Evidence for a decline with age in behavioral responsivity to the serotonin agonist, m-chlorophenylpiperazine, in healthy human subjects

Pharmacological approaches to the management of panic disorder in older patients: a systematic review

INTRODUCTION

Recommendations for treating panic disorder (PD) in older patients are scarce. The authors have systematically reviewed whether several recommended medications are superior to others and their optimal doses in this age group.

METHODS

A database search of studies involving patients with PD with/without agoraphobia aged ≥ 60 years was carried out using PubMed, PsycINFO, Embase, and Clinical Trials.gov, from their inception dates to 1 March 2023. Only four (published from 2002 to 2010) of the 1292 records screened were included. A risk of bias assessment was provided. This systematic review was performed using The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

RESULTS

Two studies were randomized clinical trials, whereas two were open-label, including paroxetine, citalopram, escitalopram, and sertraline; three studies reported short-term evaluations, whereas one study included a 26-week follow-up. Medications provided benefits, with good tolerability. Preliminary results suggested greater benefits of paroxetine in reducing panic attacks vs. cognitive - behavioral therapy, and an earlier decrease in PAs with escitalopram vs. citalopram. Risk of bias was considerable.

CONCLUSIONS

The pharmacological management of PD in older patients has received no attention. Findings are scant, dated, and affected by methodological flaws; thus, they do not provide significant advances.

Genetic characterization of low-pathogenic avian influenza viruses isolated on the Izumi plain in Japan: possible association of dynamic movements of wild birds with AIV evolution

The Izumi plain in Kagoshima Prefecture, Japan, is an overwintering site of endangered cranes (hooded cranes and white-naped cranes) and of many other migratory birds (including wild ducks) that are considered carriers of avian influenza viruses (AIVs). To assess the risks of a highly pathogenic avian influenza outbreak in the crane populations, we tested various environmental samples for AIVs in this area. In the 2014-2015 winter season, we isolated one AIV of the H6N2 subtype from the cranes' roost water and two AIVs of the H11N9 subtype from a crane fecal sample and a cloacal swab of a dead spot-billed duck. Genetic analysis of these AIV isolates indicated that our H6N2 isolate is genetically close to AIVs isolated from wild birds in Southeast Asian countries, except that the PB1 and NS genes belong to the North American virus lineage. All genes of the two H11N9 isolates are related to AIVs belonging to the Eurasian virus lineage. Notably, in our phylogenetic trees, H11 HA and N9 NA genes showing high sequence similarity to the corresponding genes of isolates from wild birds in South Africa and Spain, respectively, did not cluster in the major groups with recent wild-bird isolates from East Asia. These results suggest that AIVs with viral gene segments derived from various locations and bird species have been brought to the Izumi plain. These findings imply a possible association of dynamic movements of wild birds with AIV evolution.

Carbon dioxide inhalation induces dose-dependent and age-related negative affectivity

Background

Carbon dioxide inhalation is known to induce an emotion similar to spontaneous panic in Panic Disorder patients. The affective response to carbon dioxide in healthy subjects was not clearly characterized yet.

Methodology/Principal Findings

Sixty-four healthy subjects underwent a double inhalation of four mixtures containing respectively 0, 9, 17.5 and 35% CO₂ in compressed air, following a double blind, cross-over, randomized design. Affective responses were assessed according to DSM IV criteria for panic, using an Electronic Visual Analogue Scale and the Panic Symptom List. It was demonstrated that carbon dioxide challenges induced a dose dependent negative affect (p<0.0001). This affect was semantically identical to the DSM IV definition of panic. Older individuals were subjectively less sensitive to Carbon Dioxide (p<0.05).

Conclusions/Significance

CO₂ induced affectivity may lay on a continuum with pathological panic attacks. Consistent with earlier suggestions that panic is a false biological alarm, the affective response to CO₂ may be part of a protective system triggered by suffocation and acute metabolic distress.

A meta-analysis of cortisol response to challenge in human aging: importance of gender

An increased cortisol response to challenge is associated with a variety of age-related disorders such as Alzheimer's disease, depression, diabetes, metabolic syndrome, and hypertension. Among the healthy elderly, an increased cortisol response to challenge may be a risk factor for developing these age-related disorders. We searched Pubmed, Embase, PsychInfo, Biosis, and Digital Dissertations (January 1966-June 2003) and included 45 parallel-group (young vs. old subjects) studies that used either a pharmacological or psychological challenge in healthy volunteers and measured cortisol response to challenge. We calculated effect sizes (Cohen's d) for the standardized mean differences between groups. Compared to younger controls (n=670, mean age 28 years +/-5), older subjects (n=625, 69+/-6) showed a larger cortisol response to challenge defined as stronger response to stimulation or less inhibition after a suppression test (d=0.42, 95% confidence interval (CI), 0.26-0.57). The effect of age on cortisol release was significantly stronger in women (d=0.65, 95% CI 0.34-0.97) than men (d=0.24, 95% CI 0.02-0.47). Our results demonstrate that aging increases the cortisol response to challenge. This effect of age on cortisol response is almost three-fold stronger in women than men. Prospective studies should explore whether the higher cortisol response in the elderly is a risk factor for developing neuropsychiatric and medical disorders.

