The effect of mianserin on alpha-2 adrenergic receptor function in depressed patients

Understanding the pathophysiology of depression: From monoamines to the neurogenesis hypothesis model - are we there yet?

A number of factors (biogenic amine deficiency, genetic, environmental, immunologic, endocrine factors and neurogenesis) have been identified as mechanisms which provide unitary explanations for the pathophysiology of depression. Rather than a unitary construct, the combination and linkage of these factors have been implicated in the pathogenesis of depression. That is, environmental stressors and heritable genetic factors acting through immunologic and endocrine responses initiate structural and functional changes in many brain regions, resulting in dysfunctional neurogenesis and neurotransmission which then manifest as a constellation of symptoms which present as depression.

Guanfacine modulates the emotional biasing of amygdala-prefrontal connectivity for cognitive control

Functional interactions between amygdala and prefrontal cortex provide a cortical entry point for emotional cues to bias cognitive control. Stimulation of α2 adrenoceptors enhances the prefrontal control functions and blocks the amygdala-dependent encoding of emotional cues. However, the impact of this stimulation on amygdala-prefrontal interactions and the emotional biasing of cognitive control have not been established. We tested the effect of the α2 adrenoceptor agonist guanfacine on psychophysiological interactions of amygdala with prefrontal cortex for the emotional biasing of response execution and inhibition. Fifteen healthy adults were scanned twice with event-related functional magnetic resonance imaging while performing an emotional go/no-go task following administration of oral guanfacine (1mg) and placebo in a double-blind, counterbalanced design. Happy, sad, and neutral faces served as trial cues. Guanfacine moderated the effect of face emotion on the task-related functional connectivity of left and right amygdala with left inferior frontal gyrus compared to placebo, by selectively reversing the functional co-activation of the two regions for response execution cued by sad faces. This shift from positively to negatively correlated activation for guanfacine was associated with selective improvements in the relatively low accuracy of responses to sad faces seen for placebo. These results demonstrate the importance of functional interactions between amygdala and inferior frontal gyrus to both bottom-up biasing of cognitive control and top-down control of emotional processing, as well as for the α2 adrenoceptor-mediated modulation of these processes. These mechanisms offer a possibile method to address the emotional reactivity that is common to several psychiatric disorders.

Guanfacine modulates the influence of emotional cues on prefrontal cortex activation for cognitive control

RATIONALE

Functional interactions between limbic regions that process emotions and frontal networks that guide response functions provide a substrate for emotional cues to influence behavior. Stimulation of postsynaptic α₂ adrenoceptors enhances the function of prefrontal regions in these networks. However, the impact of this stimulation on the emotional biasing of behavior has not been established.

OBJECTIVES

This study tested the effect of the postsynaptic α₂ adrenoceptor agonist guanfacine on the emotional biasing of response execution and inhibition in prefrontal cortex.

METHODS

Fifteen healthy young adults were scanned twice with functional magnetic resonance imaging while performing a face emotion go/no-go task following counterbalanced administration of single doses of oral guanfacine (1 mg) and placebo in a double-blind, cross-over design.

RESULTS

Lower perceptual sensitivity and less response bias for sad faces resulted in fewer correct responses compared to happy and neutral faces but had no effect on correct inhibitions. Guanfacine increased the sensitivity and bias selectively for sad faces, resulting in response accuracy comparable to happy and neutral faces, and reversed the valence-dependent variation in response-related activation in left dorsolateral prefrontal cortex (DLPFC), resulting in enhanced activation for response execution cued by sad faces relative to happy and neutral faces, in line with other frontoparietal regions.

CONCLUSIONS

These results provide evidence that guanfacine stimulation of postsynaptic α₂ adrenoceptors moderates DLPFC activation associated with the emotional biasing of response execution processes. The findings have implications for the α₂ adrenoceptor agonist treatment of attention-deficit hyperactivity disorder.

