Urothelial toxicity of esketamine in the treatment of depression

RATIONALE

Ketamine is the first widely used substance with rapid-onset antidepressant action. However, there are uncertainties regarding its potential urothelial toxicity, particularly after repeated application. In the context of rising recreational ketamine use, severe side effects affecting the human urinary tract have been reported. It is assumed that ketamine interacts with bladder urothelial cells and induces apoptosis.

OBJECTIVES

This study aimed to assess whether single or repeated doses of esketamine used in an antidepressant indication are associated with urinary toxicity.

METHODS

We included male and female inpatients with a current episode of depression and a diagnosis of recurrent depressive disorder, bipolar disorder or schizoaffective disorder according to ICD-10 criteria (n = 25). The esketamine treatment schedule involved a maximum of 3× weekly dosing at 0.25-0.5 mg/kg i.v. or s.c. The primary outcome was the change in urine toxicity markers (leukocytes, erythrocytes, protein and free haemoglobin). Description of demographic, clinical and laboratory data was conducted using means, standard deviations, frequencies and percentages. Changes in urinary toxicity markers over time were evaluated using linear mixed models with gender as a covariate.

RESULTS

The participants received an average of 11.4 (SD 8) esketamine treatments, and an average number of 11.2 (SD 8) urine samples were analysed over the course of treatment. Neither urinary leukocyte concentration (F(20; 3.0) = 3.1; p = 0.2) nor erythrocyte concentration (F(20;2.2) = 4.1; p = 0.2) showed a significant trend towards increase during the course of esketamine treatment. Similarly, free haemoglobin and protein concentrations, which were analysed descriptively, did not display a rise during treatment. There was a significant improvement in depression ratings after esketamine treatment (p < 0.001).

CONCLUSIONS

This study is, to the best of our knowledge, the first to focus on urothelial toxicity of esketamine used in antidepressant indication and dose. The results indicate that the use of single or repeated doses of esketamine is unlikely to cause urothelial toxicity. The results are in need of confirmation as sample size was small.

Neurotransmitters excreted in the urine as biomarkers of nervous system activity: validity and clinical applicability

Strategies for managing the nervous system are numerous while methods of evaluating the nervous system are limited. Given the physiological importance of neurotransmitters as signaling molecules in the nervous system, the measurement of neurotransmitters has significant potential as a clinical tool. Of all the biological fluids that can be utilized, urinary neurotransmitter testing, due to its stability, sensitivity, and non-invasiveness, is the desired method to analyze nervous system function. Increasing use of this technology in a clinical setting demands a review of its feasibility, utility, and clinical value. We review the current body of literature pertaining to the mechanism of neurotransmitter transport across the blood-brain barrier as well as neurotransmitter filtration and excretion by the kidneys. In addition, this review summarizes the historical use of urinary neurotransmitter assessment to diagnose pheochromocytoma. Early research also correlated urinary assessment of neurotransmitters to various clinical symptoms and treatments of which we present research only for depression, ADHD, and inflammation because of the abundant amount of research in these areas. Finally, we review the limitations and challenges of urinary neurotransmitter testing. Taken together, evidence suggests that neurotransmitters excreted in the urine may have a place in clinical practice as a biomarker of nervous system function to effectively assess disturbances and monitor treatment efficacy.

Sleep symptoms during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women's Health Study

STUDY OBJECTIVES

Describe the severity of getting to sleep, nighttime awakening, and early morning awakening across the menopausal transition (MT) and early postmenopause (PM) and their relationship to age, menopausal transition factors, symptoms, stress-related factors, and health related factors.

DESIGN

Cohort.

SETTING

community.

PARTICIPANTS

286 women from the Seattle Midlife Women's Health Study cohort.

MEASUREMENTS

Participants completed annual menstrual calendars for MT staging, diaries in which they rated their symptoms, stress levels, and perceived health multiple times per year from 1990-2007 and provided first morning urine samples assayed for E1G, FSH, cortisol, and catecholamines. Multilevel modeling (R program) was used for data analysis.

