Sex difference in cerebrospinal fluid/blood albumin quotients in patients with schizophreniform and affective psychosis

BACKGROUND

The importance of cerebrospinal fluid (CSF) diagnostics for psychiatry is growing. The CSF/blood albumin quotient (QAlb) is considered to be a measure of the blood-CSF barrier function. Recently, systematically higher QAlb in males than in females was described in neurological patients. The aim of this study was to investigate whether a sex difference could also be detected in a well-characterized psychiatric cohort.

METHODS

The patient cohort comprised 989 patients, including 545 females and 444 males with schizophreniform and affective syndromes who underwent CSF diagnostics, including QAlb measurement. The basic CSF findings and antineuronal autoantibody data of this cohort have already been published. This re-analysis employed analysis of covariance with age correction for QAlb mean values and chi2-testing for the number of increased age-corrected QAlb levels to investigate sex differences in QAlb.

RESULTS

The QAlb levels were elevated above reference levels by 18% across all patients, and a comparison between male and female patients revealed a statistically significant sex difference, with increased values in 26% of male patients and a corresponding rate of only 10% in female patients (chi2 = 42.625, p < 0.001). The mean QAlb values were also significantly higher in males (6.52 ± 3.69 × 10-3) than in females (5.23 ± 2.56 × 10-3; F = 52.837, p < 0.001).

DISCUSSION

The main finding of this study was a significantly higher QAlb level in male compared to female patients with psychiatric disorders, complementing previously described sex differences in neurological patient cohorts. This result indicates bias from some general factors associated with sex and could be partly explained by sex differences in body height, which is associated with spine length and thus a longer distance for CSF flow within the subarachnoid space down the spine from the occipital area to the lumbar puncture site in males compared to females. Hormonal influences caused by different estrogen levels and other sex-specific factors could also play a relevant role. The significance of the study is limited by its retrospective design, absence of a healthy control group, and unavailability of exact measures of spine length.

BDNF and NGF Signalling in Early Phases of Psychosis: Relationship With Inflammation and Response to Antipsychotics After 1 Year

Previous studies have indicated systemic deregulation of the proinflammatory or anti-inflammatory balance in individuals with first-episode psychosis (FEP) that persists 12 months later. To identify potential risk/protective factors and associations with symptom severity, we assessed possible changes in plasma levels of neurotrophins (brain-derived neurotrophic factor [BDNF] and nerve growth factor [NGF]) and their receptors in peripheral blood mononuclear cells (PBMCs). Expression of the 2 forms of BDNF receptors (active TrkB-FL and inactiveTrkB-T1) in PBMCs of FEP patients changed over time, TrkB-FL expression increasing by 1 year after diagnosis, while TrkB-T1 expression decreased. The TrkB-FL/TrkB-T1 ratio (hereafter FL/T1 ratio) increased during follow-up in the nonaffective psychosis group only, suggesting different underlying pathophysiological mechanisms in subgroups of FEP patients. Further, the expression of the main NGF receptor, TrkA, generally increased in patients at follow-up. After adjusting for potential confounders, baseline levels of inducible isoforms of nitric oxide synthase, cyclooxygenase, and nuclear transcription factor were significantly associated with the FL/T1 ratio, suggesting that more inflammation is associated with higher values of this ratio. Interestingly, the FL/T1 ratio might have a role as a predictor of functioning, a regression model of functioning at 1 year suggesting that the effect of the FL/T1 ratio at baseline on functioning at 1 year depended on whether patients were treated with antipsychotics. These findings may have translational relevance; specifically, it might be useful to assess the expression of TrkB receptor isoforms before initiating antipsychotic treatment in FEPs.

Antidepressant-like behavior in brain-specific angiogenesis inhibitor 2-deficient mice

Brain-specific angiogenesis inhibitor 2 (BAI2) is a transmembrane protein that is predominantly expressed in the brain. Although BAI2 is supposed to correlate with antiangiogenesis in the brain, its psychiatric function is still unclear. In this study, we examined the influence of BAI2 gene disruption on mood-related behavior using BAI2-deficient mice. BAI2-deficient mice showed significant antidepressant-like behavior in the social defeat test and in the tail suspension test compared with wild-type mice. On the other hand, BAI2-deficient mice had normal basal locomotor activity in the home cage and in the open field test, and normal learning ability and memory retention in the Morris water maze test. Additionally, we found that hippocampal cell proliferation in BAI2-deficient mice was higher than that in wild-type mice. These results indicate that BAI2 has an important role related to depression and influences the hippocampal neurogenesis. BAI2 may be a novel therapeutic target for mood-related disorders.

