Is S-Adenosyl Methionine (SAMe) for Depression Only Effective in Males? A Re-Analysis of Data from a Randomized Clinical Trial

OBJECTIVE

The aim of this study was to examine whether gender differences may have affected treatment response to S-adenosyl methionine (SAMe) in a recent failed randomized clinical trial (RCT) for adults with major depressive disorder.

METHODS

Data from a 2-site, 12-week, double-blind RCT (n=189) assessing the efficacy of SAMe vs. placebo and a comparator selective serotonin reuptake inhibitor (escitalopram) were subjected to post-hoc analyses to evaluate effects of patient gender on treatment response.

RESULTS

When assessing the efficacy outcomes within each gender separately, SAMe was superior to placebo among males (n=51), but not among females (n=62). Males showed a significant reduction of depression severity from baseline to study endpoint on the 17-item Hamilton Depression Rating Scale (4.3 point difference; p=0.034; d=0.95), while females did not show significant change. This finding emerged despite equivalence on baseline measures of depression severity between the gender groups.

CONCLUSION

RESULTS of this secondary data analysis suggest that gender might impact the antidepressant efficacy of SAMe, with greater therapeutic effect found in males. The underlying mechanism is still relatively unknown. Further work is needed to replicate this observation in independent samples.Clinicaltrials.gov identifier: NCT00101452.

C-reactive protein, early life stress, and wellbeing in healthy adults

OBJECTIVE

To determine whether C-reactive protein (CRP) can serve as a marker for alterations in immune function prior to the manifestation of significant psychiatric and medical disorders.

METHOD

Ninety-two healthy adults were recruited from the community and determined to be free of psychiatric or medical disorders. The concentration of plasma CRP from a single resting sample was examined in relation to current mental and physical health as well as to self-reported history of early life adversity.

RESULTS

C-reactive protein showed a significant positive correlation with body mass index (BMI; r = 0.477, P < 0.001). Non-specific pain, fatigue, and lower overall quality of physical health were all associated with higher CRP concentrations (all P < 0.05 or P < 0.01), after controlling for effect of BMI and other relevant covariates. Subthreshold depression symptoms and other indices of mental/emotional wellbeing were not associated with CRP, nor was CRP significantly linked to any measures of early life adversity.

CONCLUSION

Lower-quality physical health and wellbeing, but not the presence of mood/anxiety symptoms or early life stress (ELS), were significantly related to plasma CRP. Elevated CRP does not appear to be a fundamental consequence of ELS among healthy adults.

Altered response to neuroendocrine challenge linked to indices of the metabolic syndrome in healthy adults

Metabolic syndrome (MetS) is characterized by central obesity, hypertension, insulin resistance, and hypercholesterolemia. Hypothalamic-pituitary-adrenal (HPA) axis activity is frequently abnormal in MetS, and excessive cortisol exposure may be implicated in metabolic derangements. We investigated the hypothesis that cortisol and adrenocorticotropic hormone (ACTH) responses to a standardized neuroendocrine challenge test would be associated with indices of MetS in a community sample of healthy adults. Healthy adults, 125 men and 170 women, without significant medical problems or chronic medications were recruited from the community. Participants completed the dexamethasone/corticotropin-releasing hormone (Dex/CRH) test, and anthropometric measurements, blood pressure, glycosylated hemoglobin (HbA1c), and cholesterol were measured. Participants reported on their history of early life stress and recent stress, as well as mood and anxiety symptoms. Cortisol and ACTH responses to the Dex/CRH test were negatively associated with measures of central adiposity (p<0.001) and blood pressure (p<0.01), and positively associated with HDL cholesterol (p<0.01). These findings remained significant after controlling for body mass index (BMI). Measures of stress and anxiety and depressive symptoms were negatively correlated with cortisol and ACTH responses in the Dex/CRH test but were not related to MetS indices. That altered HPA axis function is linked to MetS components even in a healthy community sample suggests that these processes may be involved in the pathogenesis of MetS. Identification of premorbid risk processes might allow for detection and intervention prior to the development of disease.