RESULTS

Severity of self-reported problems going to sleep was associated with all symptoms, perceived stress, history of sexual abuse, perceived health (-), alcohol use (-) (all P < 0.001), and lower cortisol (P = 0.009), but not E1G or FSH. Severity of nighttime awakening was significantly associated with age, late MT stage, and early PM, FSH, E1G (-), hot flashes, depressed mood, anxiety, joint pain, backache, perceived stress, history of sexual abuse, perceived health (-), and alcohol use (-) (all P < 0.001, except E1G for which P = 0.030). Severity of early morning awakening was significantly associated with age, hot flashes, depressed mood anxiety, joint pain, backache, perceived stress, history of sexual abuse, perceived health (-) (all P < or = 0.001, except E1G for which P = 0.02 and epinephrine (P = 0.038), but not MT stages or FSH. Multivariate models for each symptom included hot flashes, depressed mood, and perceived health.

CONCLUSION

Sleep symptoms during the MT may be amenable to symptom management strategies that take into account the symptom clusters and promote women's general health rather than focusing only on the MT.

Enhanced norepinephrine output during long-term desipramine treatment: a possible role for the extraneuronal monoamine transporter (SLC22A3)

To study the delay (2-6 weeks) between initial administration of norepinephrine reuptake inhibitor antidepressants and onset of clinical antidepressant action, we examined the effects of desipramine treatment on urinary and plasma catecholamines and their metabolites during the initial 6 weeks of treatment in depressed patients. Catecholamines and metabolites in 24-h urine collections and 8:00 a.m. plasma samples were measured at baseline and after 1, 4, and 6 weeks of desipramine treatment. Desipramine treatment produced significant increases in urinary norepinephrine (NE) and normetanephrine (NMN) and plasma NE at Weeks 4 and 6, but not at Week 1. The ratio of urinary NE/NMN was increased at Weeks 4 and 6, suggesting a reduction in the metabolism of NE to NMN at extraneuronal sites by Weeks 4 and 6. The increases in urinary NE and NMN and plasma NE at Weeks 4 and 6 of desipramine treatment were associated with a reduction in the conversion of NE to NMN. This would be compatible with a blockade of the extraneuronal monoamine transporter (organic cation transporter 3; SLC22A3) by NMN. Inhibition of the extraneuronal monoamine transporter may be an important component in the clinical pharmacology of the norepinephrine reuptake inhibitor antidepressant drugs, such as desipramine.

Overnight urinary cortisol release in women with borderline personality disorder depends on comorbid PTSD and depressive psychopathology

Free cortisol was investigated in BPD patients and healthy controls. A positive association was found between cortisol and depression scores, while the number of PTSD symptoms was negatively correlated with cortisol release. These findings suggest that alterations in cortisol release in BPD are strongly associated with the severity of psychopathology.

Depressive symptoms and 24-hour urinary norepinephrine excretion levels in patients with coronary disease: findings from the Heart and Soul Study

OBJECTIVE

Depressive symptoms are associated with an increased risk of cardiac events in patients with heart disease. Elevated catecholamine levels may contribute to this association, but whether depressive symptoms are associated with catecholamine levels in patients with heart disease is unknown.

METHOD

The authors examined the association between depressive symptoms (defined by a Patient Health Questionnaire score > or =10) and 24-hour urinary norepinephrine, epinephrine, and dopamine excretion levels in 598 subjects with coronary disease.

RESULTS

A total of 106 participants (18%) had depressive symptoms. Participants with depressive symptoms had greater mean norepinephrine excretion levels than those without depressive symptoms (65 microg/day versus 59 mug/day, with adjustment for age, sex, body mass index, smoking, urinary creatinine levels, comorbid illnesses, medication use, and cardiac function). In logistic regression analyses, participants with depressive symptoms were more likely than those without depressive symptoms to have norepinephrine excretion levels in the highest quartile and above the normal range. Depressive symptoms were not associated with dopamine or epinephrine excretion levels.

CONCLUSIONS

In patients with coronary disease, depressive symptoms are associated with elevated norepinephrine excretion levels. Future longitudinal studies are needed to determine whether elevations in norepinephrine contribute to adverse cardiac outcomes in patients with depressive symptoms.

Initial urinary epinephrine and cortisol levels predict acute PTSD symptoms in child trauma victims

BACKGROUND

Previous research examining biological correlates of posttraumatic stress disorder (PTSD) in children has suggested that children with chronic PTSD have altered levels of catecholamines and cortisol compared to similarly traumatized children who do not meet diagnostic criteria. The present study extended these findings by examining whether urinary hormone levels collected soon after a trauma were related to subsequent acute PTSD symptoms in child trauma victims.

