Early depressive symptoms in cancer patients receiving interleukin 2 and/or interferon alfa-2b therapy

Investigating the hedonic effects of interferon-alpha on female rats using brain-stimulation reward

Interferon-alpha (IFN-alpha) is used as a front-line treatment for cancer and other diseases. Reports of depression as a consequence of IFN-alpha therapy scatter the literature, generating interest in the CNS disruptions elicited by this cytokine. In the present work, we investigated the short- and long-term effects of a single systemic injection of vehicle, 10, or 1000 units of IFN-alpha on temperature, body weight, food intake, sickness behaviours, locomotor activity, and brain stimulation reward (BSR) thresholds elicited from the ventral tegmental area in female Long-Evans rats. Pioneered for studying motivational processes, BSR has been exploited as a tool for tracking hedonic status in animal models of depression. In this study, the main findings were that IFN-alpha did not induce anhedonia as defined by no increase in frequency thresholds. However, the analyses of sickness behaviours unveiled a significant increase in piloerection in all sham control animals that received an IFN-alpha injection while the BSR animal scores remained relatively unchanged between pre- and post-injection days. This pattern was also evident in the overall total sickness behaviour scores. Our data suggest that a single exposure to IFN-alpha treatment in female rats elicits long-term somatic effects, without altering hedonic status.

The etiology of poststroke depression: a review of the literature and a new hypothesis involving inflammatory cytokines

Although poststroke depression is unlikely to represent a single disorder and numerous etiologies for different kinds of poststroke depression will likely emerge as the result of future research, we believe that a number of poststroke depressive disorders are likely to be the result of specific changes in brain pathology and neurophysiology. Nevertheless, there are relatively few hypotheses about the pathophysiology of poststroke depression. This paper, therefore, proposes a new hypothesis for poststroke depression involving increased production of proinflammatory cytokines resulting from brain ischemia in cerebral areas linked to the pathogenesis of mood disorders. This paper reviews the evidence supporting the hypothesis that proinflammatory cytokines are involved in the occurrence of stroke as well as mood disorders linked to the brain damage. The increased production of proinflammatory cytokines such as IL-1beta, TNF-alpha or IL-18 resulting from stroke may lead to an amplification of the inflammatory process, particularly in limbic areas, and widespread activation of indoleamine 2,3-dioxygenase (IDO) and subsequently to depletion of serotonin in paralimbic regions such as the ventral lateral frontal cortex, polar temporal cortex and basal ganglia. The resultant physiological dysfunction may lead to poststroke depression. Future investigations may explore this hypothesis through more extensive studies on the role of proinflammatory cytokines, such as IL-1beta, TNF-alpha or even IL-18, in patients with poststroke depression.

TNFalpha signaling in depression and anxiety: behavioral consequences of individual receptor targeting

BACKGROUND

Increased serum levels of TNFalpha and other pro-inflammatory cytokines have been found in patients with major depression and several other psychiatric conditions. In rodents, these cytokines produce symptoms commonly referred to as "sickness behavior." Some of these, including reduced feeding and decreased social and exploratory behavior, are reminiscent of those seen in depressed patients. Interpretation of these effects is complicated by the malaise caused by acute injections of pro-inflammatory cytokines, however. Thus, it is unclear whether cytokines are involved in the etiology of depressive symptoms.

METHODS

We used a panel of behavioral assays to assess TNFR1(-/-) and TNFR2(-/-) mice for anxiety and depression-like behaviors.

RESULTS

We show that deletion of either TNFR1 or TNFR2 leads to an antidepressant-like response in the forced swim test and that mice lacking TNFR2 demonstrate a hedonic response in a sucrose drinking test compared with wildtype littermates. In addition, deletion of TNFR1 leads to decreased fear conditioning. There were no differences in behavior in anxiety tests for either null mutant.

CONCLUSIONS

These results are consistent with the hypothesis that TNFalpha can induce depression-like symptoms even in the absence of malaise and demonstrate that both receptor subtypes can be involved in this response.

Interferon alpha for the treatment of advanced renal cancer

This paper is an overview on the place of IFN-alpha in metastatic renal cell carcinoma (MRCC). After a presentation of MRCC and the mode of action of IFN-alpha, the results of studies including IFN-alpha alone or in combination with IL-2, chemotherapy and other biological modifiers are presented. Finally, new trends for new drugs, including antiangiogenic therapies, are discussed.

Role of depression and inflammation in incident coronary heart disease events

Inflammatory biomarkers and depression have been proposed as novel coronary heart disease (CHD) risk markers. However, prospective studies have rarely assessed these 2 candidate CHD risk markers simultaneously in predicting incident CHD events. Therefore, although depression and elevated inflammatory biomarkers frequently covary, it is unclear how these risk markers relate to each other and to CHD event onset. The elucidation of these causal pathways has important clinical implications for patients who are depressed and/or have elevated inflammatory biomarkers. In this review, the publications examining the relations among depression, inflammation, and CHD events are discussed.

Interferon-induced depression and cognitive impairment in hepatitis C virus patients: a 72 week prospective study

OBJECTIVES

This study assessed the rates and course of depressive symptomatology and neurocognitive deficits in hepatitis C virus (HCV) patients undergoing interferon treatment, and explored possible predictors of depression and neurocognitive deficits.

DESIGN

In order to obtain objective assessments of depression, and to evaluate cognitive impairment, a 72-week prospective study, comprising 48 weeks of treatment and 24 weeks of post-treatment follow-up was utilized.

METHODS

A total of 50 HCV patients were assessed at baseline, and 14 times during pegylated interferon plus ribavirin treatment. Patients were also assessed on four timepoints after the termination of treatment. All patients have previously been treated for hepatitis C infection with interferon and were judged to be treatment resistant in these treatments. Depression was assessed using the Center for Epidemiological Studies Depression (CES-D) questionnaire, and patients were interviewed regarding problems with memory, attention and concentration.

RESULTS

Eighty-two per cent of interferon-treated patients developed severe enough depressive symptoms to meet the CES-D criteria for possible major depressive disorder (MDD). Possible MDD onset was most frequent by the first week of treatment, and almost all possible MDD cases were observed by week 8. More severe depressive symptoms at baseline were associated with higher depressive symptoms during interferon treatment. Thirty per cent of patients complained about cognitive problems. In half of these patients cognitive impairments were still reported after the termination of treatment. There was no association between depression during interferon treatment and subjective cognitive complaints.