Temperament and response to the Trier Social Stress Test

OBJECTIVE

The personality characteristics behavioural inhibition and neuroticism have been associated with mood and anxiety disorders and, in some studies, hypothalamic-pituitary-adrenal (HPA) axis hyperactivity. We recently reported that low levels of Novelty Seeking were associated with elevated plasma cortisol responses to the dexamethasone/corticotropin-releasing hormone (Dex/CRH) test in healthy adults with no psychiatric disorder. The present study tested the association between temperament and HPA axis function in the same group of subjects using a standardized psychosocial neuroendocrine stress test.

METHOD

Subjects completed diagnostic interviews, questionnaires, and the Trier Social Stress Test (TSST).

RESULTS

Novelty Seeking was inversely associated with plasma cortisol concentrations at baseline and throughout the TSST, but was not related to adrenocorticotropic hormone (ACTH) levels.

CONCLUSION

Results of this study extend our previous finding in the Dex/CRH test to a psychosocial stress test. Future investigations are needed to replicate these findings and further elucidate how temperament and personality are linked to HPA function.

Vagus nerve stimulation for depression: rationale, anatomical and physiological basis of efficacy and future prospects

Treatment-resistant depression (TRD) is a major public health concern due to its high costs to society. One of the novel approaches for the treatment of depression is the vagus nerve stimulation (VNS). Therapeutic brain stimulation through delivery of pulsed electrical impulses to the left cervical vagus nerve now has established safety and efficacy as an adjunct treatment for medication-resistant epilepsy and has recently been approved as an adjunct long-term treatment for chronic or recurrent depression. There is considerable evidence from both animal and human neurochemical and neuroimaging studies, that the vagus nerve and its stimulation influence limbic and higher cortical brain regions implicated in mood disorders, providing a rationale for its possible role in the treatment of psychiatric disorders. Clinical studies (open-label and comparator with treatment in naturalistic setting) in patients with TRD have produced promising results, especially when the response rates at longer-term (one- and two-year) follow-up time points are considered. Ongoing research efforts will help determine the place of VNS in the armament of therapeutic modalities available for major depression.

Adjunctive gabapentin in treatment-resistant depression: a retrospective chart review

BACKGROUND

Previous studies in predominantly bipolar patients have suggested that gabapentin may be useful in treating mood disorders. This report describes its efficacy and tolerability as an adjunctive agent in treatment-resistant depression.

METHODS

A chart review was conducted on 27 outpatients presenting with a depressive disorder in whom gabapentin was added to ongoing treatment with a conventional antidepressant to which patients had not responded after at least 6 weeks. The majority of patients had either prominent anxiety or a history of soft bipolar features, but patients with bipolar I disorder were excluded. Clinical state and adverse effects were assessed retrospectively at each visit.

RESULTS

Mean gabapentin trial duration was 15.2+/-7.8 weeks, with a mean final dose of 904+/-445 mg/day (range, 300-1800 mg/day). Clinician-rated measures of clinical state improved significantly from baseline to endpoint. Overall, 37.0% (n=10) of patients were responders at endpoint; another 18.5% (n=5) manifested a transient response not sustained to endpoint. Gabapentin was well tolerated; the most common adverse effects were fatigue, sedation, dizziness, and gastrointestinal symptoms.

LIMITATIONS

Treatment was uncontrolled and efficacy assessments were retrospective.

CONCLUSION

These findings suggest that gabapentin may be of adjunctive benefit in the management of treatment-resistant depression.

Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients

OBJECTIVE

The purpose of this study was to evaluate the efficacy of continuation ECT in depression.

METHOD

The authors used retrospective chart review to identify 29 patients who received continuation ECT plus long-term antidepressant treatment after a positive response to acute treatment with ECT for a depressive episode (continuation ECT group). A retrospective case-controlled approach was used to ascertain a matching group of 29 patients who received long-term antidepressant treatment alone after responding positively to acute ECT (antidepressant-alone group). All 58 patients (46 with unipolar depression, 12 with bipolar disorder) had been chronically depressed before receiving acute ECT. Data from medical records were analyzed by using survival analysis and proportional hazards regression to determine outcome and risk factors.