Pathophysiology of depression and mechanisms of treatment

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

Structural and functional models of depression: from sub-types to substrates

OBJECTIVE

To present a functional model of depression facilitating research and clinical understanding.

METHOD

The authors conducted a systematic literature search and reviewed articles pertaining to the neurochemistry and pathophysiology of depressive disorders, focusing on the contribution made by the principal monoamines to three differing depressive structural sub-types (i.e. psychotic, melancholic and non-melancholic).

RESULTS

We suggest that the three structural depressive subtypes appear functionally underpinned by differential contributions of serotonergic, noradrenergic and dopaminergic neurotransmitters, so influencing phenotypic distinction (our structural model) and allowing an aetiological model to be derived with treatment specificity implications.

CONCLUSION

The functional model logically iterates with the structural model of depression and provides a useful framework for conceptualizing the depressive disorders. This model provides a logic for distinguishing between principal depressive subtypes, pursuing their functional underpinnings and explaining treatment differential effects across the three sub-types.

Central monoamines and their role in major depression

The role of the monoamines serotonin and noradrenaline in mental illnesses including depression is well recognized. All antidepressant drugs in clinical use increase acutely the availability of these monoamines at the synapse either by inhibiting their neuronal reuptake, inhibiting their intraneuronal metabolism, or increasing their release by blocking the alpha(2) auto- and heteroreceptors on the monoaminergic neuron. This acute increase in the amount of the monoamines at the synapse has been found to induce long-term adaptive changes in the monoamine systems that end up in the desensitization of the inhibitory auto- and heteroreceptors including the presynaptic alpha(2) and 5-HT(1B) receptors and the somatodendritic 5-HT(1A) receptors located in certain brain regions. The desensitization of these inhibitory receptors would result in higher central monoaminergic activity that coincides with the appearance of the therapeutic response. These adaptive changes responsible for the therapeutic effect depend on the availability of the specific monoamine at the synapse, as depletion of the monoamines will either reverse the antidepressant effect or causes a relapse in the state of drug-free depressed patient previously treated with antidepressant drugs. Furthermore, blocking the somatodendritic 5-HT(1A) or nerve terminal alpha(2) receptors proved to increase the response rate in the treatment of major and treatment-resistant depression, providing further support to the assumption that the antidepressant effect results from the long-term adaptive changes in the monoamine auto- and heteroregulatory receptors. On the other hand, the chronic treatment with antidepressants resulted in D(2) receptors supersensitivity in the nucleus accumbens. This supersensitivity might play a role in the mechanisms underlying antidepressant induced mood switch and rapid cycling.

Mirtazapine, but not fluvoxamine, normalizes the blunted REM sleep response to clonidine in depressed patients: implications for subsensitivity of alpha(2)-adrenergic receptors in depression

To determine whether alpha(2)-adrenergic receptor (alpha2AR) subsensitivity is a state or a trait marker of depression, we consecutively challenged 32 drug-free depressed patients with a clonidine REM suppression test (CREST). We then treated the patients with fluvoxamine, a selective serotonin reuptake inhibitor, or mirtazapine, a selective alpha(2)-adrenergic receptor antagonist. The first 10 patients from each treatment group who recovered were given a second challenge test. The CREST values of the two treatment groups at each time point were compared, and also compared with the CREST values of a group of 10 normal subjects. Before treatment, the REM sleep response to clonidine in the two groups of patients was significantly blunted compared with the REM sleep response in the healthy subjects. After treatment, there was still an abnormal REM sleep response to clonidine in the fluvoxamine-treated patients, despite clinical recovery, but there was a normalized REM sleep response in the mirtazapine-treated patients. These results are compatible with the hypothesis that alpha2AR subsensitivity is a trait marker of depression and suggest that the effects of these two antidepressants on alpha2AR sensitivity may not be linked to the alleviation of depression.

