypical subtype, and some researchers have suggested that as an antinomic depressive subtype, it may be associated with the opposite type, i.e. hypo-function, of the HPA-axis, similarly to PTSD. The purpose of this systematic review is to summarise existing studies addressing the abnormalities of the HPA-axis in melancholic and/or atypical depression.

METHOD

We conducted a systematic review in the literature by searching MEDLINE, PsycINFO, OvidSP and Embase databases until June 2017. The following search items were used: "hypothalamic-pituitary-adrenal" OR "HPA" OR "cortisol" OR "corticotropin releasing hormone" OR "corticotropin releasing factor" OR "glucocorticoid*" OR "adrenocorticotropic hormone" OR "ACTH" AND "atypical depression" OR "non-atypical depression" OR "melancholic depression" OR "non-melancholic depression" OR "endogenous depression" OR "endogenomorphic depression" OR "non-endogenous depression". Search limits were set to include papers in English or German language published in peer-reviewed journals at any period. All studies were scrutinized to determine the main methodological characteristics, and particularly possible sources of bias influencing the results reported.

RESULTS

We selected 48 relevant studies. Detailed analysis of the methodologies used in the studies revealed significant variability especially regarding the samples' definition comparing the HPA axis activity of melancholic patients to atypical depression, including healthy controls. The results were subdivided into 4 sections: (1) 27 studies which compared melancholic OR endogenous depression vs. non-melancholic or non-endogenous depression or controls; (2) 9 studies which compared atypical depression or atypical traits vs. non-atypical depression or controls; (3) 7 studies which compared melancholic or endogenous and atypical depression subtypes and (4) 5 studies which used a longitudinal design, comparing the measures of HPA-axis across two or more time points. While the majority of studies did confirm the association between melancholic depression and increased post-challenge cortisol levels, the association with increases in basal cortisol and basal ACTH were less consistent. Some studies, particularly those focusing on reversed vegetative symptoms, demonstrated a decrease in the activity of the HPA axis in atypical depression compared to controls, but the majority did not distinguish it from healthy controls.

CONCLUSIONS

In conclusion, our findings indicate that there is a difference in the activity of the HPA-axis between melancholic and atypical depressive subtypes. However, these are more likely explained by hypercortisolism in melancholia; and most often normal than decreased function in atypical depression. Further research should seek to distinguish a particular subtype of depression linked to HPA-axis abnormalities, based on symptom profile, with a focus on vegetative symptoms, neuroendocrine probes, and the history of adverse childhood events. New insights into the dichotomy addressed in this review might be obtained from genetic and epigenetic studies of HPA-axis related genes in both subtypes, with an emphasis on the presence of vegetative symptoms.

Pituitary gland in Bipolar Disorder and Major Depression: Evidence from structural MRI studies: Special Section on "Translational and Neuroscience Studies in Affective Disorders". Section Editor, Maria Nobile MD, PhD. This Section of JAD focuses on the relevance of translational and neuroscience studies in providing a better understanding of the neural basis of affective disorders. The main aim is to briefly summarise relevant research findings in clinical neuroscience with particular regards to specific innovative topics in mood and anxiety disorders

BACKGROUND

The function of the hypothalamo-pituitary-adrenal axis (HPA) has been widely investigated in mood disorders based on its role in regulating stress response. Particularly, Magnetic Resonance Imaging (MRI) reports have explored pituitary gland (PG) in both bipolar disorder (BD) and major depressive disorder (MDD). In this context, the present review summarizes the results from MRI studies with the final aim of commenting on the presence of common or distinct PG structural alterations between these two disabling illnesses.

METHODS

A bibliographic search on PUBMED of all MRI studies exploring PG volumes in BD and MDD as well as first-degree relatives (RELs) from 2000 up to October 2016 was performed.

RESULTS

Following the screening process of the available literature it can be said that a) PG enlargement has been found in both BD and MDD, therefore potentially representing a common neurobiological marker characterizing mood disorders, and b) PG volumes are moderated by age and sex in both illnesses, although the direction and the extent of this moderation are still not fully clear.

LIMITATIONS

Few MRI studies with heterogeneous results.