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.

Central serotonergic effects of m-chlorophenylpiperazine (mCPP) among normal control adolescents

Central serotonin function was studied among 21 adolescents (12 males, 9 females), mean age 14.4+/-1.5 years. A placebo-controlled design was used to measure three neuroendocrine hormones (prolactin, cortisol and growth hormone) following a challenge with the central serotonergic agonist m-chlorophenylpiperazine (mCPP). Infusion of mCPP resulted in augmented prolactin, cortisol and growth hormone release. Gender effects were significant for prolactin, cortisol and growth hormone. Females had higher baseline prolactin without significant interactions with infusion or time, cortisol levels were higher in males than in females at all time points without significant interactions with infusion or time, and the augmented growth hormone response to mCPP was limited to males. Systolic and diastolic blood pressure, heart rate and temperature were all mildly elevated following mCPP infusion. Side effects to mCPP infusion were mild and lasted approximately 20 min. We conclude that mCPP is useful in the study of serotonergic neuroendocrine hormones in adolescents, is well tolerated, and the levels of prolactin, cortisol and growth hormone are influenced by gender.

Serotoninergic involvement in gonadotropin and TSH secretion in normal cycling and postmenopausal women

We investigated the influence of a specific serotonin receptor blockade on pituitary hormone secretion in normal cycling women and postmenopausal women not receiving hormone replacement therapy. Serotonin receptor blockade was performed by using the HT-3 receptor subtype antagonist ondansetron as an i.v. bolus injection of 8 mg. Blood samples were taken before as well as 20, 30 and 40 min after ondansetron administration for the estimation of LH, FSH, and TSH. We could not find any hormonal changes in the normal cycling women. The postmenopausal women showed a significant decline in LH secretion, whereas FSH and TSH levels remained unchanged. Our results suggest serotoninergic involvement in LH secretion in postmenopausal hypoestrogenic hypergonadism.

Serotonin, cerebral blood flow, and cerebral metabolic rate in geriatric major depression and normal aging

While there is substantial evidence for abnormalities in serotonin (5-HT) neurotransmission in major depressive disorder (MDD), almost all of the findings derive from studies of young adults. Moreover, relatively little research has assessed brain 5-HT transmission in vivo. Neuroendocrine studies do not permit evaluation of a range of brain regions, but only the limited circuitry associated with hormone release. Data from autopsy studies are limited by the difficulties of assessment of the acute clinical picture before death, and by post-mortem artifacts. In vivo neuroimaging techniques overcome many of the methodological limitations of both these approaches. There is a large body of imaging data indicating regional cerebral blood flow (rCBF) and cerebral metabolic rate (rCMR) decrements both with aging and in patients with MDD. While the physiological bases for these phenomena are largely unknown, changes in brain 5-HT function may be involved. Neuroanatomical studies have revealed an intricate network of 5-HT-containing neurons within the cerebral microvasculature, with physiological evidence for serotonergic control of both rCBF and rCMR. Acute pharmacological challenges are available to probe brain 5-HT function. Such paradigms, using neuroendocrine responses as endpoints, have been of some utility in predicting outcome with antidepressant treatment. The role of 5-HT dysregulation in geriatric MDD takes on more importance given concerns regarding putative reduced efficacy of serotonin-specific reuptake inhibitors (SSRIs) in this population. If this is due to diminished responsivity of 5-HT systems, then the ability to identify antidepressant nonresponders via 5-HT challenge in combination with neuroimaging measures may have important clinical utility.

The influence of ondansetron and m-chlorophenylpiperazine on scopolamine-induced cognitive, behavioral, and physiological responses in young healthy controls

BACKGROUND

There is evidence from animal and human experiments that learning and memory come under the separate influence of both cholinergic and serotonergic pathways. We were interested in learning whether serotonergic drugs could attenuate or exacerbate the memory-impairing effects of anticholinergic blockade in humans.

