Mood disorders and serotonin transporter density in ecstasy users--the influence of long-term abstention, dose, and gender

RATIONALE

Neurotoxic effects of 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") on the serotonin (5-HT) system have been described in animals and humans, but little is known about long-term effects of ecstasy use on mood.

OBJECTIVES

To investigate short-term and long-term effects of ecstasy use on mood and its association with 5-HT neurotoxicity, dose, and gender in humans.

METHODS

Fifteen moderate ecstasy users, 23 heavy ecstasy users, 16 former heavy ecstasy users and 15 drug-using, but ecstasy-naive controls were included. Mood was assessed using the Composite International Diagnostic Interview (CIDI) and the Beck Depression Inventory (BDI). Outcomes were correlated with 5-HT transporter (SERT) density, assessed with [123I]beta-CIT single photon emission computed tomography (SPECT).

RESULTS

The prevalence of mood disorders assessed by CIDI did not differ between all groups. The overall test for differences in BDI scores between groups was near significance (P=0.056), with BDI scores higher in former heavy ecstasy users than in ecstasy-naive controls (P=0.045). BDI scores were correlated with the total number of ecstasy tablets used (r=0.310; P=0.021). No associations between CIDI or BDI outcomes and SERT density or gender were observed.

CONCLUSIONS

These results suggest that ecstasy use is not associated with clinical depression (CIDI). However, the number of ecstasy tablets taken lifetime was associated with higher BDI scores for depressive mood, and this relationship seemed to persist after ecstasy use had stopped. We did not find that depressed mood in ecstasy users was associated with decrease in SERT density. Prospective studies are needed to establish the causal relationship between ecstasy use and depressed mood.

Empathy and aggression: two faces of ecstasy? A study of interpretative cognitive bias and mood change in ecstasy users

RATIONALE

As central 5-hydroxytryptamine (5-HT) is attenuated for a period following a single dose of MDMA ("ecstasy") and low 5-HT is associated with aggression, then MDMA users may be more aggressive in the days following an acute dose of the drug.

OBJECTIVE

This study therefore aimed to determine if acute use of MDMA is associated with aggression 4 and 7 days later.

METHODS

Twenty-nine MDMA users and 32 controls were compared on self-rated aggression and depression on the night of drug use (day 0), 4 and 7 days later. On day 4, participants performed an interpretative bias task in which they processed ambiguous sentences that could be interpreted in either an aggressive or neutral way (e.g. "The painter drew the knife").

RESULTS

MDMA users had faster response times in completing ambiguous aggressive sentences than neutral sentences; controls showed the opposite pattern of performance. In a subsequent recognition task, MDMA users were more confident in judging, and responded faster to, aggressive than neutral sentences; controls again showed the opposite pattern of effects. The level of aggressive interpretative bias positively correlated with extent of MDMA use. Midweek, MDMA users had higher self-rated aggression and depression scores than controls; on day 7, scores of both groups were similar.

CONCLUSIONS

MDMA users display a cognitive bias towards interpreting ambiguous information in an aggressive way a few days after taking the drug. Self-rated mid-week low mood and mid-week aggression do not persist 7 days after use of the drug. This pattern of results is consistent both with the acute and residual effects of MDMA on central 5-HT and with the notion that 5-HT plays a role in modulating human aggression.

Preliminary evidence of hippocampal dysfunction in adolescent MDMA ("ecstasy") users: possible relationship to neurotoxic effects

RATIONALE

3,4-Methylenedioxymethamphetamine (MDMA or ecstasy) is a potent and selective serotonin neurotoxin whose use is growing among adolescents. Although cognitive deficits among adult MDMA users are well documented, little is known of the cognitive and brain functional sequelae of MDMA use during adolescence.

OBJECTIVE

We tested for evidence of cognitive deficits and changes in brain function in a pilot sample of adolescent MDMA users, who were compared with adolescent non-users of MDMA.

METHODS

Selective and divided attention and verbal working memory were examined in six adolescent MDMA users and six non-users of MDMA who were similar in age, gender, IQ, and other substance use. Brain function was assessed during performance of the working memory task using functional magnetic resonance imaging (fMRI).