CONCLUSIONS

The findings suggest that depression and cognitive impairments are frequent and persistent side-effects of interferon treatment in treatment-resistant patients.

The pathogenesis of clinical depression: stressor- and cytokine-induced alterations of neuroplasticity

Stressful events promote neurochemical changes that may be involved in the provocation of depressive disorder. In addition to neuroendocrine substrates (e.g. corticotropin releasing hormone, and corticoids) and central neurotransmitters (serotonin and GABA), alterations of neuronal plasticity or even neuronal survival may play a role in depression. Indeed, depression and chronic stressor exposure typically reduce levels of growth factors, including brain-derived neurotrophic factor and anti-apoptotic factors (e.g. bcl-2), as well as impair processes of neuronal branching and neurogenesis. Although such effects may result from elevated corticoids, they may also stem from activation of the inflammatory immune system, particularly the immune signaling cytokines. In fact, several proinflammatory cytokines, such as interleukin-1, tumor necrosis factor-alpha and interferon-gamma, influence neuronal functioning through processes involving apoptosis, excitotoxicity, oxidative stress and metabolic derangement. Support for the involvement of cytokines in depression comes from studies showing their elevation in severe depressive illness and following stressor exposure, and that cytokine immunotherapy (e.g. interferon-alpha) elicited depressive symptoms that were amenable to antidepressant treatment. It is suggested that stressors and cytokines share a common ability to impair neuronal plasticity and at the same time altering neurotransmission, ultimately contributing to depression. Thus, depressive illness may be considered a disorder of neuroplasticity as well as one of neurochemical imbalances, and cytokines may act as mediators of both aspects of this illness.

Sleep Deprivation and Psychosocial Impact in Acutely Ill Cancer Patients

Sleep is an important factor related to health and quality of life for all individuals. For people with cancer, sleep disturbances are common and are a source of distress. This article summarizes the problems and reviews the types, prevalence, etiology, risk factors, clinical sequelae, and management of sleep disturbances experienced by cancer patients. A comprehensive review of the literature is presented, along with direction for nursing practice and research.

Elevated serum cytokines correlated with altered behavior, serum cortisol rhythm, and dampened 24-hour rest-activity patterns in patients with metastatic colorectal cancer

PURPOSE

Incapacitating symptom burden in cancer patients contributes to poor quality of life (QOL) and can influence treatment outcomes because of poor tolerance to therapy. In this study, the role of circulating cytokines in the production symptoms in cancer patients is evaluated.

EXPERIMENTAL DESIGN

Eighty patients with metastatic colorectal cancer with either normal (group I, n = 40) or dampened (group II, n = 40) 24-hour rest/activity patterns measured by actigraphy were identified. Actigraphy patterns were correlated with QOL indices, serum cortisol obtained at 8:00 a.m. and 4:00 p.m. and with serum levels of transforming growth factor-alpha, tumor necrosis factor-alpha, and interleukin 6 (IL-6) obtained at 8:00 a.m. and analyzed in duplicate by ELISA. Cytokine levels and survival were also correlated.

RESULTS

Group II patients had significantly higher pre treatment levels of all three cytokines, displayed significantly poorer emotional and social functioning, had higher fatigue, more appetite loss, and poorer performance status compared with group I patients. Transforming growth factor-alpha (TGF-alpha) and IL-6 were significantly increased in the patients with WHO performance status >1 and in those with appetite loss. Fatigue was significantly associated with elevated TGF-alpha only. IL-6 was increased in those patients with extensive liver involvement and multiple organ replacement, and it was significantly correlated with dampened cortisol rhythm. In a multivariate analysis, IL-6 was correlated with poor treatment outcome.

CONCLUSIONS

Significant correlations were found between serum levels of TGF-alpha and IL-6, circadian patterns in wrist activity and serum cortisol and tumor-related symptoms in patients with metastatic colorectal cancer. These data support the hypothesis that some cancer patient's symptoms of fatigue, poor QOL, and treatment outcome are related to tumor or host generated cytokines and could reflect cytokine effects on the circadian timing system. This interplay between cytokine signaling pathways, the hypothalamic-pituitary-adrenal axis, the autonomic nervous system, and efferent pathways of the suprachiasmatic nucleus that control circadian physiology, opens the way to new rational interventions for symptom management in cancer patients.

The relationship of cancer symptom clusters to depressive affect in the initial phase of palliative radiation

Research on comorbidity across cancer symptoms, including pain, fatigue, and depression, could suggest if crossover effects from symptom-specific interventions are plausible. Secondary analyses were conducted on a survey of 268 cancer patients with recurrent disease from a northeastern U.S. city who were initiating palliative radiation for bone pain. Moderator regression analyses predicted variation in depressive affect that could be attributed to symptom clusters. Patients self-reported difficulty controlling each physical symptom over the past month on a Likert scale and depressive symptoms on a validated depression measure (Center for Epidemiologic Studies-Depression [CES-D]) over the past week on a four-category scale. An index of depressive affect was based on items of negative and positive affect from the CES-D. In predicting depressive affect, synergistic interactions of pain with fever, fatigue, and weight loss suggest separate pathways involving pain. A similar interaction with fever occurs when nausea was tested in place of pain. Further, the interaction between pain and fatigue is similar in form to the interaction between difficulty breathing and fatigue (when sleep is not a problem). Follow-up to the latter interaction reveals: 1) additional moderation by hypertension and palliative radiation to the hip/pelvis; and 2) a similar cluster not involving hypertension when appetite problems and weight loss were tested in place of fatigue. The significance and form of these interactions are remarkably consistent. Similar sickness mechanisms could be generating: 1) pain and nausea during fever; 2) pain and fatigue during weight loss; and 3) pain and breathing difficulty when fatigue is pronounced. Crossover effects from symptom-specific interventions appear promising.