RESULTS

The mean duration of the follow-up period for all patients was 3.9 years (5.4 years for the continuation ECT patients and 2.4 years for the antidepressant-alone patients). Outcome was significantly better in the continuation ECT group. The cumulative probability of surviving without relapse or recurrence at 2 years was 93% for continuation ECT patients and 52% for antidepressant-alone patients. At 5 years, survival declined to 73% for continuation ECT patients, but fell to 18% for antidepressant-alone patients. Mean survival times were 6.9 years for the continuation ECT patients and 2.7 years for the antidepressant-alone patients.

CONCLUSIONS

The findings provide strong support for the efficacy of continuation ECT plus long-term antidepressant treatment in preventing relapse and recurrence in chronically depressed patients who have responded to acute treatment with ECT.

Cerebrospinal fluid corticotropin-releasing hormone in healthy humans: effects of yohimbine and naloxone

CRH neurons projecting from the paraventricular nucleus (PVN) of the hypothalamus to the median eminence control hypothalamic-pituitary-adrenal (HPA) axis activity. However, CRH neurons outside the PVN as well as PVN neurons projecting to sites other than the median eminence also contribute to the stress response and may play a role in mood and anxiety disorders. We have attempted to investigate possible noradrenergic and opioid regulation of these non-HPA CRH neurons. We hypothesized that yohimbine (an alpha2-adrenergic antagonist) would have stimulatory action on non-HPA CRH neurons, whereas naloxone (a mu-opioid receptor antagonist) would not have this effect. Adult normal volunteers received i.v. yohimbine (n = 5; 0.4 microg/kg), naloxone (n = 4; 125 microg/kg), or placebo (n = 3; 0.9% saline). Cerebrospinal fluid (CSF) was collected continuously, and concentrations of CSF CRH, CSF norepinephrine (NE), and plasma cortisol were measured. Administration of either yohimbine or naloxone caused significant increases in plasma cortisol concentrations over time. Although yohimbine robustly increased CSF NE levels and appeared to increase CSF CRH levels, these effects were not seen after naloxone or placebo administration. Intraindividual correlations were not observed between the measured concentrations of plasma cortisol and CSF CRH for any of the subjects. The results support the idea that CSF CRH concentrations reflect the activity of non-HPA CRH neurons. Although both yohimbine and naloxone stimulated the HPA axis, only yohimbine appeared to have stimulatory effects on central NE and non-HPA CRH.

Effects of catecholamine depletion with AMPT (alpha-methyl-para-tyrosine) in obsessive-compulsive disorder

BACKGROUND

Several lines of evidence suggest that brain dopamine function may contribute to some obsessive-compulsive (OC) phenomena. The effects of catecholamine depletion were examined in drug-free patients with obsessive-compulsive disorder (OCD).

METHODS

The tyrosine hydroxylase inhibitor alpha-methyl-para-tyrosine (AMPT) and diphenhydramine hydrochloride (placebo) were administered for three consecutive days, one week apart, to 6 drug-free adult OCD patients without a personal or family history of chronic tics, in a double-blind, randomized design. The effects of AMPT and placebo on OC, depression, anxiety and global clinical symptoms were assessed.

RESULTS

AMPT produced no clinically or statistically significant change in any behavioral ratings, including OC symptom severity, compared with placebo.

CONCLUSIONS

Acute reduction of catecholamine levels does not seem to affect OC symptoms in drug-free patients with OCD. Studies of catecholamine depletion with AMPT in patients with comorbid OCD and chronic tics may be of considerable neurobiological and clinical interest.

Clinical experience with mirtazapine in the treatment of panic disorder

Data from treatment trials and biological challenge studies implicate involvement of both the serotonergic and the noradrenergic neurotransmitter systems in the pathophysiology of panic disorder. Mirtazapine, a newer antidepressant with a novel mechanism of action enhancing both norepinephrine and serotonin levels without reuptake inhibition, is a good candidate for the treatment of panic disorder. Ten adult outpatients with a primary diagnosis of panic disorder were treated openly with mirtazapine. Starting dose and titration were determined by individual clinical characteristics. Data on emergent side effects and clinical response were obtained at all follow-up visits, which typically occurred biweekly for 16 weeks. At the first follow-up visit (week 2-3), 4 of 10 patients met the criteria for response. Based on all available data, seven of the original sample demonstrated an acute response (defined as CGI = 2 or 3) by weeks 5-7, and six continued to have a positive long-term response at the 16-week end point. Side effects were reported by seven patients, with increased appetite and weight gain the most common. Prominent antihistaminic side effects such as sedation, enhanced appetite, and anxiolysis were often desired in the initial phase of treatment.