DISC1 and PDE4B are interacting genetic factors in schizophrenia that regulate cAMP signaling

The disrupted in schizophrenia 1 (DISC1) gene is a candidate susceptibility factor for schizophrenia, but its mechanistic role in the disorder is unknown. Here we report that the gene encoding phosphodiesterase 4B (PDE4B) is disrupted by a balanced translocation in a subject diagnosed with schizophrenia and a relative with chronic psychiatric illness. The PDEs inactivate adenosine 3',5'-monophosphate (cAMP), a second messenger implicated in learning, memory, and mood. We show that DISC1 interacts with the UCR2 domain of PDE4B and that elevation of cellular cAMP leads to dissociation of PDE4B from DISC1 and an increase in PDE4B activity. We propose a mechanistic model whereby DISC1 sequesters PDE4B in resting cells and releases it in an activated state in response to elevated cAMP.

Variables associated with high olanzapine dosing in a state hospital

BACKGROUND

Olanzapine has a U.S. Food and Drug Administration-approved dosing range of 10 to 20 mg/day but is often used at doses exceeding this range. Olanzapine is largely metabolized by cytochrome P450 (CYP) 1A2. Smoking, which induces CYP1A2, is expected to increase clearance of olanzapine by 40%; however, dosage adjustment in smokers is not currently recommended. Additionally, female gender is expected to reduce clearance by 30%. Many institutions target high-dose olanzapine prescribers in an effort to reduce unnecessary drug costs. However, factors such as smoking or gender may necessitate increased doses.

METHOD

A retrospective review of all patients receiving olanzapine during an inpatient stay at a state psychiatric hospital in Kentucky during 2001 was conducted. Demographic information and smoking status were collected for all patients. Olanzapine doses of > 20 mg/day were considered high doses.

RESULTS

Nine percent (48/522) of olanzapine patients were prescribed high doses. The percentages were similar in women and men (10% vs. 9%, p =.69) and in smokers and nonsmokers (9% vs. 9%, p =.82). Moreover, the mean maximum olanzapine dose was also similar in men and women (15.4 +/- 7.2 vs. 14.9 +/- 7.3 mg/day, p =.51). The odds of receiving a high dose of olanzapine were increased 2.1 for patients with a schizophrenia spectrum diagnosis (DSM-IV schizophrenia or other psychotic disorder). The odds of receiving a high dose of olanzapine were increased with each incremental increase in length of stay (intermediate length of stay [8-60 days], OR = 5.6; long-term length of stay [> 60 days], OR = 12.0, relative to acute length of stay [< 8 days]).

CONCLUSIONS

Neither gender nor smoking status was associated with receiving a high dose of olanzapine. The association of increased length of stay with high dose suggests that treatment resistance may be an important factor in receiving high daily doses of olanzapine.

The “Yoking” of glutamatergic brain mechanisms involved in controlling brain neuronal excitability and psychosis to brain mechanisms involved in appetite regulation: a new hypothesis on the origin of psychosis

The authors speculate that the human primate evolved psychosis generating brain mechanisms in the service of certain feeding behaviors (i.e., appetite, foraging) during the course of evolution. Furthermore, these "psychosis generating brain mechanisms" may have grown directly out of brain mechanisms servicing appetite, of which neuropeptide Y (NPY) played an important role. A case is made for an NPY contribution to the pathophysiology of psychosis. We hypothesize that the psychomimetic effects of NPY extend to supporting certain "psychomotor" functions that might have been useful for obtaining food resources in "stressful environments" (potentially food resource rich/predator-competitor dangerous). The "psychomotor" functions proposed include helping the evolving ancestral human primate overcome behavioral inhibitions and fears related to venturing into "stressful environments" (potentially food resource rich/predator-competitor dangerous) after their home ranges had been stripped of resources, by providing feelings of decreased anxiety (anxiolysis), infatigability, and, perhaps, even grandiose delusions of physical ability and supernatural supports. We further speculate that it is this NPY mechanism that in part becomes dysregulated in idiopathic psychotic disorders such as schizophrenia. The NPY connection with psychosis could theoretically account for the possible associations between weight changes and antipsychotic response (e.g. [Acta Psychiatr. Scand. 100 (1999) 3] reported by others and body mass index and cocaine-induced psychosis by our group (i.e. [Israel J. Psychiatr. (2004), in submission]).