RESULTS

MDMA users had significantly prolonged reaction times during tests of selective and divided attention, and failed to deactivate the left hippocampus normally during high verbal working memory load.

CONCLUSIONS

MDMA use in adolescence may be associated with cognitive impairments and dysfunction of inhibitory circuits within the hippocampus. Further work is urgently needed to delineate the developmental impact and long-term functional and clinical significance of MDMA use during adolescence.

Chronic MDMA (ecstasy) use, cognition and mood

RATIONALE

It has been suggested that 3,4-methylenedioxymethamphetamine (MDMA or ecstasy) causes damage to the serotonergic system, and that this damage results in cognitive and mood impairments.

OBJECTIVES

To examine the effect of chronic MDMA usage on a wide battery of cognitive tests and psychological abilities and processes.

METHODS

In the present study, the performance of 17 participants with a history of MDMA use was compared to the performance of 15 control subjects on a battery of neuropsychological tests. This battery included tests for depression, immediate word recall, delayed recall, attention and working memory.

RESULTS

Results indicated that the MDMA group had significantly higher scores for depression than the control group, and displayed poorer delayed recall and verbal learning than controls after accounting statistically for the effects of cannabis and depression.

CONCLUSIONS

These results suggest that MDMA users exhibit difficulties in coding information into long-term memory, display impaired verbal learning, are more easily distracted, and are less efficient at focusing attention on complex tasks.

Relationship between ecstasy use and depression: a study controlling for poly-drug use

RATIONALE

3,4-Methylenedioxymethamphetamine (MDMA or "ecstasy") causes serotonin neuron damage in laboratory animals. The serotonin system is known to be important in the regulation of mood. Previous research has shown that MDMA users score higher on self-report ratings of depression than controls. However, MDMA users commonly take other illicit substances and many studies do not fully control for poly-drug use.

OBJECTIVES

The aim of this study was to examine the relationship between MDMA use and affective disturbance, while fully controlling for poly-drug use.

METHODS

Participants were 30 current MDMA users, 30 poly-drug controls who had never used MDMA, 30 drug-naïve controls with no history of illicit drug use and 20 ex-MDMA users. The current MDMA users and poly-drug controls were well matched on all indices of non-MDMA drug use. All participants were administered the Beck Depression Inventory (BDI) and the Affective Go/No-go task, which has been shown to be sensitive to depression.

RESULTS

The current and ex-MDMA users scored significantly higher on the BDI than the drug-naive controls, but were not significantly different from the poly-drug controls. There were no differences between the groups in terms of affective bias scores on the Affective Go/No-go task.

CONCLUSIONS

Increased scores on self-report depression scales in MDMA users are not entirely attributable to MDMA use. MDMA users do not show the same attentional bias towards negatively toned material as depressed patients.

The application of the principles of clinical drug development to pharmacological challenge tests of the serotonergic system

Pharmacological challenge tests of the serotonergic system have extensively been used during the past 20 years and new tests are in development. It is of crucial importance to standardize challenge tests to ascertain that observed variability is due to the state of the challenged system and not caused by variability of the test itself. This is even more important now that challenge tests increasingly are used in complex studies (e.g. in combination with neuroimaging and in large population studies with repeated tests over time). The Guideline for Good Clinical Practice may be of great help in the standardization of these tests. This is a recently developed guideline for pharmaceutical drug-development, which increasingly is used as a reference for all research in humans. To exemplify the possible usefulness of this approach, we apply it to meta-chlorophenylpiperazine, one of the most commonly used drugs in serotonergic challenge tests. We conclude that much can be learned from the development of this particular challenge. In the discussion, we address general issues that emerged from this review and their relevance to the development of future challenge tests.

‘Ecstasy’-induced subarachnoid haemorrhage: an under-reported neurological complication?

In the face of escalating recreational use of 'Ecstasy' (3,4-methylenedioxymethamphetamine, MDMA), physicians need to be aware of its possible adverse effects. We report two young patients who suffered subarachnoid haemorrhage following ingestion of 'Ecstasy' tablets. Angiographic studies demonstrated features consistent with vasculitis in both cases. Recognition of this association is important and highlights the significance of eliciting a careful drug history, particularly in cases of 'angiogram negative' subarachnoid haemorrhage.