METHODS

Initial 12-h urine samples were collected from 82 children aged 8-18 admitted to a Level 1 trauma center. Collection was begun immediately upon admission, and samples were assayed for levels of catecholamines and cortisol. PTSD and depressive symptomatology were assessed 6 weeks following the accident.

RESULTS

Initial urinary cortisol levels were significantly correlated with subsequent acute PTSD symptoms (r=0.31). After removing the variance associated with demographic variables and depressive symptoms, urinary cortisol and epinephrine levels continued to predict a significant percentage (7-10%) of the variance in 6-week PTSD symptoms. Examination of boys and girls separately suggested that significance was primarily driven by the strength of the relationships between hormone levels and acute PTSD symptoms in boys.

CONCLUSIONS

The present findings suggest that high initial urinary cortisol and epinephrine levels immediately following a traumatic event may be associated with increased risk for the development of subsequent acute PTSD symptoms, especially in boys.

Toward a rapidly acting antidepressant: the normetanephrine and extraneuronal monoamine transporter (uptake 2) hypothesis

OBJECTIVE

The authors considered the possible role of the extraneuronal monoamine transporter (uptake 2) in accounting for the delay in clinical action of norepinephrine reuptake inhibitor antidepressant drugs.

METHOD

Literature searches were performed by means of the MEDLINE and Current Contents databases with search terms such as "extraneuronal uptake," "uptake 2," "extraneuronal monoamine transporter," and "organic cation transporter type-3."

RESULTS

The findings in this literature indicate that inhibition of glial uptake 2 by normetanephrine or other inhibitors of uptake 2 would enhance the accumulation of norepinephrine in the synapse.

CONCLUSIONS

The authors propose the hypothesis that drugs or other agents that increase levels of normetanephrine or otherwise inhibit the extraneuronal monoamine transporter, uptake 2, in the brain will speed up the clinical effects of norepinephrine reuptake inhibitor antidepressant drugs.

Recognition of childhood depression: personal reminiscences

Prior to 1970, childhood depression was not considered a valid clinical entity by American psychiatrists. One of the early clues was provided in the 1950s by the author's observation of depressive symptoms in children and young adolescents with undescended testicles. This finding was extended to children with several chronic diseases, many of whom exhibited depressive symptoms as well. Eventually, depressive symptomatology was found in children without any physical disorders. This was followed by the introduction of a diagnostic instrument, called the Children's Affective Rating Scale (CARS), later converted into a more formal system called the Child Assessment Schedule (CAS). A provisional classification of childhood depression was published in 1972. Our examination of children with depressive disorders has revealed several modes of family interaction, of which the most important were: separation from important love objects; depreciation and rejection; and affective disorders in parents. Several children with bipolar disorder stimulated our interest in this disorder and led to a pilot study of children of bipolar, lithium-responding parents. Some of these children with bipolar illness had a clear-cut response to lithium and were strong augmenters of the average evoked potentials (EPs). Next, our group investigated the urinary excretion of norepinephrine and its metabolites in chronically depressed children who differed from a normal control group. The foregoing studies, along with major contributions by other child psychiatrists, eventually led to the acceptance of childhood depression as a clinical entity in US psychiatry. The acceptance of juvenile bipolar disorder had to await further research by a new generation of child and adult psychiatrists.

Depression and endogenous melatonin in postmenopausal women

BACKGROUND

Previous reports on melatonin secretion in depression are numerous but conflicting. There are very few studies relating the duration of the nocturnal melatonin peak to depression, and the results of those studies have been equivocal.

METHODS

We studied mood disorders and urinary melatonin excretion in 382 postmenopausal women. Psychiatric diagnoses and global assessment of functioning (GAF) scores were determined based on a Structured Clinical Interview for DSM-IV Axis I Disorders (SCID). Urinary 6-sulfatoxymelatonin (6-SMT) samples were collected for two 24-h periods at home.

RESULTS

A positive family history of depression was significantly related to a longer duration of 6-SMT excretion. There were marginally significant associations between current major depression and delayed offset of 6-SMT excretion and between later acrophase and lifetime major depression, even with control for age, ethnicity, season, and several medications.

LIMITATIONS

The subjects were studied in their home environments, where light effects were not controlled. Data were restricted to postmenopausal women, including a limited number of subjects with current major depression.