Antioxidant enzyme activities and oxidative stress in affective disorders

Recent data from several reports indicate that free radicals are involved in the biochemical mechanisms underlying neuropsychiatric disorders in human. The results of several reports suggest that lower antioxidant defences against lipid peroxidation exist in patients with depression and that there is a therapeutic benefit from antioxidant supplementation in unstable manic-depressive patients. We investigated the antioxidant enzyme status and the indices of oxidative stress and lipid peroxidation end products in erythrocytes from patients with affective disorder. For this purpose, we measured superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and catalase (CAT) activities, as well as malondialdehyde (MDA) and nitric oxide (NO) levels in patients with affective disorders (n=30) in both pre- and post-treatment periods, and in a control group (n=21). CAT activities were significantly decreased in both pre-, and post-treatment periods in patients compared to the control group. GSH-Px activity in the pre-treatment period in the patients was significantly lower than both post-treatment patient and control groups. MDA levels were increased in both pre-, and post-treatment patient groups compared to the control group. NO level was lower in the pre-treatment patient group than in the control group. There were statistically significant correlations between SOD and MDA, and SOD and NO in the pre-treatment patient and control groups. Because the overall study sample was small, and the post-treatment patient group was even smaller, it can tentatively be suggested that the antioxidant system is impaired during a mood episode in patients with affective disorders, normalizing at the end of the episode.

[Brain microdialysis of isolation-reared mice under freely-moving conditions]

Brain microdialysis has become a well established and a widely-used technique for in vivo measurement of extracellular levels of neurotransmitters. However, a single neurotransmitter in the perfusates has been measured in most studies. The present paper describes a simultaneous measurement of serotonin and dopamine release in the prefrontal cortex of mice. Using this technique, we examined the modulation by serotonin(1A) receptors of serotonin, dopamine, and noradrenaline release in the cortex of isolation-reared mice. The isolation-reared mouse is a useful model of complicated mood disorders including phenotypes of anxiety, depression, and aggression. The study shows that isolation rearing selectively decreases the sensitivity of serotonin(1A) receptors to increase dopamine release.

Psychotic and mood disorders associated with the perimenopausal period: epidemiology, aetiology and management

Contrary to widely held beliefs, menopause is not associated with an increase in psychiatric illness. Although just prior to menopause there is a slight increase in minor psychological symptoms, prevalence rates of depression fall postmenopause. Hypotheses for the occurrence of depression in some perimenopausal women include: a pre-existing sensitivity to the change in the gonadal hormones leading to decreases in neural transmitters; reactions to the physiological changes associated with menopause such as night sweats, or the influence of a multitude of negative attitudes and expectations concerning menopause. The loss of the protective effects of estrogen may be related to the slight increase in the incidence of schizophrenia in women at menopause. The role of hormone replacement therapy (HRT) in treating psychiatric symptoms remains poorly understood. In nondepressed women, HRT may improve well-being either as a direct effect or as a consequence of reduced physical symptoms and fear of aging. In women with moderate to severe depressions, HRT alone does not appear to be beneficial. HRT may have some beneficial effects on short term memory. More research is needed to assess the possible role of HRT in augmenting the effects of antidepressant and antipsychotic medications.

[Olanzapine in the treatment of depressive disorders with psychotic symptoms]

We report on the successful treatment of two female patients with psychotic depression with the new atypical neuroleptic drug olanzapine. A 75-year-old female inpatient suffering from recurrent endogenous depression with tactile hallucinations and coenesthesia was refractory to a systematic sequential antidepressant treatment strategy during a 39-week period. After addition of the new atypical neuroleptic olanzapine to the SSRI citalopram, she showed immediate and ongoing symptom relief. In the second case of a 57-year-old female inpatient suffering from delusional depression, we observed marked symptom relief and correction of the delusions of impoverishment. Olanzapine is discussed with regard to its receptor-binding profile (antagonism to 5-HT2A- and D1-D4 receptors) as a potential neuroleptic drug in the treatment of affective disorders with psychotic symptoms.

Intracellular calcium signaling systems in the pathophysiology of affective disorders

In this paper, we show the importance of intracellular calcium (Ca2+) signaling systems in the pathophysiology of mood disorders based on our recent work. Patients with affective disorders appear to have an enhanced intracellular Ca2+ rise in response to serotonin. We have observed effects of antidepressant drugs on intracellular Ca2+ signaling in rat cultured neuronal cells and glioma cells, and found that acute application of several classes of antidepressant drugs inhibited intracellular Ca2+ signaling and Ca2+-related signaling. It is important to investigate the role of intracellular Ca2+ signaling system for an understanding of the pathophysiology of affective disorders.

[Clinical significance of plasma levels of clomipramine and its desmethylated and hydroxylated metabolites]

Concentrations of clomipramine and its metabolites, N-desmethylclomipramine (DC), 8-hydroxy-N-desmethylclomipramine (HDC) and 8-hydroxyclomipramine (HC), in plasma were determined in 99 patients treated with clomipramine hydrochloride. Doses patients received were not fixed but titrated according to their clinical severity and response to the treatment. Large interindividual variations were present in the concentrations of parent or each metabolic compounds in plasma, however, strong correlations existed between these drug concentrations and daily doses of clomipramine (0.40-5.10 mg/kg of body weight) (r = 0.62-0.80). Metabolic ratios for desmethylation and those for hydroxylation were calculated from these data, and revealed very large inter-individual variations of 30-36 fold and 10-96 fold, respectively. Pharmacological data from 65 of these patients with DSM-III-R mood disorders were analyzed by discriminant analysis using the scores of Global Assessment of Functioning. The overall prediction value for responder or nonresponder was calculated as 70% 2 wk after the initiation of pharmacotherapy. Concentrations of hydroxylated metabolites in plasma does contribute as much to the prediction of clinical response to clomipramine as desmethylated metabolites.