METHODS

The selective serotonin 5-HT3 receptor antagonist ondansetron (0.15 mg/kg i.v.) and the serotonergic agent m-chlorophenylpiperazine (m-CPP; 0.08 mg/kg i.v.) were administered in combination with the anticholinergic agent scopolamine (0.4 mg PO) and compared to scopolamine alone in 10 young, healthy volunteers. Testing occurred on three separate days.

RESULTS

As expected, i.v. administration of scopolamine induced significant impairments in episodic memory and processing speed; however, these scopolamine-induced cognitive deficits were not attenuated by pretreatment with i.v. ondansetron (0.15 mg/kg), nor were they exacerbated by administration of i.v. m-CPP (0.8 mg/kg) in addition to scopolamine; however, administration of i.v. m-CPP was followed by a significant increase of self-rated functional impairment, altered self-reality, and dysphoria ratings, and scopolamine's effect on pupil size was potentiated.

CONCLUSIONS

Together, these results suggest that in young, healthy volunteers scopolamine-induced changes of cognitive performance are only minimally modulated by the serotonergic effects on ondansetron and m-CPP. Further studies with older controls are needed to test whether these findings may be influenced by age.

Daily administration of m-chlorophenylpiperazine to healthy human volunteers rapidly attenuates many of its behavioral, hormonal, cardiovascular and temperature effects

The serotonergic agent meta-chlorophenylpiperazine (m-CPP) increases temperature and plasma ACTH and other hormones and decreases social interaction, locomotor activity and food intake in rats, most likely via stimulation of 5-HT2C receptors. Repeated daily administration of m-CPP to rats induces rapid tolerance to these effects of m-CPP. As m-CPP has been used in challenge tests and in preliminary treatment trials in humans, we evaluated the possible development of tolerance to m-CPP in ten healthy human volunteers using a double-blind, random assignment crossover study of placebo versus daily m-CPP infusions. Psychological and physical symptoms of anxiety, temperature, pupil size, diastolic blood pressure, and plasma ACTH, cortisol, and prolactin concentrations were increased by the first administration of m-CPP (0.08 mg/kg) compared to placebo. All of these responses were attenuated on m-CPP days 2 and 3. Plasma m-CPP levels did not differ across the 3 m-CPP days. Repeated m-CPP administration thus appears to induce rapid tolerance to its behavioral and physiological effects in humans. Further investigations of the mechanisms involved in the development of subsensitivity to m-CPP may contribute to increased understanding of the regulation of serotonin-mediated functions and of anxiety disorders.

Cerebral metabolic effects of serotonin drugs and neurotoxins

The functional effects of serotonin (5-HT) drugs and toxins on regional cerebral metabolic rates for glucose (rCMRglc) have been determined in rats with the in vivo, quantitative, autoradiographic [14C]2-deoxyglucose technique. Serotonin agents produced rCMRglc patterns different and more specific that one would predict from binding studies. At low doses 5-HT1 agonists reduced rCMRglc in limbic areas and at high doses increased rCMRglc in brain motor regions. The 5-HT2 agonists dose-dependently decreased rCMRglc in proencephalic areas and increased it in thalamic nuclei. 5-HT3 receptor antagonism resulted in rCMRglc decreases in limbic, auditory and visual areas and agents with 5-HT3 receptor activity increased rCMRglc in brain regions with high 5-HT3 receptor densities. Serotonin anxiolytics (e.g. azapirones) and antidepressants (e.g. tryciclic and non-tryciclic 5-HT reuptake inhibitors) reduced rCMRglc selectively in limbic areas and in brainstem monoaminergic nuclei. Dose, time from administration, receptor affinity, behavioral and neurochemical correlates, 5-HT system lesion and circulating glucocorticoid were all relevant factors in determining the rCMRglc effects of 5-HT drugs. Acutely neurotoxic amphetamines markedly increased rCMRglc in brain regions such as the nucleus accumbens that are thought to mediate amphetamine reinforcing properties; on the long term, toxic or electrolytic lesions or chronic treatment with 5-HT agonists produced minimal rCMRglc alterations in spite of marked and persistent changes in 5-HT function. In lesioned or chronically treated rats, acute challanges with 5-HT and non 5-HT agonists demonstrated specific deficits that were not detected in a resting state. Serotonin neuromodulation has been studied in humans by using positron emission tomography with 15O-water. Sequential measurements of regional cerebral blood flow (rCBF) were obtained during combined pharmacological challange with the 5-HT1A agonist buspirone and cognitive activation. Buspirone increased a memory related rCBF activation in task specific regions. This technique can provide a strong theoretical basis for the understanding of 5-HT drug mode of action in normal human brain and in neuropsychiatric diseases. Brain metabolism studies in animals will still be needed to elucidate the factors (e.g. pharmacokinetic and pharmacodynamic) relevant to the cerebral response to 5-HT drugs in humans.