CONCLUSIONS

These hypotheses must be taken with caution especially because the heterogeneity of the results of the studies reviewed does not allow for a definite answer about the role of PG in affective disorders. Therefore, larger longitudinal studies investigating PG volumes in BD and MDD patients at the early phases of the illness, by considering females and males separately, are needed to further corroborate these findings.

Repeated daily restraint stress induces adaptive behavioural changes in both adult and juvenile mice

Chronic stress is known to be a risk factor for the development of depression and anxiety, disorders which often begin during adolescence. Restraint stress is a commonly used stressor in adult rodents, however the effects of repeated restraint stress in juvenile mice have not been well characterised. Here we have shown for the first time the behavioural and hormonal effects of repeated restraint stress in both adult and juvenile BALB/c and C57BL/6 mice. Repeated daily restraint stress (2h/day for 3, 7 or 14days) provoked a robust physiological response evident as increased corticosterone levels and decreased body weight after 14days. However, habituation of the stress-response was evident during repeated exposure to the stressor in both adult and juvenile mice. The behavioural changes seen in response to repeated restraint stress were complex. In juvenile mice, repeated restraint stress evoked an increase in exploratory behaviours in the elevated plus maze, a decrease in time spent immobile in the forced swim test and a decrease in sucrose preference. In adult mice fewer behavioural changes were seen. Interestingly BALB/c and C57BL/6 mice showed qualitatively similar response to 3days repeated restraint stress. The behavioural changes we observed, as a result of prior stress exposure, may represent an adaptive stress-coping response or resilience. Both the hormonal and behavioural effects of stress were more pronounced in juvenile mice than in adults. This wider range of behavioural responses seen in juvenile mice might reflect a greater ability to engage in adaptive stress-coping strategies that likely have beneficial effects evident in future stress challenges.

Autobiographical memory dysfunctions in depressive disorders

Autobiographical memory (AM) is a ubiquitous human experience that belongs to long-term declarative memory. It plays interpersonal and intrapsychic functions. The main aim of this study is to present results of contemporary research on AM in recurrent depressive disorders. The available research literature suggests that AM dysfunctions are a precursor and risk factor for recurrent depressive disorders and that they also appear to be a consequence of depressive symptoms in a bidirectional and interacting manner. These data suggest that AM might be a viable therapeutic target for cognitive remediation strategies, given the impact of cognition on diverse clinical outcomes.

The neurocognitive profile of mood disorders - a review of the evidence and methodological issues

OBJECTIVES

Cognitive abnormalities are an established part of the symptomatology of mood disorders. However, questions still exist regarding the exact profile of these deficits in terms of the domains most affected, their origins, and their relationship to clinical subtypes. This review aims to examine the current state of the evidence and to examine ways in which the field may be advanced.

METHODS

Studies examining cognitive function in bipolar disorder (BD) and unipolar major depression (MDD) were examined. Given the number and variability of such studies, particular attention was paid to meta-analyses and to meta-regression analyses which examined the possible mediators of cognitive impairment.

RESULTS

Meta-analyses are available for MDD and BD in both depression and euthymia. Several analyses examine mediators. Results do not support the presence of domain specific deficits but rather a moderate deficit across a range of domains in BD and in MDD. The data on clinical mediators is inconsistent, even with regard to the effect of mood state.

CONCLUSIONS

A two-tiered approach, with the broad-based application of standardized measures on a large-scale, and the refined application of theoretically driven experimental development would significantly further our understanding of neurocognitive processing in mood disorder.

WITHDRAWN: Antiglucocorticoid treatments for mood disorders

In the original submission two of the authors declared a filing of a pharmaceutical patent. This does not comply with Cochrane's Commercial Sponsorship Policy. The remaining authors are unable to update the review at this time and have therefore withdrawn it from the Cochrane library.

The editorial group responsible for this previously published document have withdrawn it from publication.