[Serotonin-2 receptor-mediated intraplatelet calcium mobilization in affective disorders: relevance to the pathophysiology of depression]

Abnormal serotonin-2(5-HT2) receptor function in the central nervous system has been suggested to play a role in the pathogenesis of affective disorders. The presence of 5-HT2 receptors on human platelet similar to those in brain may permit direct study of 5-HT2 receptor function in living persons. 5-HT-stimulated intracellular calcium (Ca) concentration change was studied in the platelets of healthy subjects, using fluorescent Ca indicator fura-2. 5-HT increased the Ca response in a concentration-dependent manner. The maximal response was obtained at 10 microM of 5-HT and its EC50 value was 0.4 microM. This response was potently inhibited by selective 5-HT2 receptor antagonists, suggesting that the 5-HT-induced Ca mobilization is mediated by 5-HT2 receptors. This 5-HT-stimulated Ca response was not significantly affected by the time of blood sampling, gender, age, meal or exercise. Therefore, it may be concluded that the 5-HT-induced Ca response in human platelets is a stable parameter and that it is suitable for assessing 5-HT2 receptor function in depressed patients. Thus, the 5-HT-induced Ca mobilization was measured in the platelets of depressed patients. The response was significantly higher in unmedicated patients with bipolar depression and melancholic major depression than in those with non-melancholic major depression and normal controls. The enhanced Ca response to 5-HT failed to correlate with severity of depressive symptoms. In patients with bipolar depression and melancholic major depression, there was no significant difference in 5-HT-stimulated Ca response between unmediated group and euthymic-treated group. These results suggest that 5-HT2 receptor function is increased in some type of affective disorders and that the enhanced Ca response to 5-HT may be trait dependent rather than state dependent.

Impulsive aggression and central serotonergic system function in humans: an example of a dimensional brain-behavior relationship

A dimensional relationship between central serotonergic (5-HT) system function and indices of suicidal and impulsive aggressive behaviors has been suggested by more than a decade of research in patients with psychiatric disorders. This paper reviews a series of studies conducted in healthy male individuals and in male patients with major mood and/or personality disorder involving pharmacochallenge and neurochemical strategies designed to explore the role of central 5-HT system function in the regulation of suicidal and impulsive aggressive behavior in humans. The results of these studies suggest that reduced overall central 5-HT function in the limbic-hypothalamic system is associated with suicidal and/or impulsive aggressive behaviors in patients with major mood and/or personality disorders and that diminished 5-HT post-synaptic receptor function in this brain region may be an important biological correlate of these behaviors.

Increased sensitivity of dopamine receptors and recurrence of affective psychosis after childbirth

OBJECTIVE

To test the hypothesis that affective psychosis after childbirth is associated with an altered sensitivity to dopaminergic stimulation.

DESIGN

Prospective study of pregnant women at high risk of developing an affective psychosis after childbirth. Clinical assessments in pregnancy and after delivery were made by using a semistructured interview (schedule for affective disorders and schizophrenia) and psychiatric illnesses were categorised according to operational criteria (research diagnostic criteria).

SETTING

Obstetric and psychiatric departments in and around Greater London.

SUBJECTS

29 pregnant women with a history of bipolar or schizoaffective psychosis and 47 control pregnant women. Of these, 16 from each group participated in a growth hormone challenge test and the results for 15 women in each group were analysed.

INTERVENTIONS

On the fourth day postpartum women participating in the hormone challenge test were given a subcutaneous injection of a small dose (0.005 mg/kg) of the dopamine agonist apomorphine.

MAIN OUTCOME MEASURES

Growth hormone secretion in response to apomorphine as an index of the functional state of hypothalamic dopamine receptors.

RESULTS

Eight of the 15 women at risk of psychosis subsequently had a recurrence of illness (five bipolar, one schizomanic, and two major depressive illnesses); these women had significantly greater growth hormone responses to apomorphine than the seven at risk women who remained well and the 15 controls, and there were no significant differences between groups in average baseline growth hormone concentrations. The mean (SD) concentrations for women with recurrence, women at risk who remained well, and control women respectively were: average baseline concentrations 1.06 (1.14), 1.44 (1.39), and 0.90 (1.34) mU/l; peak increase in concentrations 13.68 (12.95), 3.46 (4.68), and 3.40 (3.83) mU/l (between group difference p less than 0.05); average increase in concentrations 6.74 (7.01), 1.78 (3.39), and 1.40 (2.05) mU/l (p less than 0.05).