Mirtazapine augmentation in the treatment of refractory depression

BACKGROUND

Pharmacotherapeutic strategies that target specific actions at multiple neuronal receptors or cellular components may offer a superior approach for treatment of refractory depression. Mirtazapine is a novel antidepressant which has a mechanism that involves the enhancement of noradrenergic and serotonergic neurotransmission via blockade of alpha2-adrenergic autoreceptors and heteroreceptors without activity at the serotonin transporter. Mirtazapine is thus a compelling candidate for augmentation treatment in patients who fail to achieve adequate response with other antidepressant medications.

METHOD

Twenty patients with DSM-IV major depression or dysthmia who had persistent depressive syndromes despite at least 4 weeks of standard antidepressant pharmacotherapy were given augmentation with mirtazapine (15 to 30 mg p.o. q.h.s.) on an open-label basis. Clinical assessments of status at baseline, 2 weeks, and 4 weeks were used to rate response.

RESULTS

Forty-five percent (N = 9) of the sample were responders at 2 weeks. At the 4 week follow-up, 55% (N = 11) were responders, 30% (N = 6) were nonresponders, and 15% (N = 3) had discontinued treatment owing to side effects. Common side effects included weight gain and sedation.

CONCLUSION

These data suggest that the addition of mirtazapine may be beneficial for patients who have refractory depression, but side effects are prominent at the doses we used. Controlled trials to further evaluate the efficacy and safety of mirtazapine augmentation are needed.

Tryptophan depletion during continuous CSF sampling in healthy human subjects

The tryptophan (TRP) depletion paradigm has been employed to investigate mood and behavioral effects of acutely lowering plasma TRP, and presumably brain serotonin (5-hydroxytryptamine [5-HT]) levels through administration of a special diet and/or amino acid drink. Our goal was to test the assumption that a corresponding fall in central levels of TRP and 5-HT (measured by its major metabolite, 5-hydroxyindoleacetic acid [5-HIAA]) occurs during the standard execution of this method in healthy adult subjects. Three males and two females completed the protocol, which included a one-day low-TRP diet and a TRP-free amino acid drink. Lumbar puncture was performed, with placement of an indwelling catheter connected to a peristaltic pump and fraction collector. Cerebrospinal fluid (CSF) was sampled continuously for a 13.5-hour period (before, during, and after the drink), with fractions removed every 15 minutes. Plasma samples were simultaneously obtained. CSF TRP levels and plasma TRP levels were highly correlated, falling a mean of 92% and 85% from baseline, respectively. CSF nadirs were reached several hours after plasma nadirs. CSF 5-HIAA decreased modestly (24% to 40%, mean 31% change from baseline), with lowest concentrations observed 8-12 hours after the amino acid drink. These data suggest that TRP depletion results in substantial declines in central 5-HT turnover.

[123I]beta-CIT SPECT imaging of dopamine transporter availability after mazindol administration in human cocaine addicts

The in vivo potency of mazindol for binding to striatal dopamine transporters (DAT) was assessed by [123I]beta-CIT ([123I]2beta-carbomethoxy-3beta-(4-iodophenyl)tropane) single photon emission computed tomography (SPECT). Cocaine-dependent subjects (n = 12) underwent three SPECT scans; one before, between, and after subchronic (1 week) administration of 2 mg/day and 4 mg/day mazindol. For each scan, subjects were injected with [123I]beta-CIT and imaged 24 h later under equilibrium conditions. Results showed a statistically significant main effect of mazindol dose (df = 2, F = 10.30, P < 0.001, repeated measures ANOVA) in reducing the specific to non-displaceable equilibrium partition coefficient, V3'' (a measure proportional to DAT binding potential). Regression analysis of the logit transformed data enabled estimation of the 50% displacement dose of mazindol (ED50 = 30mg/day). These data suggest that low doses of mazindol (i.e., 2-4 mg) occupy a small percentage (i.e., < 25%) of DAT in human cocaine abusers and that much higher, potentially intolerable doses (i.e., > or = 30 mg/day) may be required to antagonize significantly cocaine binding in vivo.