Induced depressive behavior impairs learning and memory in rats

While it is generally accepted that cognitive processes such as learning and memory are affected by emotion, the impact of depression on learning and memory has rarely been directly studied in experimental animals. Effects of induced depressive behavior on learning and memory were determined in rats, using an open space swim test, a novel animal model of depressive behavior that is developed recently in our laboratory. The model indexes searching activity of the animals, with the induced depressive immobility behavior showing specific sensitivity to three major prototypic classes of antidepressants and a selective serotonin reuptake inhibitor. The induced depressive behavior in rats showed a delayed response to chronic antidepressant treatment and had a lasting effect on the ability of rats to learn and recall the learned experience. It impaired the subsequent ability of rats to learn and recall both a spatial water maze task and a multi-trial passive avoidance task. These impairments were all sensitive to antidepressant therapeutics, but not to buspirone, an anxiolytic. By way of contrast, the ability of the rats to sense and move to a visible platform and to escape from an unconditioned shock stimulus was neither impaired by inducing the depressive behavior nor altered by the drug treatment, suggesting that non-specific changes in sensorimotor ability were not involved. These impairments of learning and memory indicate that the depressive behavior-induced deficits show generalizability and are not context-limited. This animal model of depressive behavior shows promising potential as a screen for novel antidepressive therapeutics and as a disease model for revealing network/cellular/molecular mechanisms in the pathophysiology of depression and depression-induced cognitive deficits.

The phenomenology and treatment of interferon-induced depression

Interferon (IFN)-alpha, IFN-beta, and IFN-gamma are currently available for the treatment of malignancies, viral infections (e.g., hepatitis C virus), multiple sclerosis (MS), and skin conditions. In addition to their therapeutic effects, IFNs commonly cause various side effects. Most common among the side effects of IFN are "flu-like" symptoms such as chills, fever, and muscle soreness. However, IFN can also cause significant neuropsychiatric side effects, particularly symptoms of depression. A literature search was conducted in order to summarize current information on (1) the frequency, characteristics, and risk factors of IFN-induced depression, (2) possible biochemical mechanisms associated with IFN-induced depression, and (3) the treatment strategies for IFN-induced depression. Review of the literature suggests that symptoms of depression induced by IFN therapy, in particular IFN-alpha therapy, are common and can limit the treatment utility, often necessitating discontinuation of IFN therapy or the use of psychopharmacologic agents. Depression is also a suspected side effect of therapy with IFN-beta and IFN-gamma; however, the association has not been as convincingly confirmed. Importantly, IFNs affect neurochemical pathways putatively involved in the etiology of depression. While these depressive side effects usually resolve after the completion of IFN therapy, they can persist or reappear with dose escalations. It is recommended that health care providers, patients and their families be informed about the potential risk of the psychiatric disturbances that can occur with IFN-alpha therapy. Screening and monitoring, ideally using symptom rating scales for depression, and early antidepressant treatment intervention appear necessary to optimize IFN therapy for the majority of patients.

Sleep-wake disturbances in people with cancer part II: evaluating the evidence for clinical decision making

PURPOSE/OBJECTIVES

To evaluate the quality of evidence on sleep-wake disturbances in people with cancer as a basis for clinical decision making and to discuss implications of the evidence for oncology clinicians, educators, and researchers.

DATA SOURCES

Published, peer-reviewed articles.

DATA SYNTHESIS

Members of the 2001 Oncology Nursing Society (ONS) Advanced Practice Nurse Retreat Evidence-Based Practice Sleep Working Group selected and evaluated data sources using criteria and processes outlined by ONS.

CONCLUSIONS

The development of nursing science related to sleep-wake disturbances among people with cancer and the application of research findings to clinical decision making are limited by the quantity and quality of published evidence.

IMPLICATIONS FOR NURSING

Clinicians are challenged to develop a plan of care that includes the assessment of sleep-wake disturbances and interventions to address them. Nurse educators are challenged to include sleep-wake content and skills to evaluate empirical data and interventions for sleep-wake disturbances in degree and continuing education curricula. Nurse researchers are challenged to specify consistent conceptual and operational definitions of key variables in sleep-wake models, use measurement instruments with evidence of reliability and validity, and design clinical trials to test interventions for sleep-wake disturbances among people with cancer.

Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment

PURPOSE/OBJECTIVES

To provide an overview of normal sleep, describe common sleep disorders, and discuss underlying sleep regulatory processes and how cancer, cancer treatment, and associated patient responses may adversely affect sleep.

DATA SOURCES

Published peer-reviewed articles and textbooks.

DATA SYNTHESIS

The duration, structure, and timing of sleep have a profound impact on health, well-being, and performance. Patients with cancer may be at risk for disturbances in sleeping and waking resulting from disease- and nondisease-related circumstances that interfere with normal sleep regulation, including demographic, lifestyle, psychological, and disease- and treatment-related factors.

CONCLUSIONS

Patients with cancer are at high risk for sleep-wake disturbances.

IMPLICATIONS FOR NURSING

An understanding of normal sleep, sleep pathology, and the factors that can precipitate sleep disturbance provides a context for nurses to interpret sleep complaints in their patients, evaluate responses to sleep-promoting interventions, and guide decision making regarding referrals.

Depression and adipose polyunsaturated fatty acids in the survivors of the Seven Countries Study population of Crete

The purpose of the present study was to investigate the relation between adipose tissue polyunsaturated fatty acids, an index of long-term or habitual fatty acid dietary intake and depression. The sample consisted of 150 elderly males from the island of Crete. The subjects were survivors of the Greek Seven Countries Study group. The mean age was 84 years. The number of subjects with complete data on all variables studied was 63. Subjects were examined by the Preventive Medicine and Nutrition Clinic of the University of Crete. Depression was assessed through the use of the short form of the Geriatric Depression Scale (GDS-15). Depression correlated negatively with adipose tissue alpha-linolenic acid (C18:3n-3). Depressed subjects had significantly reduced (-10.5%) adipose tissue C18:3n-3 levels than non-depressed subjects. The observed negative relation between adipose tissue C18:3n-3 and depression, in the present study, appears to indicate increasing long-term dietary C18:3n-3 intakes with decreasing depression. This agrees with findings of other studies indicating an inverse relation between depression and consumption of fish and n-3 polyunsaturated fatty acids. This is the first literature report of a relation between adipose tissue C18:3n-3 and depression. Furthermore, this is the first report of a relation between adipose PUFA and depression in an elderly sample. Depression has been reported to be associated with elevated cytokines, such as, IL-1, IL-2, IL-6, INF-gamma and INF-alpha. Fish oil and omega-3 fatty acids, on the other hand, have been reported to inhibit cytokine production. The observed negative relation between adipose C18:3n-3 and depression, therefore, may stem from the inhibiting effect of C18:3n-3 or its long-chain metabolites on cytokine synthesis.