CONCLUSIONS

The onset of affective psychosis after childbirth was associated with increased sensitivity of dopamine receptors in the hypothalamus and possibly elsewhere in the brain. Such changes may be triggered by the sharp fall in circulating oestrogen concentrations after delivery.

No difference in basal ganglia mineralization between schizophrenic and nonschizophrenic patients: a quantitative computerized tomographic study

The role of iron in schizophrenia (SC) has aroused attention because of its modulatory effect on the dopamine receptor and its role as a cofactor for tyrosine hydroxylase. In addition, several postmortem studies suggest that increased mineralization (especially iron) of the basal ganglia is a possible clinicopathological correlate of schizophrenia. In order to quantitate the in vivo mineral content in the basal ganglia of patients with SC, a protocol was developed to analyze CT scans films with a LOATS computer analysis system. A total of 725 consecutive CT scans (275 SC, 450 nonSC) from a psychiatric population were reviewed. Eighteen scans (2.3%) revealed basal ganglia mineralization of which 7 cases carried a diagnosis of SC and 11 had other psychiatric disorders. All subjects had received neuroleptics, and 8 of the 11 patients in the nonschizophrenic group were demented. Both the SC and nonSC patients exhibited a prevalence (2.5%) of basal ganglia mineralization similar to that found in a postmortem series of the general population.

Effect of lithium treatment on the GH-clonidine test in affective disorders

The effects of short-term lithium (Li) administration on alpha 2-adrenoceptor sensitivity was studied in 10 healthy volunteers and in 15 patients with normothymic, phasic depressive disorders. The GH-clonidine test was used to examine alpha 2-adrenoceptor sensitivity, administered before and after Li treatment (600 mg/day for 7 days in controls and for 15 days in patients). Before treatment, the GH response to clonidine in the patients was blunted, and afterwards it tended to increase in the patients and it was significantly decreased in the controls. The difference between the response in the two groups was significant and was correlated both with the diagnosis and the pretreatment GH response to the stimulus. The opposing pattern of the response in patients and controls to Li administration suggests that the drug exerts a modulatory effect on alpha 2-adrenoceptor sensitivity, with up or down regulation inversely correlated with pretreatment status.

Glucose utilization in the temporal cortex of affectively ill patients: positron emission tomography

As temporal lobe dysfunction has been postulated in the affective disorders, the authors investigated glucose utilization in the temporal lobes of 13 affectively ill patients in comparison with 18 normal volunteer controls and 17 previously reported schizophrenic patients, following injections of fluorine 18-2-deoxy-D-glucose (FDG) during somatosensory stimulation to the right forearm. Using a boundary-finding algorithm to outline each temporal lobe, maximum glucose use relative to maximums elsewhere in the same positron emission tomography (PET) slice were calculated. In a small group of moderately to severely depressed patients, this relative measure was significantly reduced in the right (with a similar trend in the left) temporal lobe compared to normal volunteers and the other comparison groups. The lack of a significant increase in glucose utilization, measured either as a maximum or in relation to other areas in the PET scan slice, suggests that a temporal lobe activation or a seizure-like process is not generally occurring during active depressive phases of the illness.

Electroacupuncture: an alternative to antidepressants for treating affective diseases?

The monoamine hypothesis for affective disorders indicates a functional impairment of the monoamine systems in CNS as the causative factor for the development of depression. Pharmacological manipulations of the monoaminergic neuronal system using tricyclics and monoamine oxidase inhibitors produced promising therapeutic effects as well as certain unwanted side effects, which urged the search of a physiological means to activate the central monoamine systems. In the present paper, evidence from animal experiments is presented to show that acupuncture or electroacupuncture (EA) is capable of accelerating the synthesis and release of serotonin (5-HT) and norepinephrine (NE) in the CNS. Clinical data indicate that EA is effective in treating depressive patients, and at least as effective and with a higher therapeutic index than tricyclic amitriptyline.

The dexamethasone suppression test in affective illnesses and schizophrenia: relationship with psychotic symptoms

The authors studied the dexamethasone suppression test (DST) on a series of 112 inpatients including 65 patients with major depressive disorder (21 bipolars: 4 with, 17 without psychotic symptoms; 44 unipolars: 13 with, 31 without psychotic symptoms), 15 patients with depressive disorder, 10 schizoaffective and 22 schizophrenic patients. Using different diagnostic criteria, they confirm the best performances of the DST in depression for the diagnosis of a major depressive disorder, primarily endogenous. They also examined the potential influence of psychotic symptoms, suicidal behavior and family history of affective illness on the DST. The only significant difference found is in the cortisol plasma level at 4 p.m. in bipolar patients with psychotic symptoms. That fact and the high rate of abnormality of the DST in schizoaffective and schizophrenic patients indicate that psychotic symptoms per se may play a role in a dysregulation of the hypothalamo-pituitary adrenal axis.