Mechanisms underlying neurocognitive dysfunctions in recurrent major depression

Recent work shows that depression is intimately associated with changes in cognitive functioning, including memory, attention, verbal fluency, and other aspects of higher-order cognitive processing. Changes in cognitive functioning are more likely to occur when depressive episodes are recurrent and to abate to some degree during periods of remission. However, with accumulating frequency and duration of depressive episodes, cognitive deficits can become enduring, being evident even when mood improves. Such changes in cognitive functioning give depression links to mild cognitive impairment and thereby with neurodegenerative conditions, including Alzheimer’s disease, Parkinson’s disease, schizophrenia, and multiple sclerosis. Depression may then be conceptualized on a dimension of depression – mild cognitive impairment – dementia. The biological underpinnings of depression have substantial overlaps with those of neurodegenerative conditions, including reduced neurogenesis, increased apoptosis, reactive oxygen species, tryptophan catabolites, autoimmunity, and immune-inflammatory processes, as well as decreased antioxidant defenses. These evolving changes over the course of depressive episodes drive the association of depression with neurodegenerative conditions. As such, the changes in cognitive functioning in depression have important consequences for the treatment of depression and in reconceptualizing the role of depression in wider neuroprogressive conditions. Here we review the data on changes in cognitive functioning in recurrent major depression and their association with other central conditions.

Associations between hypothalamic-pituitary-adrenal axis function and facial emotion processing in depressed and control participants

AIM

The current study examined the relation between facial emotion processing accuracy and an aspect of hypothalamic-pituitary-adrenal axis function in 64 inpatients with major depression and 49 healthy controls over a 2-week period.

METHODS

The Dexamethasone Suppression Test and a Facial Expression Recognition Task were completed at baseline and 10-14 days after baseline. Treatment response was determined 6 weeks after baseline by change in the Montgomery-Asberg Depression Rating Scale.

RESULTS

Increased cortisol response to dexamethasone was significantly correlated with reduced ability to recognize facial expressions of anger, sadness and disgust within the total sample, but these correlations did not remain significant at 10-14 days. Surprisingly, cortisol response to dexamethasone was comparable in acutely depressed inpatients and healthy controls, and did not change over time in relation to treatment response.

CONCLUSION

The study findings provide preliminary evidence that hypothalamic-pituitary-adrenal axis functioning and processing threat-related facial expressions are related, perhaps through involvement of the amygdala.

Can variation in hypothalamic-pituitary-adrenal (HPA)-axis activity explain the relationship between depression and cognition in bipolar patients?

Background

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is thought to be associated with more mood symptoms and worse cognitive functioning. This study examined whether variation in HPA axis activity underlies the association between mood symptoms and cognitive functioning.

Methodology/Principal Findings

In 65 bipolar patients cognitive functioning was measured in domains of psychomotor speed, speed of information processing, attentional switching, verbal memory, visual memory, executive functioning and an overall mean score. Severity of depression was assessed by the Inventory of Depressive Symptomatology-self rating version. Saliva cortisol measurements were performed to calculate HPA axis indicators: cortisol awakening response, diurnal slope, the evening cortisol level and the cortisol suppression on the dexamethasone suppression test. Regression analyses of depressive symptoms and cognitive functioning on each HPA axis indicator were performed. In addition we calculated percentages explanation of the association between depressive symptoms and cognition by HPA axis indicators. Depressive symptoms were associated with dysfunction in psychomotor speed, attentional switching and the mean score, as well as with attenuation in diurnal slope value. No association was found between HPA axis activity and cognitive functioning and HPA axis activity did not explain the associations between depressive symptoms and cognition.

Conclusions/Significance

As our study is the first one in this field specific for bipolar patients and changes in HPA-axis activity did not seem to explain the association between severity of depressive symptoms and cognitive functioning in bipolar patients, future studies are needed to evaluate other factors that might explain this relationship.

Is treatment-resistance in unipolar melancholic depression characterized by decreased serotonin₂A receptors in the dorsal prefrontal - anterior cingulate cortex?

OBJECTIVES

Quite a number of patients diagnosed with major depression are resistant to several well carried-out psychopharmacological interventions. It remains unclear as to how the serotonergic system is implicated in the phenomenon of treatment-resistance.

METHODS

We examined the involvement of post-synaptic 5-HT(2A) receptors in the pathophysiology of treatment-resistance in unipolar melancholic major depression with (123)I-5-I-R91150 SPECT. 15 antidepressant-naïve (ADN) first-episode depressed patients, 15 antidepressant-free treatment-resistant depressed (TRD) patients and 15 never-depressed individuals, matched for age and gender were studied.