Reversible inactivation of the dorsal vagal complex blocks lipopolysaccharide-induced social withdrawal and c-Fos expression in central autonomic nuclei

Peripheral administration of lipopolysaccharide (LPS), a potent activator of the immune system, induces symptoms of behavioral depression, such as social withdrawal, concommitant with increases in c-Fos expression in central autonomic network nuclei. Previous studies implicated vagal visceral sensory nerves in transduction of immune-related signals relevant to for the induction of social withdrawal, a symptom of behavioral depression. Vagal sensory nerves terminate in the dorsal vagal complex (DVC) of the brainstem, a region that functions to integrate visceral signals and may also play a role in modulating arousal and affect. The objective of the current study was to determine whether the DVC contributes to immunosensory pathways driving symptoms of social withdrawal associated with LPS-induced behavioral depression, using a reversible lesion technique to temporarily inactivate the DVC. To assess the effects of DVC inactivation on LPS-induced social withdrawal and the subsequent changes in brain activation, we used behavioral assessment of social withdrawal, and analyzed c-Fos expression, a marker of neuronal activation, in the central nucleus of the amygdala (CEA), bed nucleus of the stria terminalis (BST), hypothalamic paraventricular nucleus (PVN), and ventromendial preoptic area (VMPO). Two hours following intraperitoneal LPS injection, there was a significant increase in c-Fos immunoreactivity in forebrain regions in animals treated with LPS. DVC inactivation completely blocked LPS-induced social withdrawal and dramatically reduced LPS-induced Fos expression in all four forebrain regions assessed. Collectively, these findings support the idea that the DVC acts as an immune-behavior interface between the peripheral stimuli and brain areas involved in modulating social behavior.

Does neuroimmune dysfunction mediate seasonal mood changes in winter depression?

BACKGROUND

Animal studies have demonstrated seasonal changes in immune function mediated by nocturnal melatonin duration as a biological signal for photoperiod. Recent research has highlighted the potential role of neuroimmune dysfunction in depressive disorders. The etiology of winter depression (seasonal affective disorder, or SAD) is not known, but a number of studies have provided support for both photoperiod and neurotransmitter hypotheses.

HYPOTHESIS

A new hypothesis is presented that links the SAD data on melatonin, photoperiod, and neurotransmitters by proposing that seasonal increases in proinflammatory cytokines are critical in the pathophysiology of winter SAD.

TESTING THE HYPOTHESIS

In SAD patients, but not healthy subjects: proinflammatory cytokines will be increased and the Th1/Th2 balance will be shifted to the left in winter compared to summer; neuroimmune function will be correlated with nocturnal melatonin duration in SAD patients; and light treatment will correct neuroimmune dysfunction.

IMPLICATIONS OF THE HYPOTHESIS

Diagnostic tests for SAD may be developed using cytokine assays; neuroimmune dysfunction may be predictors of response to treatments; new treatments for SAD (immune or anti-inflammatory treatment) may be developed.

Raised plasma levels of tumor necrosis factor alpha in patients with depression: normalization during electroconvulsive therapy

OBJECTIVE

To examine whether electroconvulsive therapy (ECT) could modulate tumor necrosis factor (TNF)alpha levels in patients with depressive disorders.

METHOD

Plasma levels of TNFalpha were analyzed in 23 depressed patients, mainly with severe depressive disorders, and in 15 sex- and age-matched healthy controls. Fifteen depressed patients were followed longitudinally with measurement of TNFalpha before, during, and after repeated ECT treatment. For comparison, TNFalpha levels were also analyzed longitudinally in the 8 depressed patients not receiving ECT.

RESULTS

Patients with depressive disorders had markedly raised TNFalpha levels compared with healthy controls. The clinical improvement during repeated ECT was accompanied by a gradual and significant decline in TNFalpha level, reaching levels comparable with those in healthy controls at the end of the study. Such a decline was not seen in the depressed patients not receiving ECT, who instead showed raised TNFalpha levels throughout the study period.

CONCLUSION

Our findings support an association between inflammation and TNFalpha in particular and severe depression, and suggest that ECT may down-regulate this immune activation.

Circulating alpha-2-macroglobulin levels and depression scores in patients who underwent abdominal cancer surgery

BACKGROUND

Although depression is a predominant health care problem, it is difficult to diagnose in patients who underwent abdominal cancer surgery. Relevance of elevated levels of serum of alpha-2-macroglobulin (A2M) to psychological depression has been recently suggested.

PATIENTS AND METHODS

Serum A2M levels were measured and depression scores were determined by the Hospital Anxiety and Depression Scale before and 1 year after abdominal cancer surgery in 45 patients.

RESULTS

Serum levels of A2M and depression scores were significantly (P = 0.0006, P = 0.0045, respectively) increased after total gastrectomy compared with preoperative values, whereas there was no interval change in both measurements of patients having colorectal resection. Of the patients who had undergone distal or total gastrectomy for gastric cancer, serum A2M concentrations in a depressed group were significantly higher (P = 0.028) than those in non-depressed group.

CONCLUSIONS

Patients with total gastrectomy are predisposed to depression, and circulating A2M elevation may be implicated in the development of postoperative depression in these patients.

Pathways linking depression, adiposity, and inflammatory markers in healthy young adults

Despite mounting evidence that depression increases risk for cardiovascular morbidity and mortality, little is known about the mechanisms responsible for this association. The current study examined the inter-relationships between depression, adiposity, and inflammatory molecules implicated in the pathogenesis of coronary heart disease. One hundred adults were enrolled. Half were clinically depressed; the others were matched controls with no history of psychiatric illness. All subjects were in excellent health, defined as having no acute infectious disease, chronic medical illness, or prescribed medication regimen. Structural equation modeling yielded support for a model in which depressive symptoms promote weight accumulation, which in turn activates an inflammatory response through two distinct pathways: expanded adipose tissue release of interleukin-6 and leptin-induced upregulation of interleukin-6 release by white blood cells (CFI =.99; NNFI =.99; RMSEA =.05). It did not support a sickness behavior model in which the inflammatory molecules arising from expanded adipose tissue promote depressive symptoms.

Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients

OBJECTIVES

This study investigated the relationships between a mindfulness-based stress reduction meditation program for early stage breast and prostate cancer patients and quality of life, mood states, stress symptoms, lymphocyte counts, and cytokine production.

METHODS

Forty-nine patients with breast cancer and 10 with prostate cancer participated in an 8-week MBSR program that incorporated relaxation, meditation, gentle yoga, and daily home practice. Demographic and health behavior variables, quality of life (EORTC QLQ C-30), mood (POMS), stress (SOSI), and counts of NK, NKT, B, T total, T helper, and T cytotoxic cells, as well as NK and T cell production of TNF, IFN-gamma, IL-4, and IL-10 were assessed pre- and postintervention.

RESULTS

Fifty-nine and 42 patients were assessed pre- and postintervention, respectively. Significant improvements were seen in overall quality of life, symptoms of stress, and sleep quality. Although there were no significant changes in the overall number of lymphocytes or cell subsets, T cell production of IL-4 increased and IFN-gamma decreased, whereas NK cell production of IL-10 decreased. These results are consistent with a shift in immune profile from one associated with depressive symptoms to a more normal profile.

CONCLUSIONS

MBSR participation was associated with enhanced quality of life and decreased stress symptoms in breast and prostate cancer patients. This study is also the first to show changes in cancer-related cytokine production associated with program participation.

Association study of the interleukin-1 beta (C-511T) genetic polymorphism with major depressive disorder, associated symptomatology, and antidepressant response

Proinflammatory cytokines, including interleukin (IL)-1beta, are suggested to have a role in the pathogenesis of major depressive disorder (MDD) and be related to the therapeutic effects of antidepressants. To elucidate a genetic predisposition of MDD, we studied biallelic polymorphism in the promoter region (position -511) of the IL-1beta gene in 157 patients with MDD and in 112 controls. We also examined the association of this polymorphism and fluoxetine therapeutic response in 119 MDD patients who received a 4-week fluoxetine treatment. No significant difference was found in the genetic polymorphism between MDD patients and controls. However, MDD patients who were homozygous for the -511T allele of the IL-1beta gene had a trend of less severity of depressive symptoms and more favorable fluoxetine therapeutic response than -511C carriers. Further study with a larger sample is needed to clarify the role of the IL-1beta genetic polymorphisms in the symptoms and treatment effects in MDD.

Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms

BACKGROUND

Cancers and cancer treatments produce multiple symptoms that collectively cause a symptom burden for patients. These symptoms include pain, wasting, fatigue, cognitive impairment, anxiety, and depression, many of which co-occur. There is growing recognition that at least some of these symptoms may share common biologic mechanisms.

METHODS

In November 2001, basic and clinical scientists met to consider evidence for a cytokine-immunologic model of symptom expression along with directions for future research.

RESULTS

The characteristics of cytokine-induced sickness behavior in animal models have much in common with those of symptomatic cancer patients. Sickness behavior refers to a set of physiologic and behavioral responses observed in animals after the administration of infectious or inflammatory agents or certain proinflammatory cytokines. In some cases, these responses can be prevented by cytokine antagonists. A combination of animal and human research suggests that several cancer-related symptoms may involve the actions of proinflammatory cytokines.

CONCLUSIONS

Based on the similarities between cancer symptoms and sickness behavior, the authors discussed approaches to further test the implications of the relationship between inflammatory cytokines and symptoms for both symptom treatment and symptom prevention.

Cytokines in depression and heart failure

OBJECTIVE

There is a convincing body of evidence linking depression, cardiovascular disease, and mortality. There is also growing evidence that depression is a risk factor for congestive heart failure (CHF) and that CHF patients with major depression have higher rates of mortality and repeat hospitalizations. Currently there are no proposed neurobiological or neuroimmune mechanisms for the comorbidity of heart failure and depression.

METHODS

This review focuses on the recent literature about the role of cytokines in CHF and depression as separate conditions. This review also attempts to identify the overlapping immunological mechanisms that have a potential for future research in the pathophysiology of comorbid depression and CHF.

RESULTS

Results of current studies suggest that cytokines exert deleterious effects on the heart and that soluble tumor necrosis factor (TNF) receptor 2 leads to reversal of the cardiotoxic effects of TNF, although the clinical significance of this is unclear. Major depression has been associated with alteration of various aspects of the innate immune system, including cellular components (such as microphages, neutrophils, and natural killer cells) and soluble mediators (such as acute-phase reaction proteins and cytokines). It is inconclusive whether antidepressants have immunoregulatory effects.

CONCLUSIONS

The literature has not yet addressed the role of cytokines in comorbid depression and CHF. But cytokines may provide a new avenue in understanding brain-body interaction in depression and heart failure.

Immunological research in clinical psychiatry: report on the consensus debate during the 7th Expert Meeting on Psychiatry and Immunology

There is convincing evidence that cytokines are involved in the physiology and pathophysiology of brain function and interact with different neurotransmitter and neuroendocrine pathways. The possible involvement of the immune system in the neurobiological mechanisms that underlie psychiatric disorders has attracted increasing attention in recent years. Thus in the last decade, numerous clinical studies have demonstrated dysregulated immune functions in patients with psychiatric disorders. Such findings formed the basis of the 7th Expert Meeting on Psychiatry and Immunology in Muenster, Germany, where a consensus symposium was held to consider the strengths and weaknesses of current research in psychoneuroimmunology. Following a general overview of the field, the following topics were discussed: (1) methodological problems in laboratory procedures and recruitment of clinical samples; (2) the importance of pre-clinical research and animal models in psychiatric research; (3) the problem of statistical vs biological relevance. It was concluded that, despite a fruitful proliferation of research activities throughout the last decade, the continuous elaboration of methodological standards including the implementation of hypothesis-driven research represents a task that is likely to prove crucial for the future development of immunology research in clinical psychiatry.