Amitriptyline v. the rest: still the leading antidepressant after 40 years of randomised controlled trials

BACKGROUND

Tricyclic antidepressants have similar efficacy and slightly lower tolerability than selective serotonin reuptake inhibitors (SSRIs). However, there are no systematic reviews assessing amitriptyline, the reference tricyclic drug, v. other tricyclics and SSRIs directly.

AIMS

To review the tolerability and efficacy of amitriptyline in the management of depression.

METHOD

A systematic review of randomised controlled trials (RCTs) comparing amitriptyline with other tricyclics/heterocyclics or with an SSRI.

RESULTS

We reviewed 186 RCTs. The overall estimate of the efficacy of amitriptyline revealed a standardised mean difference of 0.147 (95% CI 0.05-0.243), significantly favouring amitriptyline. The overall OR for dropping out was 0.99 (95% CI 0.91-1.08) and that for side-effects was 0.62 (95% CI 0.54-0.70), favouring the control drugs. With drop-outs included as treatment failures, the estimate of the effectiveness of amitriptyline v. tricyclics/heterocyclics and SSRIs showed a 2.5% difference in the proportion of responders in favour of amitriptyline (number needed to treat 40, CI 21-694; OR 1.12 (95% CI 1.01-1.24)).

CONCLUSIONS

Amitriptyline is less well tolerated than tricyclics/heterocyclics and SSRIs, but slightly more patients treated on it recover than on alternative antidepressants.

Polymorphism in the promoter region of the alpha 2A adrenergic receptor gene and mood disorders

Alpha 2 adrenergic receptors are thought to play a crucial role in the etiology or treatment of mood disorders. Polymorphism(s) in the promoter region of the alpha 2 receptor may affect the gene expression and be associated with mood disorders. We studied the previously reported polymorphisms of the alpha 2A receptor gene at position-1291 in 114 healthy controls and 103 mood disorder patients. There was statistically no difference between controls and patients in either the genotype or the allele frequency. There was statistically no difference between the genotype and the clinical characteristics. Our results suggest there is no association between this polymorphism in the promoter region of the alpha 2A receptor gene and mood disorders.

The effect of chronic administration of amitriptyline on the effects of subsequent electroconvulsive treatment on responsiveness of alpha 1-and beta-adrenoceptors in the rat cortical slices

Both antidepressant drugs and repeated electroconvulsive shock (ECS) produce adaptive changes in cerebral neurotransmitter systems. As in the clinical practice ECS is used almost always after therapeutical failure of pharmacotherapy, we investigated presently how chronic administration of an antidepressant amitriptyline affects the action of subsequent multiple ECS in rats. Amitriptyline differed from ECS and from other classical antidepressant in producing no beta-downregulation and potentiating the inhibitory effect of protein kinase C activator, 12-O-tetradecanoylphorbol 13-acetate (TPA), on responses of alpha 1-adrenoceptor system to noradrenaline. The action of ECS on alpha 1-adrenoceptor system remained essentially unaffected by previous amitriptyline administration. Its downregulatory effect on responses of beta-adrenoceptor system to noradrenaline, and particularly to isoproterenol, were attenuated by previous drug treatment. The present results suggest that previous chronic administration of antidepressant drugs may alter the effect of subsequent ECS.

Alpha-adrenoceptors

Major advances have been made in our understanding of the molecular structure and function of the alpha-adrenoceptors. Many new subtypes of the alpha-adrenoceptor have been identified recently through biochemical and pharmacological techniques and several of these receptors have been cloned and expressed in a variety of vector systems. Currently, at least seven subtypes of the alpha-adrenoceptor have been identified and the molecular structure and biochemical functions of these subtypes are beginning to be understood. The alpha-adrenoceptors belong to the super family of receptors that are coupled to guanine nucleotide regulatory proteins (G-proteins). A variety of G-proteins are involved in the coupling of the various alpha-adrenoceptor subtypes to intracellular second messenger systems, which ultimately produce the end-organ response. The mechanisms by which the alpha-adrenoceptor subtypes recognize different G-proteins, as well as the molecular interactions between receptors and G-proteins, are the topics of current research. Furthermore, the physiological and pathophysiological role that alpha-adrenoceptors play in homeostasis and in a variety of disease states is also being elucidated. These major advances made in alpha-adrenoceptor classification, molecular structure, physiologic function, second messenger systems and therapeutic relevance are the subject of this review.