Serotonin and the regulation of hypothalamic-pituitary-adrenal axis function

That serotonin (5HT) is involved in regulating hypothalamic-pituitary- adrenal axis (HPA) function has long been recognized. A variety of drugs including precursors of 5HT such as 5HTP, drugs which release 5HT such as fenfluramine and drugs which act directly on 5HT receptors such as ipsapirone increase cortisol and ACTH concentrations. There is a general assumption that such stimulation occurs at a hypothalamic level. However, our increasing understanding of the complex interplay between 5HT and the HPA raises questions as to the validity of this simple model. An increasing volume of experimental research indicates that 5HT can act directly on the adrenal gland and possibly on the anterior pituitary as well. These findings have major implications for the interpretation of neuroendocrine studies of 5HT conducted in psychiatric conditions, such as depression.

Neuroendocrine responses to serotonergic agonists as indices of the functional status of central serotonin neurotransmission in humans: a preliminary comparative analysis of neuroendocrine endpoints versus other endpoint measures

The status of central serotonergic neurotransmission and of specific serotonin (5-HT) receptor subtype sensitivity has been inferred from neuroendocrine and other endpoint responses to serotonergic agents given to humans. The question of whether changes in neuroendocrine responsivity to the 5-HT2C partial agonist, meta-chlorophenylpiperazine (m-CPP), are accompanied by similar changes in other endpoints (temperature, behavior) is addressed in this brief review of published studies. These studies were selected based on the following criteria: (1) neuroendocrine (cortisol, prolactin increases) and at least one other endpoint (behavior and/or temperature increases) were measured in the same populations, and (2) statistically significant changes were observed after m-CPP in the healthy volunteer control or pre-long-term-treatment subjects. Parenthetically, in the 13 of 14 studies that reported both prolactin and cortisol responses, the results were congruent for the two neuroendocrine measures in 12 of the 13 (92%). However, neuroendocrine versus behavioral results were in agreement in fewer (7 of the 13) studies (54%). Neuroendocrine vs. temperature results were non-concordant in all 4 of the studies which included temperature measurements. These generally disparate findings suggest that these different endpoints may reflect brain serotonin neuroanatomic and receptor subsystem complexity and/or m-CPP's complex pharmacological properties. Thus, these neuroendocrine response measures cannot at this time be considered a general index of the other response measures, nor necessarily an index of the functional status of central serotonergic neurotransmission until this is established by more direct experimental investigations.

Complex effects of age and gender on hypothermic, adrenocorticotrophic hormone and cortisol responses to ipsapirone challenge in normal subjects

The effects of a challenge dose of the 5-HT1A agonist, ipsapirone (0.3 mg per kg body weight), or placebo on body temperature and on adrenocorticotrophic hormone (ACTH) and cortisol release, were examined in 30 normal subjects (14 males, 19-74 years and 16 females, 22-69 years) using a randomized, double blind design. Irrespective of age or gender, ipsapirone induced a significant reduction in body temperature relative to placebo and a significant increase in ACTH and cortisol release. Maximal temperature reduction by ipsapirone was significantly blunted in older subjects and was inversely related to age. There was no gender difference in the hypothermic response to ipsapirone. ACTH and cortisol responses showed an opposite impact of aging in males and females. Whereas both responses diminished with age in male subjects, they increased with age in females. The cortisol response of older females was significantly larger than that of all the other subjects. Adverse effects of ipsapirone were also more marked in elderly females and were correlated with ACTH and cortisol responses. These findings should be taken into consideration in the use of ipsapirone and other 5-HT1A agonists as challenge procedures for studying central serotonergic function in depression and other disorders. Careful matching of control and experimental subjects is indicated so as to avoid spurious results which reflect the effects of age and gender rather than the pathophysiology of the disorders being investigated.