Cytokine-induced sickness behavior

The behavioral repertoire of humans and animals changes dramatically following infection. Sick individuals have little motivation to eat, are listless, complain of fatigue and malaise, loose interest in social activities and have significant changes in sleep patterns. They display an inability to experience pleasure, have exaggerated responses to pain and fail to concentrate. Proinflammatory cytokines acting in the brain cause sickness behaviors. These nearly universal behavioral changes are a manifestation of a central motivational state that is designed to promote recovery. Exaggerated symptoms of sickness in cancer patients, such as cachexia, can be life-threatening. However, quality of life is often drastically impaired before the cancer becomes totally debilitating. Although basic studies in psychoneuroimmunology have defined proinflammatory cytokines as the central mediators of sickness behavior, a much better understanding of how cytokine and neurotransmitter receptors communicate with each other is needed. Advances that have been made during the past decade should now be extended to clinical studies in an attempt to alleviate sickness symptoms and improve quality of life for cancer patients.

Cytokines and depression: the need for a new paradigm

Considerable clinical and experimental data support the existence of a relationship between cytokines and depression. At the experimental level, proinflammatory cytokines have been found to induce alterations in brain function analogous to the behavioral and biological abnormalities occurring in depressed patients, including social withdrawal, cognitive impairment, anhedonia, increased activity of the hypothalamus-pituitary-adrenal axis, altered neurotransmission, and cross-sensitization with stressors. At the clinical level, the evidence in favor of innate immune system activation in depressed patients is still controversial, despite accumulating evidence for an increased risk of depressive disorders in patients receiving recombinant cytokines for the treatment of cancer and viral infection. This last issue has received significant attention recently, given that the administration of therapeutic cytokines provides a quasi-experimental model for studying the mechanisms which underlie the effects of cytokines on mood, cognition, and neurovegetative functions. Although the vulnerability factors that account for the risk of depression have yet to be identified, tryptophan depletion, likely related to the induction of indoleamine 2,3-dioxygenase enzyme, may represent an important mediator for the development of depressed mood in cytokine-treated patients. This paper discusses ways in which these emerging data may lead to advances in the recognition and management of non-specific neurobehavioral symptoms associated with the development and progression of cancer.

Cytokines, stress and depressive illness: brain-immune interactions

Cytokines, signaling molecules of the immune system, have been implicated as a contributing factor for mood disorders such as depression. Several lines of evidence supporting this contention are briefly reviewed and caveats are introduced. Essentially, a relationship between cytokines and depression is based on the findings that: 1) proinflammatory cytokines (interleukin-1, interleukin-6, tumor necrosis factor-alpha) and bacterial endotoxins elicit sickness behaviors (e.g., fatigue, soporific effects) and symptoms of anxiety/depression that may be attenuated by chronic antidepressant treatment, 2) cytokines induce neuroendocrine and central neurotransmitter changes reminiscent of those implicated in depression, and these effects are exacerbated by stressors, 3) severe depressive illness is accompanied by signs of immune activation and by elevations of cytokine production or levels, and 4) immunotherapy, using interleukin-2 or interferon-alpha, promotes depressive symptoms that are attenuated by antidepressant treatment. It is argued that cytokine synthesis and release, elicited upon activation of the inflammatory response system, provoke neuroendocrine and brain neurotransmitter changes that are interpreted by the brain as being stressors, and contribute to the development of depression. Furthermore, such effects are subject to a sensitization effect so that a history of stressful experiences or cytokine activation augment the response to later challenges and hence the evolution of depression

Association between decreased serum tryptophan concentrations and depressive symptoms in cancer patients undergoing cytokine therapy

Cytokine therapy for cancer or viral diseases is accompanied by the development of depressive symptoms in a significant proportion of patients. Despite the increasing number of studies on the neurotoxic effects of cytokines, the mechanisms by which cytokines induce depressive symptoms remain largely unknown. In view of the relationship between neurotransmitter precursors and mood, the present study aimed at assessing the relationship between serum concentrations of the amino acids tryptophan and tyrosine, major precursors of serotonin and norepinephrine respectively, and depressive symptoms in cancer patients undergoing cytokine therapy. Sixteen cancer patients eligible to receive immunotherapy with interleukin-2 and/or interferon-alpha participated in the study. At baseline and after one week and one month of therapy, depressive symptoms were assessed using the Montgomery-Asberg Depression Rating Scale (MADRS), and blood samples were collected for the determination of the large neutral amino acids (LNAA) (tryptophan, tyrosine, valine, leucine, isoleucine, phenylalanine) which compete for transport across the blood-brain barrier. Serum concentrations of tryptophan as well as the tryptophan/LNAA ratio significantly decreased between baseline, one week and one month of therapy. The development and severity of depressive symptoms, especially anorexia, pessimistic thoughts, suicidal ideation and loss of concentration were positively correlated with the magnitude of the decreases in tryptophan concentrations during treatment. These findings indicate that the development of depressive symptoms in patients undergoing cytokine therapy could be mediated by a reduced availability of the serotonin relevant amino acid precursor, tryptophan.

Depression and adipose essential polyunsaturated fatty acids

The objective of the present study was to investigate the relation between adipose tissue polyunsaturated fatty acids, an index of long-term or habitual fatty acid dietary intake, and depression. The sample consisted of 247 healthy adults (146 males, 101 females) from the island of Crete. The number of subjects with complete data on all variables studied was 139. Subjects were examined at the Preventive Medicine and Nutrition Clinic of the University of Crete. Depression was assessed through the use of the Zung Self-rating Depression Scale. Mildly depressed subjects had significantly reduced (-34.6%) adipose tissue docosahexaenoic acid (DHA) levels than non-depressed subjects. Multiple linear regression analysis indicated that depression related negatively to adipose tissue DHA levels. In line with the findings of other studies, the observed negative relation between adipose tissue DHA and depression, in the present study, appears to indicate increasing long-term dietary DHA intakes with decreasing depression. This is the first literature report of a relation between adipose tissue DHA and depression. Depression has been reported to be associated with increased cytokine production, such as IL-1, IL-2, IL-6, INF-gamma and INF-alpha. On the other hand, fish oil and omega-3 fatty acids have been reported to inhibit cytokine synthesis. The observed negative relation between adipose DHA and depression, therefore, may stem from the inhibiting effect of DHA on cytokine synthesis.