Basal hypersecretion of cortisol in relation to abnormal dexamethasone suppression test response in depression

The activity of the hypothalamus-hypophysis-adrenal axis was evaluated in a group of patients with primary affective disorder by correlation of basal cortisol hypersecretion and abnormal response to dexamethasone suppression test (DST). The increase in basal cortisol was not found to be responsible for suppression failure. Moreover, this biochemical abnormality was common in the groups of psychiatric patients studied, although the physiopathologic mechanisms involved are different. Further research is necessary to clarify the results.

Nonlinear pharmacokinetics of chlorimipramine after infusion and oral administration in patients

In this study the pharmacokinetics of 75 mg and 150 mg chlorimipramine after infusion and tablets was followed for four weeks in chronically treated patients. The clearance was found to be dose dependent. From the time course of the metabolite desmethylchlorimipramine in plasma it can be concluded, that chlorimipramine tablets are resorbed totally. No correlation between pharmacokinetic and improvement parameters could be found. Doubling of the dosage leads to 3 fold chlorimipramine and 4 fold desmethylchlorimipramine concentrations. The estimated half lives are higher than known hitherto. Especially for chronic treatment with 150 mg chlorimipramine, plasma concentration monitoring is recommended, because 20% of the patients did not reach steady state for chlorimipramine and 60% for desmethylchlorimipramine, in these 4 weeks.

Effects of carbamazepine on noradrenergic mechanisms in affectively ill patients

Noradrenergic mechanisms have been postulated to account for the anticonvulsant and psychotropic effects of carbamazepine. In order to assess this possibility in man, cerebrospinal fluid (CSF) was obtained from affectively ill patients before and during treatment with carbamazepine (average duration 29 days) at doses averaging 860 mg/day, achieving blood levels of 8.86 micrograms/ml. Neither plasma nor CSF norepinephrine (NE) nor CSF 3-methoxy-4-hydroxy-phenylglycol (MHPG) was significantly altered by carbamazepine. Baseline medication-free values in 21 depressed patients were not predictive of the degree of subsequent clinical antidepressant response. CSF NE decreased in four manic patients treated with carbamazepine. The many effects of carbamazepine on noradrenergic mechanisms in animals are discussed in relationship to these first studies of carbamazepine in man.

Lithium's effects on muscarinic receptor binding parameters: a relationship to therapeutic efficacy?

Variables confounding efforts to interpret data on lithium's effects in laboratory animals in vivo and from in vitro muscarinic receptor binding studies are discussed. After accounting for the effects of these variables, the author concludes that it is of theoretical interest and heuristic value to hypothesize that lithium renders cholinergic systems more stable or less perturbable in the face of mono-aminergic overdrive. Thus lithium may diminish the propensity of cholinergic systems to undergo up-regulation and supersensitization consequent to exogenous and endogenous events apt to induce these changes. Lithium's antidepressant, antimanic, and anticycling efficacy may depend on its cholinotropic properties. The potential significance of lithium's cholinergic effects is highlighted by findings that seizures and verapamil induce similar cholinotropic effects. The author hypothesizes that with further investigation anticycling agents will come to be regarded as unique among psychotropics by virtue of their effects on cholinergic-monoaminergic interactions and mechanisms.

Muscarinic cholinergic receptors on skin fibroblasts in familial affective disorder

Cultured human skin fibroblasts possess muscarinic receptors with the properties of specific binding, saturability, pharmacologic specificity, inhibition of norepinephrine-stimulated adenylate cyclase, and increased binding after incubation with an antagonist. The number of binding sites appears to be a stable characteristic of each cell line. We studied fibroblasts from 18 patients with a major affective disorder and found that they had a higher density of binding sites than cells from 12 normal controls. Fibroblasts from 18 relatives who had histories of major or minor affective disorder also had a higher density, and those from five normal relatives were similar to controls. These results, although still preliminary, suggest that increased cholinergic-receptor density may be associated with vulnerability to affective disorders in some familial cases.

Common mechanism of action of biochemically "specific" antidepressants

NE turnover in depressed patients treated with three drugs which have specifically different primary biochemical effects is compared before and after treatment. Turnover is quantitated as the sum of NE and its major metabolites excreted in the urine using a new mass spectrometric assay. Clorgyline , a MAOI specific for Type A; desipramine, a selective NE uptake inhibitor; and zimelidine, a selective 5HT uptake inhibitor, were used. All three antidepressants, including zimelidine, reduced NE turnover although producing very different effects on the metabolic profile of NE. It remains likely that effects on NE are related to therapeutic effect.