CONCLUSIONS

These results suggest that there might be a familial vulnerability in the endogenous melatonin signal in subjects prone to depression, and an abnormality in the duration of the melatonin signal in those with current major depression.

Right frontal EEG and pregnancy/neonatal outcomes

Fifty-two pregnant women recruited during their second trimester were given EEGs and divided into greater relative right and left frontal EEG activation groups. The greater relative right frontal EEG women had lower dopamine levels during their second trimester and lower dopamine and higher cortisol levels during the neonatal period. The newborns of the right frontal EEG mothers also showed greater relative right frontal EEG, had lower dopamine and serotonin levels, spent more time in indeterminate sleep and had inferior Brazelton scores. A discriminant function analysis based on the mothers' prenatal depression scores and biochemical measures correctly classified 74% of the women as greater relative right or left frontal EEG group members.

Urinary free cortisol excretion in elderly persons with minor and major depression

Several studies have found that cortisol hypersecretion may occur in severely depressed patients, characterized by melancholic features. On the other hand, illness chronicity seems to be related to low, rather than high, cortisol levels. This study aims to trace factors associated with 24-h urinary free cortisol levels in a sample of 23 elderly persons with major or minor depression and 21 non-depressed control subjects. Depressive episodes were subdivided according to severity and chronicity (i.e. length and recurrence). None of the depressed persons showed unusually high 24-h cortisol levels, and cortisol excretion was not elevated as compared with that in the control group, regardless of subtype of depression. The results suggest, however, that hyposecretion of cortisol may be a feature of chronic depressive episodes, especially in males.

Circadian abnormalities in older adults

This study examined the circadian phase adjustment of symptomatic elders ages 60-79 years in comparison with that of young, healthy adults ages 20-40 years. Seventy-two elders with complaints of insomnia or depression, and 30 young, healthy adults were assessed for 5-7 days at home. Sleep and illumination were recorded with Actillume wrist monitors and sleep diaries. Urine was collected over two 24-hr periods and assayed for 6-sulphatoxymelatonin (6-smt). The volunteers were then observed continuously for 5 nights and 4 days in the laboratory. In the laboratory, sleep periods were fixed at 8 hr with polysomnographic assessment of sleep, apnea-hypopnea, and nocturnal myoclonus. Circadian dispersion, defined as the mean variation of 6-smt acrophase from the median age-specific acrophase, was significantly greater in the older vs. young adults. Likewise, circadian malsynchronization, defined as the absolute number of hours (advance or delay) between the 6-smt acrophase and the middle of the sleep period, was significantly greater in the older vs. young volunteers. For the older volunteers, multiple regressions were calculated associating sleep with potential correlates of sleep disturbance. Nocturnal myoclonus and circadian malsynchronization were more strongly associated with sleep impairment than other factors (e.g., sleep apnea, depression). These observations suggest that circadian malsynchronization might be a common and significant cause of disturbed sleep among adults over age 60.

Urinary phenylacetate and response to methylphenidate

Phenylacetate (PAA) is the metabolic end-product of phenylalanine, a catecholamine precursor, and of phenylethylamine, a centrally active neurochemical substance which has been implicated in the actions of stimulant medications. PAA has been reported to be low in unipolar depression. We measured 24-h urinary PAA in normal controls (N = 21) and in-patients with unipolar depression (N = 33; 12 drug-free) and did subsequent dexamethasome suppression tests (DST). We also gave patients methylphenidate challenges, examining mood response. There were no significant differences between depressed patients and controls in 24-h urinary PAA excretion (P greater than 0.9). However, the variance in PAA excretion was higher in patients than normals and 5 patients had values at or above the 99% confidence limits for the normal control group. There was no association of DST results with PAA excretion (P greater than 0.4). Patients with a worsened mood after taking methylphenidate excreted less PAA than those with an improved mood, however (P less than 0.025). The clinical and theoretical significance of these results is discussed.