[Acute liver failure caused by Ecstasy]

Ecstasy is a synthetic amphetamine widely used as a "week-end" recreational drug because it produces euphoria and eliminate the sense of fatigue. It was initially considered to be a drug with few toxic effects, but later various complications and even fatal cases have been reported. Although the 23 year old woman already tried the Ecstasy in the past, but during the month before the admission she took 8 pills. She became icteric after 6 days taking the last pill and 3 days later her prothrombin level became very low. Due to the rapid deterioration we planed liver transplantation, but since there was no acceptable donor, we could only make plasmapheresis. The autopsy proved sever liver necrosis.

Risk of valvular heart disease associated with use of fenfluramine

BACKGROUND

Estimates of excess risk of valvular heart disease among prior users of fenfluramine and dexfenfluramine have varied widely. Two major forms of bias appear to contribute to this variability and also result in a systematic under-estimation of risk. The first, a form of nondifferential misclassification, is the result of including background, prevalent cases among both exposed and unexposed persons in calculations of risk. The second bias results from not considering the relatively short duration of exposure to drugs.

METHODS

We examined data from all available echocardiographic studies reporting the prevalence of aortic regurgitation (AR) and mitral regurgitation (MR) among persons exposed to fenfluramine or dexfenfluramine and a suitable control group. We also included one study in which previously existing AR or MR had been excluded. We corrected for background prevalent cases, estimated incidence rates in unexposed persons, and performed a person-years analysis of apparent incidence rates based on exposure time to provide an unbiased estimate of relative risk.

RESULTS

Appearance of new AR was strongly related to duration of exposure (R2 = 0.75, p < 0.0001). The summary relative risk for mild or greater AR was 19.6 (95% CI 16.3-23.5, p < 0.00001); for moderate or greater MR it was 5.9 (95% CI 4.0-8.6, p < 0.00001).

CONCLUSION

These findings provide strong support for the view that fenfluramine and dexfenfluramine are potent causal factors in the development of both aortic and mitral valvular heart disease.

Long-term effectiveness of risperidone and olanzapine in resistant or intolerant schizophrenic patients. A mirror study

OBJECTIVE

To evaluate the long-term effectiveness of the second generation antipsychotics, risperidone and olanzapine on hospitalization, clinical response, and adherence to therapy after switching from conventional antipsychotics or clozapine in a naturalistic setting of schizophrenic patients.

METHOD

Data were registered for periods of identical duration before and after switching.

RESULTS

Fifty-seven patients were included. Mean study period was 3.1 +/- 0.2 years. Mean number of in-patient days after switching declined by 78% of the level before switching (P=0.0002). There was no significant differences in ratio responders/non-responders between the subgroups. The number of patients with extrapyramidal symptoms (EPS) was significantly reduced after switching. However, intolerable weight gain led to a lack of adherence to therapy in 18% of the olanzapine-treated patients.

CONCLUSION

Long-term treatment with the second generation antipsychotics, risperidone and olanzapine significantly improved the clinical outcome. However, weight gain may be a significant reason for discontinuation of treatment and reducing the long-term adherence to therapy.

Mood, cognition and serotonin transporter availability in current and former ecstasy (MDMA) users

RATIONALE

Chronic recreational ecstasy (MDMA) use has often been reported to be associated with psychopathology, memory impairments and serotonergic alterations. However, the findings have not been consistent.

OBJECTIVES

To attempt to replicate these findings, to investigate whether such alterations would be reversible and whether they could be predicted by parameters of previous drug use.

METHODS

In a cross-sectional design, 30 current and 31 ex-ecstasy users with ecstasy abstinence of at least 5 months, and 29 polydrug and 30 drug-naive controls were compared on measures of psychopathology, cognitive performance and serotonin transporter availability.