Alpha 2-adrenergic receptor sensitivity in depressed patients: relation between 3H-yohimbine binding to platelet membranes and clonidine-induced hypotension

Alpha 2-adrenergic receptor changes during antidepressant treatment were studied using 3H-yohimbine binding to human platelet membranes and clonidine-induced hypotension. Twenty-six patients with major depressive disorder (MDD) participated for 4-6 weeks in a trial of imipramine (2.5 mg/kg/day), tyrosine (100 mg/kg/day), or placebo. Alpha 2-adrenergic receptors measured by 3H-yohimbine binding were not significantly changed following antidepressant treatment. Similarly, clonidine-induced hypotension did not differ significantly following treatment. No measure of alpha 2-adrenergic receptor sensitivity was significantly correlated with clinical improvement. The correlation between platelet receptor binding and clonidine-induced hypotension was not statistically significant, even though both tests are considered to be measures of alpha 2-adrenoceptor sensitivity.

Growth hormone responses to the alpha 2-adrenoceptor agonist guanfacine and to growth hormone releasing hormone in depressed patients and controls

Growth hormone (GH) responses to the alpha 2-adrenoceptor agonist guanfacine and to GH releasing hormone (GHRH) were measured in 13 patients fulfilling Research Diagnostic Criteria and DSM-III criteria for major depressive disorder and in 13 controls matched for age and sex. Dexamethasone suppression tests were performed in all subjects. The peak GH response to guanfacine correlated to the peak GH response to GHRH both in depressed patients and in controls. Neither the response to guanfacine nor the response to GHRH was significantly lower in depressed patients than in controls. Dexamethasone suppression tests, which were performed about 3 days before the GH stimulation tests, were abnormal in 61% (8/13) of the depressed patients but in none of the controls. No difference between dexamethasone suppressors and nonsuppressors with respect to GH response to guanfacine or GHRH was observed. The data are discussed in relation to the blunted GH response to clonidine described in depression.

Clonidine challenge testing of alpha-2-adrenoceptor function in man: the effects of mental illness and psychotropic medication

The clonidine challenge test is a means of assessing alpha-2-adrenoceptor sen sitivity in man. We review studies which have used this test to investigate central alpha-2- adrenoceptor changes in psychiatric illness, and to determine receptor changes after adminis tration and withdrawal of psychotropic treatments. Patients with severe depression show evidence of reduced alpha-2-adrenoceptor sensitivity, especially a reduced growth hormone response to clonidine. This may delineate a subgroup of patients with severe depressive illness from those with milder depression, and may even provide a trait marker for some depressed patients. Patients with panic disorder show evidence of subsensitivity to some and supersensitivity to other clonidine-induced responses. Other disorders, although less well investigated, may have abnormal test responses which may provide additional information about their cause and treatment. Changes in response after drug treatment have provided important information on the mode of action of antidepressants, and have suggested that noradrenergic function is altered by a variety of different antidepressants.

Selective effects of ECT on hypothalamic-pituitary activity

The hypothesis that ECT produces selective effects on hypothalamic-pituitary activity was investigated by determining the effect of ECT on pituitary hormone release in nine depressed patients. After ECT there were massive and rapid increases in the plasma concentrations of nicotine- and oestrogen-stimulated neurophysin (NSN and ESN), prolactin (PRL) and adrenocorticotropin (ACTH), smaller increases in plasma luteinizing hormone (LH) and cortisol, a significant decrease in plasma growth hormone (GH) concentration but no change in plasma thyrotropin (TSH). There was significant attenuation of PRL responses with repeated ECT. The hormonal responses to ECT cannot simply be attributed to stress, since a similar pattern of increases in plasma hormone concentrations did not occur in psychologically normal patients in whom plasma hormone concentrations were measured during induction of anaesthesia and abdominal incision for cholecystectomy. Analysis of these hormonal responses in terms of the knowledge available on the neurotransmitter control of pituitary hormone release suggests that some of these hormonal responses to ECT may be mediated by the activation of serotonergic neurones, while others are probably due to direct stimulation of the neuroendocrine neurones themselves.