Possible acceleration of alcoholic cirrhosis in a patient with bulimia

We report the case of a 27-year-old Caucasian woman with a history of bulimia and alcohol abuse who developed cirrhosis at a rapid rate. We hypothesize that the patient's bulimia, in combination with other possible predisposing factors, potentially accelerated the development of her alcoholic cirrhosis and subsequent medical complications. The association between eating disorders and liver disease is discussed, and the importance of aggressive treatment of eating disorders in combination with alcohol abuse is highlighted.

A risk-benefit assessment of drugs used in the management of obsessive-compulsive disorder

Established efficacy and tolerability in large multicentre controlled studies have made serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SRIs) the mainstay of monotherapy for adult obsessive-compulsive disorder (OCD). When compared with the selective serotonin reuptake inhibitors (SSRIs), the tricyclic compound clomipramine has a higher incidence of adverse effects but is well tolerated by most OCD patients and may confer the best overall antiobsessional effects. Consideration of specific adverse effect profiles, special patient population characteristics, drug interactions and relative cost of the various agents may direct clinicians in choosing the most appropriate first-line drug. Alternative agents as monotherapies have been explored, but none has consistently proven effective to date. Investigations of SRI augmentation with serotonin-enhancing agents have also failed to demonstrate substantial benefits for treatment-refractory OCD. Combination treatment with SRIs and dopamine receptor antagonist drugs appears to provide an improved response for the subpopulation of OCD patients who have comorbid 'tic-spectrum' disorders, though large-scale studies of the efficacy and tolerability of these regimens are not yet available.

The definition and operational criteria for treatment outcome of major depressive disorder. A review of the current research literature

A review of research articles published in nine journals over a 2-year period was conducted to determine how critical changes in the clinical course of depressive disorder are defined in the research literature. These change points, labeled by terms such as response, recovery, and relapse, are critical for evaluation and communication of study results. The review focused on studies of unipolar depression that used a criterion-based diagnostic system and involved some form of therapeutic maneuver. The review showed significant inconsistency in the labeling and definition of change points and indicated the need for more precise conceptual definitions and operational criteria to enhance comparison, generalization, and application of results from clinical studies of depression.

Features associated with suicide attempts in recurrent major depression

Sixty-seven individuals with recurrent major depression and a history of suicide attempts are compared with 163 individuals with recurrent major depression and no history of suicide attempts. The groups are contrasted on demographic features, clinical course, severity of depression, co-morbidity, and acute symptom profiles. Patients with a history of attempts are distinguished from non-attempters by suicidal ideation, marital isolation, neurovegetative signs, feelings of failure, and co-morbid alcoholism or bipolar II disorder. Logistic regression analysis using a model which included a portion of the significant variables correctly classified 77% of the cases. These findings are discussed with reference to prediction of suicide attempts in individuals with major affective disorder.

Family history in recurrent depression

The authors report morbid risks found for depression, alcoholism, and bipolar disorder in first-degree relatives of 179 probands with recurrent depression. Comparisons were made for relatives' gender, probands' gender, and probands' age at onset. Results showed overall morbid risks of 20.7% for non-bipolar depression, 15.4% for alcoholism, and 1.1% for bipolar disorder. Female relatives were found to be at greater risk for depression than males, while the reverse was true for alcoholism. Sex of proband had no effect. Risk to relatives of early-onset probands was significantly elevated compared to late-onset probands. Various cutoffs for ages at onset were examined, and the effect became more marked as the cutoff age was decreased to 20.

Possible role of antidepressants in precipitating mania and hypomania in recurrent depression

This prospective study examined the incidence of mania or hypomania in 230 patients with recurrent depression treated with imipramine. Overall, only six individuals (2.6%) developed hypomania, representing 0.9% of those in the acute phase and 2.5% of those in the continuation phase of drug treatment. Patients with a history of bipolar II depression (N = 33) did not have a greater incidence of hypomania than those with unipolar depression (N = 197). Younger patients did not switch to hypomania more rapidly than older ones, and women were not more likely to switch than men. Systematic assessment of mania, stringent diagnostic criteria, and the recurrent nature of the sample may account for this low incidence of hypomania compared to that reported by other investigators.