RESULTS

The groups did not differ significantly in age, gender distribution, education level and premorbid intelligence. The ecstasy groups did not differ significantly from polydrug controls on most of the relevant parameters of concomitant illegal drug use. Reported drug use was confirmed by hair and urine analyses. All three groups of drug users exhibited significantly elevated psychopathology compared with drug-naive controls. Only ex-ecstasy users were significantly impaired on verbal recall. Current ecstasy users showed significantly reduced distribution volume ratios of serotonin transporter availability in the mesencephalon and caudate nucleus. Regression analyses indicated that psychopathology and serotonergic alterations were best predicted by the number of ecstasy tablets taken on a typical event.

CONCLUSION

The results indicate that verbal memory impairments were possibly aggravated after prolonged ecstasy abstinence while there was tentative evidence of serotonergic recovery. On the other hand, self-reported elevated psychopathology appeared to be associated with polydrug use in general and not specifically with ecstasy use.

Reduced social interaction following 3,4-methylenedioxymethamphetamine is not associated with enhanced 5-HT 2C receptor responsivity

This study examined the long-term change in serotonergic (5-hydroxytryptamine, 5-HT) neuronal function and 5-HT(2C) receptor agonist-induced behaviour following treatment of young rats with 3,4-methylenedioxymethamphetamine (MDMA). On post-natal day (PND) 28, Lister-hooded rats received either MDMA (15 mg/kg i.p.) or saline (1 ml/kg i.p.) twice daily for 3 days. On PND 50 social interaction was assessed between treatment-matched pairs of rats derived from separate litters. The effect of either the 5-HT(2C) receptor agonist, m-chlorophenylpiperazine (m-CPP, 2.5 or 1 mg/kg i.p., respectively) or saline was examined on open-field exploration (PND 52) and elevated plus-maze behaviour (PND 56). Acutely, MDMA produced hyperlocomotion and hypothermia compared with saline injection (p<0.001). Following 20 days abstinence, social interaction was decreased by 26% (p<0.05) in MDMA pre-treated rats compared with saline controls, without any change in locomotion. There was no difference in open-field or elevated plus-maze behaviour between pre-treatment groups. m-CPP caused hypolocomotion in the open-field and decreased both the percentage entries into, and time spent in, the open arms of the elevated plus-maze to a comparable extent in MDMA and saline pre-treated rats. Hippocampal and frontal cortical 5-HT and 5-hydroxyindoleacetic acid (5-HIAA) were significantly reduced in MDMA pre-treated rats, without any change in [(3)H]paroxetine binding or plasma corticosterone levels. These data suggest that the MDMA-induced reduction in social interaction is not mediated via alteration of 5-HT(2C) receptor function.

The content of ecstasy tablets: implications for the study of their long-term effects

AIMS

To examine the variation in the content of ecstasy tablets seized in the north-west of England during 2001 and to compare it to the UK average from 1991 to 2001.

MEASUREMENTS

All tablets submitted to the Forensic Science Service in the north-west of England during 2001 were analysed by high performance liquid chromatography with diode array detection (HPLC-DAD). The mean MDMA content of these tablets are reported and compared to results from all Forensic Science Service laboratories in the United Kingdom from 1991 to 2001. Multiple samples (n= 80) from a single large seizure of White Dove tablets were analysed to determine the variation due to manufacturing.

FINDINGS

All tablets submitted from the north-west of England to the Forensic Science Service in 2001 were found to contain 3,4-methylenedioxymethamphetamine (MDMA) and some also contained 3,4-methylenedioxyethamphetamine (MDEA). The MDMA content of these tablets ranged from 20 to 109 mg and the mean was in the 60-69 mg range. Mitsubishi tablets were the most common type and they were found across the whole range. The low variation of MDMA content in the White Dove tablets suggests that these tablets were well manufactured. The data from the north-west of England in 2001 are in agreement with tablet analyses over the past 10 years which show that the average MDMA content is falling.

CONCLUSIONS

The amount of MDMA in ecstasy tablets is axiomatic to the discussion of their long-term effects. In order for the observed differences in ecstasy users to be the result of MDMA-induced neurotoxicity it is necessary for them to have ingested one or more neurotoxic doses. These data indicate that the amount of MDMA in ecstasy tablets is dropping and that dose-effect relationships need to take this into account.