Effect of chronic antidepressant treatment on noradrenergic modulation of [3H]dopamine release from rat nucleus accumbens and striatal slices

Unlike desipramine, a potent blocker of noradrenaline uptake, the antidepressant drugs, mianserin and citalopram did not, after chronic administration (28 days), attenuate the clonidine-induced inhibition of [3H]dopamine (DA) release from rat nucleus accumbens slices. Mianserin, like desipramine, failed to alter the isoproterenol-induced enhancement of [3H]DA release from rat nucleus accumbens and striatal slices. These findings suggest that antidepressant action does not necessarily involve desensitization of central alpha 2- or beta-adrenoceptors which influence neuronal transmission.

Effects of trazodone treatment on alpha-2 adrenoceptor function in depressed patients

Tricyclic antidepressant drugs reduce the sensitivity of alpha 2 adrenoceptors during long-term treatment. In the present study, the alpha 2 adrenergic agonist clonidine was administered to 11 depressed patients before and during treatment with the triazolopyridine antidepressant trazodone (TRZ). Clonidine's ability to decrease blood pressure (BP) and plasma levels of the norepinephrine metabolite 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG), and to increase sedation and plasma growth hormone (GH), were measured. TRZ had little effect on these indices of pre- and postsynaptic alpha 2 receptor function, suggesting that the antidepressant properties of TRZ are not related to changes in alpha 2 adrenoceptor sensitivity.

Adrenoreceptor interactions of the enantiomers and metabolites of mianserin: are they responsible for the antidepressant effect?

Mianserin is a tetracyclic antidepressant whose postulated mechanism of action involves release of noradrenaline mediated via cortical alpha 2-adrenergic autoreceptor blockade. This property resides stereoselectively in the S(+)-enantiomer of mianserin, which is also more potent in behavioural tests indicative of antidepressant activity, and in the reversal of clonidine-induced effects. Cortical receptor binding studies have indicated that although a similar stereoselectivity prevails for the inhibition of both alpha 2-binding (clonidine) and alpha 1-binding (prazosin), mianserin and its enantiomers are more potent antagonists at alpha 2- than at alpha 1-binding sites. However, no stereoselectivity is apparent for the antagonism of cortical alpha 2-heteroreceptors controlling serotonin release. Following chronic administration, (+/-)- and S(+)-mianserin, but not the R(-)-enantiomer, produce functional supersensitivity at alpha 2-autoreceptors which is unaccompanied by changes in clonidine binding. Neither mianserin nor its enantiomers alter the sensitivity of alpha 2-heteroreceptors following chronic administration. Like mianserin and its S(+)-enantiomer, but unlike R(-)-mianserin and the 8-hydroxy metabolite, the desmethyl metabolite inhibits noradrenaline uptake in vitro. 8-hydroxymianserin and, to a lesser extent, desmethylmianserin release noradrenaline from cortical slices via alpha 2-autoreceptor antagonism, but only the 8-hydroxy metabolite blocks alpha 2-autoreceptors and alpha 2-heteroreceptors in synaptosomal preparations. It is likely that S(+)-mianserin, desmethylmianserin, and 8-hydroxymianserin contribute substantially to the overall facilitating effect of mianserin on noradrenergic transmission in vivo. As yet it is unclear whether this effect is exclusively responsible for the antidepressant activity of mianserin or whether the stereoselectivity also shown by the mianserin enantiomers towards serotonin receptors plays a complementary role.