Research into mood disorders at the Royal Ottawa Hospital

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CSF and urinary biogenic amines and metabolites in depression and mania. A controlled, univariate analysis

Levels of 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) in the CSF, and norepinephrine (NE), epinephrine (E), vanillylmandelic acid, normetanephrine, metanephrine, and MHPG in the urine, were measured in 151 hospitalized patients with affective disorders and in 80 healthy controls following a two-week drug-free period. Unipolar and bipolar depressed subjects differed only in NE and E levels. Compared with controls, depressed subjects had higher CSF MHPG levels, women had higher 5-HIAA levels, and men had lower HVA levels. All urinary metabolites were elevated in depression and mania, with the exception of MHPG. The patterns of NE-E differences discriminated among the forms of affective disorders. These data suggest an imbalance of monoamine transmission in depression, characterized by the hyperactive sympathetic nervous system and adrenal medulla. However, MHPG may not be the measure of choice to reflect this imbalance, necessitating measurement of total body monoamine output.

A cholinergic role in the mechanism of lithium in mania

Based on evidence that mania may include an alteration of cholinergic function, we have previously investigated the effects of various monovalent ions on the muscarinic cholinergic receptor from human caudate nucleus utilizing the radio-labeled antagonist (3H)quinuclidinyl benzilate (QNB). In this study we observed that Li+ at 1 mM was unique in its ability to specifically reduce the affinity of 3H-QNB for the muscarinic receptor (increasing the QNB dissociation constant from 35.9 pM to 72.4 pM). The sodium-specific induction of positive cooperativity (nHill) at the muscarinic cholinergic receptor was inhibited in the presence of Li+. Both observations achieved statistical significance at p less than 0.05. A Li+-related decrease in specific QNB binding sites (Bmax) by 23% (from 2480 to 1900 pmole/g protein) was additionally manifest, albeit only achieving a statistical trend (p less than 0.10). The exact mode of Li+ action in the management of major affective illnesses remains speculative. The observations that this cation specifically mediates a reduction of muscarinic receptor affinity and number of binding sites within the human caudate suggests further consideration of the association between muscarinic cholinergic activity and mania as it relates to Li+.

Electrolyte metabolism in patients with periodic affective disorders during treatment with rubidium

Five patients suffering from periodic affective disorders with short mood-cycles were treated with rubidium chloride, producing peak erythrocyte concentrations between 9 and 13 mmol/l. Loading with rubidium was associated with decreased total body potassium, but red-cell potassium was unchanged. Regular mood-cycling was disturbed, together with the associated body-weight changes. There was a slight extracellular "metabolic" acidosis. Electrolyte concentrations fluctuate abnormally in these patients, and two muscle biopsy specimens had very low potassium contents.

An effective method for measuring salivary lithium in patients on anticholinergic drugs

The parotid salivary response to citric acid and cholinergic agonist and antagonist was assessed in normal volunteers. Gustatory stimulation by circulation of citric acid in the mouth evoked reproducible parotid salivary burst. The salivary response to citric acid was minimally affected by anticholinergic drugs. Analysis of citric acid-evoked parotid saliva revealed a linear relationship between saliva and serum lithium concentrations in affectively ill patients treated with lithium only, or with lithium in combination with anticholinergic drugs. We suggest that parotid saliva lithium levels can be used to guide lithium therapy in patients for whom phlebotomy is not practical.

Neurotransmitter parameters in plasma and urine of affective patients in depression and in normothymia after drug treatment

Several neurochemical parameters were estimated in plasma and urine of patients with affective disorders in the depressive phase and later in normothymia, after successful drug treatment. Significant increases were found for the activity of the enzyme dopamine-beta-hydroxylase in plasma and the concentrations of cyclic AMP in plasma and urine. No consistent changes were found for prolactin or cyclic GMP in plasma, and for methoxyhydroxyphenylgkyglycol, homovanillic acid, 5-hydroxyindoleacetic acid and cyclic GMP in urine. The major change we observed in the clinical state of the patients is thus not reflected in change in the urinary biogenic amine metabolites. Their changes were found to correlate inversely to their pretreatment values. In normothymia, high values decrease and low values increase for all three amine metabolites, indicating that antidepressives act towards a normalization of the amine turnover mechanisms.

Specific norepinephrine and serotonin uptake inhibitors in man: a crossover study with pharmacokinetic, biochemical, neuroendocrine and behavioral parameters

Eight depressed patients with major affective illness were treated with both zimelidine, a selective serotonin-uptake inhibitor, and with desipramine, a selective norepinephrine uptake inhibitor, following a double-blind crossover design. At steady-state the active metabolite of zimelidine, norzimelidine, predominated in the CSF by a factor of 7 to 1 over parent drug. As predicted, even high concentrations of norzimelidine were not associated with decreased 3-methoxy-4-hydroxy-phenylglycol (MHPG) in the CSF. In the same individuals, desipramine concentrations were highly correlated with decreases of MHPG in the CSF. Despite specific effects on monoamine neurotransmitter systems which have been implicated in the control of neuroendocrine secretion, neither drug had consistent effects on plasma cortisol, luteinizing hormone, growth hormone or prolactin. Both drugs had a marked and unexpected common effect on the 24-hour rest-activity cycle. The excess activity during the normal rest period (0--700 hr.) which has been noted in severely depressed individuals was significantly reduced by both the serotonergic zimelidine and the noradrenergic desipramine. These findings suggest that effects on the rest-activity pattern may be a common pathway for antidepressant effect.