Acute interferon beta-1b administration alters hypothalamic-pituitary-adrenal axis activity, plasma cytokines and leukocyte distribution in healthy subjects

It has been suggested that the immune-endocrine communication plays an important role in development and progression of multiple sclerosis (MS). Interferon beta (IFN beta-1b) treatment is the therapy of choice in patients suffering from relapsing remitting or secondary chronic progressive multiple sclerosis. While typical adverse events of IFN beta-1b treatment such as flu-like symptoms or fatigue are well studied, little is known about the acute changes in the immune and neuroendocrine system. Therefore, we analyzed the short-term effects of IFN beta-1b on cortisol, epinephrine, norepinephrine, prolactin and growth hormone (GH) plasma levels before and 4, 8 and 24 h after IFN beta-1b administration in healthy subjects. Moreover, we determined heart rate, blood pressure, body temperature, leukocyte and lymphocyte subsets and plasma levels of interleukin (IL)-1 beta, IL-6, IL-10 and tumor necrosis factor (TNF)-alpha. IFN beta-1b led to an increase in body temperature and heart rate, and in parallel, elevated cortisol, prolactin and GH plasma levels at 4 and 8 h after IFN beta-1b injection. There were no significant alterations in blood pressure, norepinephrine or epinephrine plasma levels. Simultaneously, IFN beta-1b injection led to an immediate granulocytosis while concomitantly decreasing peripheral lymphocytes, especially natural killer (NK) cells. At the same time, IL-6, IL-10 and TNF-alpha plasma levels showed an overall increase. Overall, cytokine administration exerts strong stimulatory effects on the hypothalamic-pituitary-adrenal (HPA)-axis that may contribute to the side effects of IFN beta-1b therapy and affect the efficacy of IFN beta-1b treatment.

Chronic psychological stress and the regulation of pro-inflammatory cytokines: a glucocorticoid-resistance model

This study examined whether chronic stress impairs the immune system's capacity to respond to hormonal signals that terminate inflammation. Fifty healthy adults were studied; half were parents of cancer patients, and half were parents of healthy children. Parents of cancer patients reported more psychological distress than parents of healthy children. They also had flatter diurnal slopes of cortisol secretion, primarily because of reduced output during the morning hours. There was also evidence that chronic stress impaired the immune system's response to anti-inflammatory signals: The capacity of a synthetic glucocorticoid hormone to suppress in vitro production of the pro-inflammatory cytokine interleukin-6 was diminished among parents of cancer patients. Findings suggest a novel pathway by which chronic stress might alter the course of inflammatory disease.

Quality of life in patients with malignant melanoma participating in a phase I trial of an autologous tumour-derived vaccine

Quality of life (QOL) plays an increasingly important role in the decision-making process and the ultimate acceptability of particular treatments for patients. We prospectively examined QOL in patients with advanced melanoma treated with surgery followed by heat-shock protein peptide complex 96 (HSPPC-96) vaccine, an active, patient-specific immunotherapy. QOL (the RAND 36-Item Health Survey; SF-36) and cancer-related intrusive thoughts (Impact of Event Scale; IES) were measured at the start of treatment, 3 weeks later on the final day of treatment, and at follow-up 1 month later in 30 patients with stage III or IV malignant melanoma. Mixed model analyses revealed no significant change over time in the SF-36 Physical or Mental Component Summary scores, or the IES scores. In comparisons with other populations, at the 1 month follow-up assessment, melanoma patients reported similar QOL to patients with metastatic renal cell carcinoma who received the same treatment, significantly worse QOL on the physical dimensions and similar QOL on the psychosocial and emotional dimensions compared with the general population, similar QOL to patients with type II diabetes, and significantly better QOL on all three dimensions than patients with congestive heart failure. There was also a significant negative association between IES scores at baseline and mental health scores at each time point ( < 0.002 for all). QOL remained stable during treatment with the HSPPC-96 vaccine. In addition, patients who reported high levels of cancer-related intrusive thoughts at the start of treatment reported worse mental health at the end of the treatment.

Interferon-induced fatigue in patients with melanoma: a pilot study of exercise and methylphenidate

PURPOSE/OBJECTIVES

To examine the effect of exercise and methylphenidate on fatigue, functional ability, and cognitive function in patients with melanoma.

DESIGN

Pilot study with comparison to historic controls.

SETTING

University-based cancer center.

SAMPLE

12 patients with melanoma entered and completed the study. The mean age was 44 years.

METHOD

Eligible patients were recruited before their first dose of interferon-a (IFN-a). Patients were instructed to take 20 mg sustained-release methylphenidate every morning and follow an aerobic exercise program four days a week for 15-30 minutes. Measures included a 12-minute walk, the Schwartz Cancer Fatigue Scale, Trail Maker Forms A and B, Medical Outcomes Study 36 Short Form, body weight, and daily logs. Fatigue scores were compared to usual care historical controls with melanoma receiving only IFN-a.

MAIN RESEARCH VARIABLES

Fatigue, functional ability, and cognitive function.

FINDINGS

66% adhered to exercise and methylphenidate; all adhered to exercise. Fatigue was lower for the exercise and methylphenidate group than historic controls. Functional ability increased 6% for all patients and 9% for the exercise and methylphenidate group. Cognitive function was stable for the exercise and methylphenidate group. The exercise-only group showed marked cognitive slowing.

CONCLUSION

The combination of aerobic exercise and methylphenidate may have a positive effect on fatigue, cognitive function, and functional ability. A larger sample size and randomized trial is needed to more rigorously evaluate the results of exercise and methylphenidate alone or in combination.

IMPLICATIONS FOR NURSING

Although further study is needed, a combination of exercise and methylphenidate may be a practical intervention for patients receiving IFN-a for melanoma.