Is bipolar II a unique disorder?

The authors investigated differences between 27 outpatients who met RCD "definite" criteria for bipolar II disorder and 188 unipolar patients on several dimensions: clinical characteristics, response to acute treatment, personality profiles after recovery, and family history. The bipolar II group was found to have a higher morbid risk for depression among fathers, a greater incidence of past suicidal attempts, and a greater frequency of psychomotor retardation. A high degree of selectivity for protocol inclusion may account for the similarity seen between the bipolar II group and the unipolars on the other variables examined. The present findings suggest these two groups can be successfully combined in the treatment of recurrent depressive episodes.

Sex differences in recurrent depression: are there any that are significant?

The authors report on sex differences in a group of 230 patients with recurrent depression. Male and female patients were similar in clinical characteristics and baseline measures of severity. Some sex differences in depressive symptoms were apparent, especially as reflected by self-report instruments. The women reported more appetite and weight increase, more somatization, and expressed anger and hostility. The men demonstrated a more rapid response to treatment. Various interpretations of these findings are discussed.

Recurrent depression: an assessment of family burden and family attitudes

Recognition that a psychiatrically ill family member has profound effects on family life and significant others has stimulated the need for more precise assessments of family members. The authors evaluated the burden experienced by those in the immediate environment of an individual with recurrent depressive illness as well as the beliefs they hold about the illness. This report presents a preliminary body of data on the level and types of distress shared by family members, especially family members living with the patient. Such information is valuable in designing educational interventions for family members in order to explore their attitudes and belief systems about depressive illness, to decrease the impact of family and other relationship stress on the patient, and to enhance the significant others' support of the patient.

A psychoeducational workshop for depressed patients, family, and friends: description and evaluation

Since 1982 depressed patients enrolled in a treatment study at the Western Psychiatric Institute and Clinic and their family and friends have participated in a day-long psychoeducational workshop conducted by the clinic's staff. The workshop is designed to help family and friends become useful, long-term resources for patients with recurrent depression and to enlist their assistance in the treatment study. During the morning session, the group discusses the symptomatology, theory, etiology, and treatment of depression, and staff describe the treatment study. In the afternoon, patients and their families and friends meet separately, the patients to discuss methods of coping with depression and interacting with significant others, and the families to discuss the impact of the patient's depression on their lives and to share common problems. More than 83 percent of family and friends who evaluated the workshop considered it moderately or extremely helpful. The results of the evaluation are summarized.

Is diurnal variation a meaningful symptom in unipolar depression?

The present study found that defining groups of patients based on the presence or absence of diurnal variation highlighted several important differences between the two groups. Diurnal patients had longer episodes, better response to treatment, and were less frequently classified as RDC agitated. Within this diurnal population, evening sufferers had more decrease in appetite than morning sufferers. Equivalent percentages of diurnal-a.m. and diurnal-p.m. received RDC endogenous diagnoses, but more diurnal-a.m. patients were found in the DSM-III melancholia category. While this study found some evidence inconsistent with the generally accepted notion regarding the constellation of symptoms associated with endogenous and non-endogenous depressions, the authors suggest that diurnal variation may represent a predictor of unipolar depression which is biologically based.

Optical performance of a diffraction-limited molded-glass biaspheric lens

Optical performance results are reported for a molded-glass biaspheric lens. The 6-mm optical diam lens is intended for use in a laser-based optical disk application. The design with fabrication tolerances has an expected on-axis transmitted wave-front performance of 0.06-wave rms optical path difference (OPD) when tested at 0.6328 ,4m and a numerical aperture of 0.45. Transmitted wave-front aberrations were measured on actual molded lenses using a heterodyne interferometer. Typical performance was 0.05-0.08-wave rms- OPD. Experimental results involving mold rotation indicate that lens performance is primarily limited by a surface figure accuracy of one of the molds.

Alcoholic personality: reality or fiction?

The Sixteen Personality Factor Questionnaire was administered to 266 male alcoholics when they voluntarily entered the 60-day Treatment Program at the Lexington, Kentucky, Veterans Administration Hospital. These alcoholics scored significantly higher than the standardization group on 6 scales and scored significantly lower on 6 other scales. The data support the view that chronic alcoholics are a distinct personality type.