Catecholamines in depression: a cumulative study of urinary norepinephrine and its major metabolites in unipolar and bipolar depressed patients versus healthy volunteers at the NIMH

Studies comparing urinary norepinephrine (NE) and its metabolites in unipolar or bipolar depressed patients and healthy volunteers have not yielded consistent findings. However, in unipolar depressed patients, most studies in non-elderly populations consistently report elevated concentrations of plasma NE, at least following an orthostatic challenge. Expanding upon previous studies which showed elevated plasma NE in depression, we compared the urinary excretion of NE, normetanephrine (NMN), 3-methoxy-4-hydroxyphenylglycol (MHPG), and vanillylmandelic acid (VMA) in age- and sex-matched unipolar and bipolar depressed patients versus healthy volunteers hospitalized at an inpatient unit at the National Institute of Mental Health. Only depressed subjects with a minimum 4-week drug-free period were included. Total turnover (NE + NMN + MHPG + VMA) was reduced in this sample of unipolar and bipolar depressed patients. MHPG concentration did not distinguish unipolar from bipolar depressed patients and was not significantly different from that in healthy volunteers. A construct of the average fractional extraneuronal concentration of NE (NE + NMN/NE + NMN + MHPG + VMA) was significantly higher in unipolar and bipolar depressed patients than in healthy volunteers. This finding extends data suggesting that unmedicated unipolar and bipolar depressed patients have a 'hyperresponsive' noradrenergic system and provides a framework which ties together plasma and urinary findings.

Increased 24-hour urinary cortisol excretion in patients with post-traumatic stress disorder and patients with major depression, but not in patients with fibromyalgia

There is now firm evidence that major depression is accompanied by increased baseline activity of the hypothalamic-pituitary-adrenal (HPA) axis, as assessed by means of 24-h urinary cortisol (UC) excretion. Recently, there were some reports that fibromyalgia and post-traumatic stress disorder (PTSD), two disorders which show a significant amplitude of depressive symptoms, are associated with changes in the baseline activity of the HPA axis, such as low 24-h UC excretion. The aim of the present study was to examine 24-h UC excretion in fibromyalgia and PTSD patients compared to normal controls and patients with major depression. In the three patient groups, severity of depressive symptoms was measured by means of the Hamilton Depression Rating Scale (HDRS) score. Severity of fibromyalgia was measured using a dolorimetrically obtained myalgic score, and severity of PTSD was assessed by means of factor analytical scores computed on the items of the Composite International Diagnostic Interview (CIDI), PTSD Module. Patients with PTSD and major depression had significantly higher 24-h UC excretion than normal controls and fibromyalgia patients. At a threshold value of > or = 240 micrograms/24 h, 80% of PTSD patients and 80% of depressed patients had increased 24 h UC excretion with a specificity of 100%. There were no significant differences in 24-h UC excretion either between fibromyalgia patients and normal controls, or between patients with major depression and PTSD patients. In the three patient groups, no significant correlations were found between 24-h UC excretion and the HDRS score. In fibromyalgia, no significant correlations were found between 24-h UC excretion and the myalgic score. In PTSD, no significant correlations were found between 24-h UC excretion and severity of either depression-avoidance or anxiety-arousal symptoms. In conclusion, this study found increased 24-h UC excretion in patients with PTSD comparable to that in patients with major depression, whereas in fibromyalgia no significant changes in 24-h UC were found.

Differential trace amine alterations in individuals receiving acetylenic inhibitors of MAO-A (clorgyline) or MAO-B (selegiline and pargyline)

Marked, dose-dependent elevations in the urinary excretion of phenylethylamine, para-tyramine, and meta-tyramine were observed in depressed patients treated for three or more weeks with 10, 30, or 60 mg/day of the partially-selective inhibitor of MAO-B, selegiline (l-deprenyl). In comparative studies with other, structurally similar acetylenic inhibitors of MAO, pargyline, an MAO-B > MAO-A inhibitor used in doses of 90 mg/day for three or more weeks, produced elevations in these trace amines which were similar to those found with the highest dose of selegiline studied. Clorgyline, a selective inhibitor of MAO-A used in doses of 30 mg/day for three or more weeks (a dose/time regimen previously reported to reduce urinary, plasma, and cerebrospinal fluid 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) > 80%, indicating a marked inhibitory effect on MAO-A in humans in vivo) produced negligible changes in trace amine excretion. In comparison to recent studies of individuals lacking the genes for MAO-A, MAO-B, or both MAO-A and MAO-B, the lack of change in trace amine excretion in individuals with a mutation affecting only MAO-A is in agreement with the observed lack of effect of clorgyline in the present study. Selegiline produced larger changes in trace amines--at least at the higher doses studied--than found in individuals lacking the gene for MAO-B, in agreement with other data suggesting a lesser selectivity for MAO-B inhibition when selegiline was given in doses higher than 10 mg/day. Overall, trace amine elevations in individuals receiving the highest dose of deprenyl or receiving pargyline were approximately three to five-fold lower than the elevations observed in individuals lacking the genes for both MAO-A and MAO-B, suggesting that these drug doses yield incomplete inhibition of MAO-A and MAO-B.