Effect of fenfluramine-derivative diet pills on cardiac valves: a meta-analysis of observational studies

BACKGROUND

Fenfluramine-derivative diet pills were withdrawn from the market in 1997 because of an association with valvular regurgitation, but subsequent estimates of the prevalence of this condition have varied widely. We systematically reviewed evidence regarding the prevalence of valvular disease after fenfluramine exposure.

METHODS

We searched multiple databases with multiple search terms. Conference proceedings from 1997 onward were searched by index. Authors of eligible studies were contacted to identify unpublished works. Selection criteria were liberally determined. Ten of the identified 11 articles met these criteria. Reviewers assessed the studies' methodologic quality by use of a standard form to evaluate selection, attrition, performance, and detection bias. The studies were analyzed in 2 groups on the basis of length of exposure (<90 days or >90 days). The Mantel-Haenszel method was used to summarize data. Quantitative and qualitative tests for heterogeneity were performed. Tests for publication bias were also done.

RESULTS

Tests for heterogeneity were nonsignificant after removing 1 outlier trial. The pooled prevalence of valvular regurgitation meeting Food and Drug Administration criteria (at least mild aortic regurgitation or at least moderate mitral regurgitation) among patients treated for >90 days was 12.0% compared with 5.9% for the unexposed group (prevalence odds ratio 2.2, 95% CI 1.7-2.7). The combined analyses also identified a small but statistically significant increase in mitral regurgitation not previously identified by individual studies (exposed 3.5%, unexposed 1.8%, prevalence odds ratio 1.6, 95% CI 1.05-2.3). Among patients exposed for <90 days, a trend toward more regurgitation was not statistically significant by either combined Food and Drug Administration criteria (exposed 6.8%, unexposed 5.8%, prevalence odds ratio 1.4, 95% CI 0.8-2.4) or by individual valve.

CONCLUSIONS

These data indicate that fenfluramine-associated valvular regurgitation is less common than initially reported, but still present in 1 of 8 patients treated for >90 days.

Major depressive episodes and diet pills

A variety of medications used to assist with weight loss have been implicated in the precipitation or induction of depressive symptoms and disorders. This is true of a large number of phenylethylamine agents possessing psychostimulant properties, non-phenylethylamine psychostimulants (e.g., caffeine) and the serotonergic agent, fenfluramine. There is, as yet, no substantial evidence linking the more modern weight loss drugs, sibutramine and orlistat, to the aetiology of major depression. Nevertheless, when these drugs are used, major depression will continue to be an important clinical consideration because of the elevated frequency with which major depression occurs in obese patients, the contribution that major depression may make to poor outcomes in non-pharmacological weight loss treatment and because of the interplay between symptoms of depression and weight loss treatment.

[Serotonin syndrome]

The serotonin syndrome is a hyperserotoninergic state resulting from an excess of intrasynaptic 5-hydroxytryptamine, induced by multiple psychotropic agents, but also non psychiatric drugs. It is a potentially dangerous and sometimes lethal condition. The clinical manifestations usually include cognitive, neuromuscular and autonomic features and are mediated by the action of serotonin on various subtypes of receptors. The main differential diagnosis is the neuroleptic malignant syndrome. Treatment is mainly supportive. No pharmacological agent has been definitely demonstrated really effective. However, reports of cases treated with the 5-HT2 blockers, including cyproheptadine or chlorpromazine have suggested that these agents could have some efficacy. Serotonin syndrome is a toxic condition which requires heightened clinical awareness among physicians in order to prevent, recognize, and treat the condition promptly.

Serotonin syndrome: a reported case

We describe a patient treated with SSRI and Ldopa, who developed agitation, rigidity, hyperreflexia, restlessness, autonomic instability, fever and finally death. CSF examination, MRI of the brain, laboratory investigations, except for serum CK, glycemia and WBC, were normal. His condition was thought to result from an central serotonin activity. The serotonin syndrome occurs following the use of serotomimetic agents (serotonin reuptake inhibitors, tricyclic and tetracyclic antidepressants, tryptophan alone or in combination with monoamine oxidase inhibitors).