Serotonergic modulation of anticholinergic effects on cognition and behavior in elderly humans

Cholinergic neurotransmission is thought to be modulated by serotonin as documented in animal and human studies. We examined the effects of the muscarinic antagonist scopolamine (0.4 mg IV) given alone or together with the serotonin mixed agonist/antagonist m-chlorophenylpiperazine (m-CPP, 0.08 mg/kg IV), and the selective 5-HT3 receptor antagonist ondansetron (0.15 mg/kg IV). Ten normal elderly volunteers each received five separate pharmacologic challenges (placebo, ondansetron, scopolamine, scopolamine+ondansetron, and scopolamine+m-CPP). Cognitive, behavioral, and physiologic variables were analyzed using repeated measures analysis of variance. The acute effects of scopolamine in certain cognitive, behavioral, and physiological measures were significantly exaggerated by the addition of m-CPP. Scopolamine's cognitive effects were unaffected by ondansetron at the dose tested, nor did ondansetron given alone affect basal cognitive performance. This pilot study suggests that the serotonin mixed agonist/antagonist m-CPP may influence cholinergic neurotransmission. The changes associated with the combination of scopolamine and m-CPP do not appear to be secondary to simple pharmacokinetic alterations and suggest a complex interaction between the cholinergic and serotonergic systems centrally.

Neuroendocrine probes of serotonergic function: a critical review

Neuroendocrine probes of serotonergic function are based on the premise that serotonin (5-HT) exhibits an excitory influence on the release of certain anterior pituitary hormones and that the extent of release of these hormones following a challenge with a 5-HT agonist would provide an index of central 5-HT activity. This paper critically reviews studies published to date on healthy volunteers to assess the validity of tests of serotonergic function. Using standardized criteria, it is concluded that although extensive data is available on 5-HT-neuroendocrine probes, there is no test that is currently available that would fulfil all the proposed requirements for a test to be acceptable, although ipsapirone, m-chlorophenylpiperazine (m-CPP), and possibly fenfluramine challenge tests come very close. The rapid development and availability of more specific and stereo-selective 5-HT agonists/antagonists seem to indicate that it will not be too long before a valid neuroendocrine test for the assessment of serotonergic function emerges.

Effect of fenfluramine on mood: a double-blind placebo-controlled trial

Depressed patients (n = 10), schizophrenics (n = 6), and normal control subjects was (n = 9) were administered fenfluramine hydrochloride (FF) (60 mg/os) or placebo in the context of a randomized, double-blind crossover trial. No effect of FF on mood or activation was detected over a 6-hr period. A previous report claiming acute antidepressant effects of FF in depressed subjects was not confirmed.

m-Chlorophenylpiperazine as a probe of serotonin function

m-Chlorophenylpiperazine (mCPP) is the most extensively used probe of serotonin function in psychiatry. This article reviews its in vitro and in vivo properties in animals, normal human subjects, and psychiatric patients. mCPP is a safe, reliable, direct 5-hydroxytryptamine (5HT) agonist, which may be used to evaluate 5HT receptor sensitivity. It causes a consistent, dose-dependent elevation of ACTH, cortisol, and prolactin levels in both animals and humans, as well as increased body temperature in man. It also causes a variety of behavioral effects, depending on the population studied. These effects are probably 5HT receptor-related, although specific 5HT receptor subtype mechanisms have not yet been established. mCPP may be considered an important addition to armamentarium of 5HT receptor probes, which is especially useful until more selective 5HT receptor agonists have been tested.

Neuroendocrine responses to serotonergic agents in alcoholics

Previous studies have suggested a possible deficit in serotonergic function in alcoholism. In order to further assess the serotonergic system in alcoholism, the plasma cortisol and prolactin (PRL) responses following 6-chloro-2-[1-piperazinyl]pyrazine (MK-212), a direct-acting serotonin2 (5-HT2)/5-HT1c receptor agonist, L-5-hydroxytryptophan (L-5-HTP), a precursor of 5-HT, and placebo were compared in male alcoholics and normal controls. The increase in plasma cortisol following L-5-HTP was significantly lower in the alcoholic subjects compared with the normal controls. The plasma PRL, but not the plasma cortisol response, following MK-212 was also significantly lower in the alcoholics. L-5-HTP had no significant effect on plasma PRL levels in either group. The basal plasma cortisol and PRL concentrations of the alcoholics and normal controls were not significantly different. These data are consistent with previous reports of a serotonergic abnormality in alcoholism.

Effects of daily oral m-chlorophenylpiperazine in elderly depressed patients. Initial experience with a serotonin agonist

Six patients (mean age 62.5 +/- 7.6 years) with major depression were treated for 2 weeks with the serotonin agonist m-chlorophenylpiperazine (m-CPP), 80 mg/day in a double-blind, placebo-controlled, crossover-design pilot study. Two patients showed clinically significant improvement in depressive symptoms during active drug treatment, whereas two others showed modest effects. All patients tolerated the drug, with no major side effects and no changes in vital signs or in liver, renal, thyroid, or hematological function. Further studies are needed to determine the characteristics of the possible antidepressant effects of m-CPP; such work may yield greater understanding of the role of serotonin in affective and other psychiatric disorders.