RESULTS

Compared to ADN patients and healthy controls, TRD patients displayed significantly lower 5-HT(2A) receptor binding index (BI) in the dorsal regions of the prefrontal and the anterior cingulate cortex. No significant 5-HT(2A) receptor BI differences between ADN patients and controls were observed.

CONCLUSIONS

At the cortical level, 5-HT(2A) receptor BI does not significantly differ in first-episode melancholic depressed patients compared to healthy controls. This observation might imply a limited short-term impact on the serotonergic system in first episode depression. Our results also suggest that when encountered with treatment-resistance, the 5-HT(2A) receptors in the DPFC-ACC axis are significantly down-regulated. However, whether this assumed underlying pathophysiological mechanism is due solely to abnormalities in the serotonergic system remains to be answered. This article is part of a Special Issue entitled 'Anxiety and Depression'.

A transdisciplinary perspective of chronic stress in relation to psychopathology throughout life span development

The allostatic load (AL) model represents an interdisciplinary approach to comprehensively conceptualize and quantify chronic stress in relation to pathologies throughout the life cycle. This article first reviews the AL model, followed by interactions among early adversity, genetics, environmental toxins, as well as distinctions among sex, gender, and sex hormones as integral antecedents of AL. We next explore perspectives on severe mental illness, dementia, and caregiving as unique human models of AL that merit future investigations in the field of developmental psychopathology. A complimenting transdisciplinary perspective is applied throughout, whereby we argue that the AL model goes beyond traditional stress–disease theories toward the advancement of person-centered research and practice that promote not only physical health but also mental health.

Cognitive correlates of hypothalamic-pituitary-adrenal axis in major depression

Depressive disorder has become a major health problem and is ranked among the leading causes of disability worldwide. Depression-related cognitive impairment contributes to loss of economic productivity and psychosocial functioning and calls for more efficient treatment strategies. Although the pathogenesis of cognitive impairments in patients with major depressive disorder (MDD) is still insufficiently understood, increasing evidence implicates hypothalamus-pituitary-adrenal (HPA) axis as an important neurobiological determinant of cognitive impairment in depression. In this article, major findings of both HPA axis function abnormalities and cognitive impairments in depressed patients are summarized, focusing on their inter-relationship. Novel approaches in pharmacotherapy and psychotherapy have emerged which will be discussed with regard to their ability to reinstate normal HPA axis function in MDD and to treat cognitive impairments in MDD.

Processing of facial emotion expression in major depression: a review

Processing of facial expressions of emotion is central to human interaction, and has important effects on behaviour and affective state. A range of methods and paradigms have been used to investigate various aspects of abnormal processing of facial expressions in major depression, including emotion specific deficits in recognition accuracy, response biases and attentional biases. The aim of this review is to examine and interpret data from studies of facial emotion processing in major depression, in the context of current knowledge about the neural correlates of facial expression processing of primary emotions. The review also discusses the methodologies used to examine facial expression processing. Studies of facial emotion processing and facial emotion recognition were identified up to December 2009 utilizing MEDLINE and Web of Science. Although methodological variations complicate interpretation of findings, there is reasonably consistent evidence of a negative response bias towards sadness in individuals with major depression, so that positive (happy), neutral or ambiguous facial expressions tend to be evaluated as more sad or less happy compared with healthy control groups. There is also evidence of increased vigilance and selective attention towards sad expressions and away from happy expressions, but less evidence of reduced general or emotion-specific recognition accuracy. Data is complicated by the use of multiple paradigms and the heterogeneity of major depression. Future studies should address methodological problems, including variations in patient characteristics, testing paradigms and procedures, and statistical methods used to analyse findings.

Association of glucocorticoid receptor polymorphisms with the susceptibility to major depressive disorder and treatment responses in Korean depressive patients

OBJECTIVE

Major depressive disorder (MDD) is closely related to stress reactions and serotonin probably underpins the pathophysiology of MDD. Alterations of the hypothalamic-pituitary-adrenal axis at the gene level have reciprocal consequences on serotonin neurotransmission. Glucocorticoid receptor (GR) polymorphisms affect glucocorticoid sensitivity, which is associated with cortisol feedback effects. Therefore, we hypothesised that GR polymorphisms are associated with the susceptibility to MDD and predict the treatment response.