Fluoxetine treatment of depressive disorders in methadone-maintained opioid addicts

This study tested the effectiveness of fluoxetine as a treatment for depression in a population of methadone-maintained opioid addicts. Methadone-maintained opioid addicts (44) with depression received fluoxetine or placebo in addition to their methadone, in a double-blind randomized trial, for 12 weeks. Depressive symptoms decreased significantly overall with no significant differences between the groups treated with fluoxetine versus placebo. In addition, drug use outcomes, including cocaine and heroin self-reported use and urine toxicology were measured. There was a significant decrease in heroin use in treatment, but no medication effect. Cocaine use, was unchanged from pre-treatment to endpoint. In separately analyzing data for the subsample of subjects with the most severe depression, there was a significant decrease in depression during treatment and a significant decrease in self-reported cocaine use, but no medication effect on either depressive symptoms or on cocaine use. This study suggests that fluoxetine is not an effective agent in treating depression or cocaine use in this population.

Immune markers in fibromyalgia: comparison with major depressed patients and normal volunteers

BACKGROUND

There is a high degree of comorbidity between fibromyalgia and major depression. The latter is characterized by signs of immune activation, whereas the immune status in fibromyalgia is not yet elucidated. The aims of the present study were to examine (i) neopterin and biopterin excretion in 24-h urine of patients with fibromyalgia compared with normal volunteers and patients with major depression; and (ii) the effects of subchronic treatment with sertraline (11 weeks) on the urinary excretion of neopterin and biopterin.

METHODS

Measurements of neopterin, biopterin, pseudouridine, creatinine and uric acid in 24-h urine were performed by means of HPLC in 14 fibromyalgia and ten major depressed patients and 17 normal volunteers.

RESULTS

There were no significant differences in urine excretion of the above five analytes between patients with fibromyalgia and normal volunteers. Patients with major depression showed significantly higher urinary neopterin excretion than normal volunteers and fibromyalgia patients. Patients with fibromyalgia and major depression had a significantly increased neopterin/creatinine ratio. Fibromyalgia patients had significantly lower urinary excretion of creatinine than patients with major depression. In fibromyalgia patients, there were no significant effects of sertraline treatment on any of the urine analytes.

CONCLUSIONS

The findings suggest that fibromyalgia, in contrast to major depression, may not be accompanied by activation of cell-mediated immunity.

LIMITATION

Other immune markers should be measured in fibromyalgia before drawing definite conclusions.

CLINICAL RELEVANCE

Increased urinary excretion of neopterin can be used as a marker for major depression, but not fibromyalgia.

Urinary free cortisol excretion in chronic fatigue syndrome, major depression and in healthy volunteers

Urinary free cortisol excretion (UFC) was compared in 21 patients with chronic fatigue syndrome (CFS), in 10 melancholic depressives and in 15 healthy controls. Patients with depression had UFC values which were significantly higher than healthy comparison subjects, whereas UFC excretion of CFS patients was significantly lower than the comparison group. These findings are in keeping with currently held hypotheses of hyperactivity and hypoactivity of the hypothalamic-pituitary-adrenal (HPA) axis in depression and chronic fatigue syndrome respectively. Five of the 21 CFS patients had a co-morbid depressive illness. This sub-group retained the profile of UFC excretion of those with CFS alone, suggesting a different pathophysiological basis for depressive symptoms in CFS.

Is there a role for a pure noradrenergic drug in the treatment of depression?

Depression is thought to result from a dysfunction in the noradrenergic or serotonergic systems. The noradrenergic system appears to be associated with increased drive, whereas the serotonergic system relates more to changes in mood and it is possible that the different symptoms of depression may benefit from drugs acting mainly on one or other of the neurotransmitter systems. A series of studies has shown that interruption of serotonin synthesis compromises the efficacy of serotonin but not noradrenaline reuptake inhibitors, and interruption of noradrenaline synthesis compromises the efficacy of noradrenaline but not serotonin reuptake inhibitors (SSRIs). This suggests that the two classes of drugs owe their activity to functional changes in different neurotransmitter systems. Reboxetine represents a new class of drugs-the selective noradrenaline reuptake inhibitors (NARIs). It acts specifically at noradrenergic sites unlike the non-selective tricyclic antidepressants (TCAs). NARIs have a role in the treatment of depression, either alone or as adjunctive therapy.