Plasma interleukin-18 levels in patients with psychiatric disorders

There are an increasing number of reports on an association between the alteration of circulating cytokine levels and pathophysiology of psychiatric disorders. Plasma concentrations of interleukin (IL)-18 were measured in 13 nonmedicated patients with psychiatric disorders. There was a significant elevation of IL-18 levels in patients with major depression (n = 8) and panic disorder (n = 5), compared with normal controls. The mean IL-18 value of our psychiatric patients was comparable with that of various somatic disorders reported. We suggest that the elevation of plasma IL-18 levels reflects the increased production and release of IL-18 in the central nervous system under stressful settings. We propose that the measurement of IL-18 plasma levels may provide a useful index for the involvement of immune system in psychiatric disorders.

Cytokines and depression: an analogic approach

A growing body of evidence suggests that major depressive disorders may be accompanied by immune dysfunction and more particularly by an enhanced production of pro-inflammatory cytokines. The possible involvement of cytokines in depressive illness are based upon an analogic model. Pro-inflammatory cytokines are known to induce behavioral effects, and neuro-endocrine and immune activation similar to those observed in depression; these can be alleviated by antidepressant treatment. In this paper, we review research literature on the links between depressive illness and cytokine production and address further questions on this cytokine pathway. Further research is needed to see whether cytokines sustain specific depressive syndromes or whether cytokines induce depressive-like symptoms.

Association between immune activation and early depressive symptoms in cancer patients treated with interleukin-2-based therapy

The relationship between immune activation and the development of early depressive symptoms were studied in 33 cancer patients undergoing cytokine therapy. Patients were treated either with subcutaneous IL-2 administered alone (n=13) or in association with IFN-alpha (n=5), or with IFN-alpha alone administered subcutaneously at low doses (n=5) or intravenously at high doses (n=10). The intensity of depressive symptoms was assessed during a clinical interview carried out before the start of cytokine therapy and five days later using the Montgomery and Asberg Depression Rating Scale (MADRS). On the same days, blood samples were collected for each patient to measure serum concentrations of cytokines (IL-6, IL-10, IL-1ra) and cytokine-receptors (sIL-2R, LIF-R). Results showed that patients treated with IL-2 or IL-2+IFN-alpha displayed concomitant mood symptoms and increased serum cytokine levels during treatment. In these patients, the intensity of depressive symptoms at endpoint was positively correlated with the increases measured in serum levels of IL-10 between baseline and endpoint. IL-10 is an anti-inflammatory cytokine that is produced in response to the production of pro-inflammatory cytokines, and thereby reflects an inflammatory response. These results support the hypothesis of close relationship between depressive symptoms and the activation of the cytokine network.

Timing and specificity of the cognitive changes induced by interleukin-2 and interferon-alpha treatments in cancer patients

OBJECTIVE

Neuropsychological changes develop in patients treated by cytokine immunotherapy with interleukin-2 (IL-2) and interferon-alpha (IFN-alpha). However, the time course of appearance of these effects remains unclear, and their precise nature is still incompletely characterized. The objective of this study was to assess and characterize the early cognitive changes induced by IL-2 and IFN-alpha in cancer patients at the end of the first week of treatment and to investigate the subsequent evolution of these changes.

METHODS

The study was conducted in 47 cancer patients who received subcutaneous IL-2, administered alone (N = 17) or with IFN-alpha (N = 7), or IFN-alpha alone, administered subcutaneously at low doses (N = 7) or intravenously at high doses (N = 16). An automated battery of neuropsychological tests (Cambridge Neuropsychological Test Automated Battery) was used to measure reaction time, spatial working memory, and planning tasks. Cognitive tests were performed before treatment (day 1) and after 5 days (day 5) and 1 month of treatment.

RESULTS

On day 5, patients treated with IL-2 alone had impaired spatial working memory and lower accuracy of planning abilities. In contrast, patients treated with IFN-alpha did not show any impairment in performance accuracy in these tasks but showed longer latencies in the test of reaction time. Most of these early alterations persisted at the end of the first month of treatment without any obvious sign of worsening.

CONCLUSIONS

These findings suggest the existence of early differential neuropsychological changes in patients treated with IL-2 and IFN-alpha.

Cytokine-induced sickness behavior: mechanisms and implications

Sickness behavior refers to a coordinated set of behavioral changes that develop in sick individuals during the course of an infection. At the molecular level, these changes are due to the brain effects of proinflammatory cytokines such as interleukin-1 (IL-1) and tumor necrosis factor alpha (TNFalpha). Peripherally released cytokines act on the brain via a fast transmission pathway involving primary afferent nerves innervating the bodily site of inflammation and a slow transmission pathway involving cytokines originating from the choroid plexus and circumventricular organs and diffusing into the brain parenchyma by volume transmission. At the behavioral level, sickness behavior appears to be the expression of a central motivational state that reorganizes the organism priorities to cope with infectious pathogens. There is evidence that the sickness motivational state can interact with other motivational states and respond to nonimmune stimuli probably by way of sensitization and/or classical conditioning. However, the mechanisms that are involved in plasticity of the sickness motivational state are not yet understood.

Cytokine-induced sickness behavior: where do we stand?

Sickness behavior refers to the coordinated set of behavioral changes that develop in sick individuals during the course of an infection. At the molecular level, these changes are due to the effects of proinflammatory cytokines, such as interleukin-1 (IL-1) and tumor necrosis factor-alpha (TNFalpha), in the brain. Peripherally released cytokines act on the brain via a fast transmission pathway involving primary afferent nerves innervating the body site of inflammation and a slow transmission pathway involving cytokines originating from the choroid plexus and circumventricular organs and diffusing into the brain parenchyma by volume transmission. At the behavioral level, sickness behavior appears to be the expression of a central motivational state that reorganizes the organism's priorities to cope with infectious pathogens. There is clinical and experimental evidence that activation of the brain cytokine system is associated with depression, although the exact relationship between sickness behavior and depression is still elusive.

[The contribution of alcohol to nutrition: addition or substitution according to cultural origins]

The relation of alcohol intake to diet is analyzed through multiple linear regression for a sample of 475 males living in Geneva. Control variables are age, relative weight index, marital status and employment status. Whereas alcohol is associated with higher dietary intake for people of mediterranean origin, it tends to replace food calories for natives of german speaking areas.