METHOD

Ninety-six subjects with a minimum score of 17 on the 21-item Hamilton Depression Scale (HAMD) at baseline were enrolled into the present study. The genotypes of GR (N363S, ER22/23EK, Bcl1, and TthIII1 polymorphisms) were analysed. The HAMD score was again measured after 1, 2, 4 and 8 weeks of antidepressant treatment to detect whether the therapeutic effects differed with the GR genotype.

RESULTS

Our subjects carried no N363S or ER22/23EK genetic polymorphisms and three types of Bcl1 and TthIII1 genetic polymorphisms. The C/C genotype and C allele at Bcl1 polymorphism were more frequent in MDD patients than in normal controls (p < 0.01 and p = 0.01, respectively). The genotype distributions did not differ significantly between responders and non-responders.

CONCLUSION

These results suggest that GR polymorphism cannot predict the therapeutic response after antidepressant administration. However, GR polymorphism (Bcl1) might play a role in the pathophysiology of MDD. Future studies should check this finding in larger populations with different characteristics.

The impact of one HF-rTMS session on mood and salivary cortisol in treatment resistant unipolar melancholic depressed patients

BACKGROUND

Recent studies indicate that medication resistant depressed patients can be successfully treated by a series of sessions of High Frequency repetitive Transcranial Magnetic Stimulation (HF-rTMS), delivered on the left dorsolateral prefrontal cortex (DLPFC). However, changes in subjectively experienced mood give only limited insight into the underlying physiological responses. Previous studies in depressed patients, as well as in healthy volunteers, have reported a possible impact of HF-rTMS on the hypothalamic-pituitary-adrenal (HPA) axis.

OBJECTIVE

We wanted to evaluate the emotional and neurobiological impact of one session of HF-rTMS applied on the left DLPFC in a sample of unipolar treatment resistant depressed patients of the melancholic subtype.

METHODS

20 right-handed antidepressant-free depressed patients were studied using a sham-controlled, 'single' blind, crossover design. We examined subjective mood changes with Visual Analogue Scales (VAS). To examine HF-rTMS effects on the HPA-axis, we analyzed salivary cortisol levels. Mood assessment and salivary cortisol levels were assessed before and immediately after stimulation. To detect any delayed effects, all measurements were also re-assessed 30 min post HF-rTMS. The left DLPFC was determined under MRI guidance.

RESULTS

One session of HF-rTMS did not result in any subjectively experienced mood changes. However, salivary cortisol concentrations decreased significantly immediately and 30 min after active HF-rTMS.

CONCLUSIONS

Although one session of HF-rTMS on the left DLPFC did not influence mood subjectively in melancholic unipolar depressed patients, we found support for the hypothesis that a single session has a significant impact on the HPA-axis, as measured by salivary cortisol. Our results may provide more insight into the underlying working mechanisms of HF-rTMS in unipolar melancholic depression, and could add further information about endocrinological functioning in affective disorders.

Treatment-resistant depression: critique of current approaches

The aim of the present study was to critically appraise current conceptual approaches; demographic, neurobiological and clinical correlates; and management strategies of treatment-resistant depression (TRD), especially in light of recent research findings. To this end, a review of the relevant English-language literature was undertaken using Medline, Embase and Psychinfo. TRD has been defined in conceptually restrictive terms as symptomatic non-response to physical therapies alone, with little systematic study of aetiology made. It is likely that a range of sociodemographic (such as higher socioeconomic status), genetic (such as variation in functional monoamine polymorphisms) and clinical variables (such as signal hyperintensities seen on structural neuroimaging scans) are responsible for non-response in individuals. There is insufficient evidence to suggest that TRD is associated with specific subtypes of depression, physical comorbidity, personality or chronicity. The large-scale Sequenced Treatment Alternatives to Relieve Depression (STAR*D) and other studies have suggested that a structured psychotherapy such as cognitive behaviour therapy may be as effective as medication in initial drug non-responders. Also conventional alternatives such as the use of older antidepressant classes, pharmacological augmentation or electroconvulsive therapy in established cases of TRD are not as effective as traditionally thought. There is insufficient preliminary evidence to make formal recommendations about the use of novel brain stimulation techniques in TRD. TRD should be re-defined as the failure to reach symptomatic and functional remission after adequate treatment with physical and psychological therapies. Treatment resistance may be more usefully conceived within the context of well-defined cohorts such as patients with specific subtypes of depression. Although neurobiological markers such as gene polymorphisms, which are potentially predictive of medication tolerance and efficacy, may be used in the future, it is likely that sociocultural variables such as beliefs about depression, and evidence-based treatments for it, will also determine treatment resistance.