Biological component of the NIMH clinical research branch collaborative program on the psychobiology of depression: II. Methodology and data analysis

A preceding paper has reviewed the history, background, and rationale for this collaborative effort exploring the biologic basis of the affective disorders. This paper details the "flow" of a subject through the experimental protocol, the instrumentation used to obtain the clinical and behavioural data, and the biologic methodologies employed in the analysis of the body fluids. Data management and analysis techniques developed for this study are also examined.

[Different effects of tricyclic (clomipramine and amitriptyline) and tetracyclic (maprotiline) antidepressors on the release of thyroid stimulating hormone, prolactin and growth hormone to thyrostimulating releasing hormone in patients with psychoaffective disorders (author's transl)]

The hormonal alterations induced by tricyclic and tetracyclic antidepressors (AD) were studied in patients with psychoaffective disorders (PAD) to ascertain the role of certain biogenic amines in the regulation of thyroid stimulating hormone (TSH), prolactin (PRL) and growth hormone (GH). The responsiveness of plasma TSH, PRL and GH to synthetic thyrostimulating release hormone (TRH; 250 microgram i.v.) was determined in 57 patients distributed in 5 groups according to the treatment: 10 non treated patients, 16 tricyclic (clomipramine and amitriptyline) treated patients, 6 patients treated by clomipramine in association with lithium, 6 tetracyclic (maprotiline) treated patients and 19 patients treated by major neuroleptics. Results of untreated patients were compared to those observed in 10 age and sex matched normal subjects. Basal plasma levels of TSH were normal in all the patients. The TSH response to TRH (delta TSH) was blunted in non treated patients. delta TSH was normal in the patients treated by maprotiline or neuroleptics and increased in the group treated by tricyclic AD in association with lithium. Basal plasma levels of PRL and PRL response to TRH (delta PRL) were decreased in the women treated by tricyclic AD, but remained normal under maprotiline. They were markedly increased in the neuroleptic group. No inadequate response of GH to TRH was noted in our series of patients. The different hormonal effects induced by AD--dissociation between delta TSH and delta PRL under tricyclics and normal or increased delta TSH under maprotiline--may be logically explained by the various ways of action of these AD on the brain monoamines. delta TSH decrease and tendency to an increased delta PRL observed with clomipramine argue for a serotoninergic regulation of these two hormones, whereas the normalisation of delta TSH under maprotiline argues for a noradrenergic regulation of this hormone. Effectively, tricyclic AD inhibits mainly the serotonin recaptation and tetracyclic inhibits rather norepinephrine recaptation. The persistent delta TSH increase observed in the group treated by the association clomipramine-lithium demonstrates that the tricyclics do not interact with the hypophyso-thyroid positive feedback.

[Modifications of cerebral amine metabolism in psychiatric illness]

Abnormalities in brain monoamines have been implicated in the pathogenesis of several psychiatric disorders. A brief revue of biochemical studies on indolamines and catecholamines in mental disorders with special emphasis on endogenous depression will be presented. Progress in neurochemistry makes it possible to investigate the biochemical disturbances present in the major psychoses. Recent knowledge in the neuropharmacological mechanism of action of psychotropic drugs have shed some light on the basic understanding of the pharmacological treatment of psychotic disorders. The implication of biogenic amine studies in psychiatry for endocrinological research in mental disorders will also be discussed.

Further light on the tyramine test in depression

In studies of post-partum women, the oral tyramine loading test is shown to be of predictive value in identifying those subjects with a lifetime history of depressive illness. The cause of the decreased output of conjugated tyramine, after tyramine ingestion, is still unclear. Some possible mechanisms have been under scrutiny.

The thyroid-stimulating hormone response to thyrotropin-releasing hormone in mania and bipolar depression

The release of thyroid-stimulating hormone (TSH) from the pituitary after infusion of 500 microgram of thyrotropin-releasing hormone (TRH) was decreased (p < 0.01) in manic patients and increased (p < 0.01) in bipolar depressed patients compared to a control group of patients with personality disorders. These results suggest that the TRH test may be useful in the diagnosis of psychiatric disorders and in the prediction of response to pharmacotherapy. We discuss the role of central monoaminergic systems in changes in the TSH response to TRH.