Antiglucocorticoid treatments for mood disorders

BACKGROUND

Antiglucocorticoids may have antidepressant effects and have been reported to be efficacious in the treatment of severe psychiatric disorders. The efficacy and safety of antiglucocorticoid treatments for mood disorders is the subject of this systematic review.

OBJECTIVES

To compare the efficacy and safety of antiglucocorticoid agents in the treatment of mood episodes (manic, mixed affective or depressive) with placebo or alternative drug treatment in mood disorders.

SEARCH STRATEGY

CCDANCTR-Studies and CCDANCTR-References were searched on 11-9-2007. Additional searches of electronic databases were conducted in December 2006. Conference proceedings were searched. Experts and pharmaceutical companies were contacted.

SELECTION CRITERIA

Randomised controlled trials comparing antiglucocorticoid drugs in the treatment of mood episodes with placebo or alternative drug treatment in mood disorders were selected.

DATA COLLECTION AND ANALYSIS

Data were extracted and the methodological quality of each study was assessed independently by two review authors. Meta-analyses were performed using Review Manager software. Relative risk (RR) with 95% confidence intervals (CI) were calculated for dichotomous outcomes. For continuous data, weighted mean differences (WMD) were calculated.

MAIN RESULTS

Nine studies met criteria for inclusion. A number of drugs were examined, including mifepristone [RU-486], ketoconazole, metyrapone and DHEA. Three trials were in patients with psychotic major depression (pMDD), five trials in non-psychotic major depression and one trial in bipolar disorder. When examining all trials together across all affective episodes, there was no significant difference in the overall proportion of patients responding to antiglucocorticoid treatment over placebo, although the mean change in HAM-D scores indicated a significant difference in favour of treatment (WMD -4.54, 95%CI -6.78 to -2.29). Of the five trials in non-psychotic depression (unipolar or bipolar), there was a significant difference favouring treatment (HAM-D 50% reduction: RR 0.72, 95%CI 0.56 to 0.91). In pMDD, there was no evidence of an overall antidepressant effect (HAM-D 50% reduction: RR 0.98, 95%CI 0.79 to 1.22) or an effect on overall psychopathology (BPRS 30% reduction: RR 0.96, 95%CI 0.76 to 1.22). In these subtypes, the mean change in HAM-D indicated a significant difference in favour of treatment.

AUTHORS' CONCLUSIONS

The use of antiglucocorticoids in the treatment of mood disorders is at the proof-of-concept stage. Considerable methodological differences exist between studies with respect to the compounds used and the patient cohorts studied. Results in some diagnostic subtypes are promising and warrant further investigation to establish the clinical utility of these drugs in the treatment of mood disorders.

Neuropsychological impairment in major depression: its nature, origin and clinical significance

Neuropsychological impairment is well established as a feature of major depressive disorder (MDD) but studies have shown a variable pattern of impairment. This paper seeks first to clarify this by examining methodological and clinical factors that give rise to variability in study findings. Second, it examines theories of the origin of these neuropsychological abnormalities. Third, it reviews evidence regarding the clinical significance of different patterns of deficit. A selective review was undertaken of the literature with a particular emphasis on methodological factors, the influence of clinical subtypes and prevalent theories of neuropsychological abnormality. Methodological issues and the heterogeneity of MDD account for considerable variability in results. Specific investigation of the subtypes of psychotic MDD, melancholic MDD and bipolar depression reduces this heterogeneity and results are more consistent in the elderly. Hypothalamic-pituitary-adrenal axis dysfunction is associated with neuropsychological dysfunction in MDD although evidence of direct causation is not definitive at present. Impairment of executive and psychomotor function is a consistent finding, particularly in the elderly, and may reflect frontostriatal-limbic dysfunction. There is growing evidence that this may have clinical significance. It is suggested that future research take very careful account of the exact phenotype of MDD. Classification based on neuropsychological profile may, in fact, be useful. Further research should examine further the clinical importance of patterns of neuropsychological impairment.