Nocturnal melatonin and 24-hour 6-sulphatoxymelatonin levels in various phases of bipolar affective disorder

Nine bipolar patients (2 men and 7 women) and 12 healthy control subjects completed overnight sampling for serum melatonin (MT) and urinary 6-sulphatoxymelatonin (aMT6s). The patients were investigated during manic, depressed, and/or euthymic states. Although serum MT levels did not differ significantly across the bipolar groups, in all cases serum MT levels were significantly lower than in control subjects. Differences in MT levels were also present between bipolar patients who were in a depressed phase and control subjects. There were no statistically significant differences in urinary aMT6s levels among the patients and control subjects, although in all cases nocturnal aMT6s levels were significantly higher than daytime levels. This study provides tentative evidence for decreased serum MT as a trait but not a state marker in bipolar affective disorder.

[Prediction of therapeutic response in depressive states]

Predicting the clinical improvement of patients with antidepressant drugs, at an early stage and in a individualistic manner, allows to choose the product which is most adapted to each case and to avoid leaving patients under an inefficient medication for several weeks. Predictability studies have multiplied. A general review of these studies is made here by examining the clinical, biological, electrophysiological, and finally the pharmacokinetic predictors. Clinical predictors have a practical use as they define certain clinical types of depression which best respond to antidepressants specific to a monoaminergic axis. It has been shown that a complete absence of symptomatic improvement after two weeks of treatment predicts the inefficacy of the treatment. Inversely, to this day, none of the biological predictors lead to a practical application during the treatment of patients, but they allow a better understanding of the antidepressants' mode of action. Finally, the elaboration of pharmacokinetic equations define for each patient the doses that allow to determine the therapeutic zones when these have been recognized.

Low levels of MHPG in depressive spectrum patients

There is some preliminary laboratory support for the proposed classification of depressed patients into depressive spectrum disease (DSD) and non-DSD. This study explores whether there is a difference in the levels of the norepinephrine metabolite, MHPG, in DSD and non-DSD patients. MHPG levels from 38 DSD patients were compared with 24 non-DSD patients. After controlling for the influence of age and gender on MHPG, the DSD patients had MHPG levels that were lower than non-DSD patients; 1655 +/- 90 mg/day vs. 1965 +/- 174 mg/day, respectively; P = 0.05. This study provides additional laboratory support for the DSD subtype. Possible implications of this finding are discussed.

The relationship between the effects of metyrapone treatment on depressed mood and urinary steroid profiles

In order to investigate mechanisms by which the adrenal 11 beta-hydroxylase inhibitor metyrapone might exert its antidepressant effect, we used gas chromatography to analyse the 24 h urinary steroid profiles from six females with major depression taking part in a trial of metyrapone (2-4 g/day) as an antidepressant. Due to concurrent administration of hydrocortisone (30 mg/day), plasma cortisol levels were not significantly reduced. Treatment with metyrapone resulted in greatly increased urinary excretion of 11-deoxy corticosteroids, including the GABA-modulatory steroid tetrahydro-11-deoxycorticosterone (from 68 +/- 34 to 219 +/- 75 micrograms/24 h, p < .05). Metyrapone also had multiple extra-adrenal effects on corticosteroid metabolism, including inhibition of the peripheral conversion of cortisone to cortisol as demonstrated by a significant decrease in the ratio of 11 beta-hydroxy/11-oxo metabolites of cortisol (from 0.81 +/- 0.08 to 0.46 +/- 0.04, p < .01). The decreased Montgomery-Asberg Depression Rating Scale scores seen during treatment with metyrapone did not correlate with changes in plasma cortisol, but did correlate significantly with total 11-deoxycortisol metabolites (r = 0.778, n = 12, p < .01). We conclude that, in addition to decreased cortisol synthesis, increased secretion of cortisol precursors and reduced local bioavailability of cortisol may play a role in the antidepressant effect of metyrapone.

Catecholamine changes in patients with depression under the action of high-intensity light

Preponderance in depression of the melancholy affect was characterized by a drop in the level of norepinephrine (NE) and rise in epinephrine (E). Exposure to light was associated with fall in E, with no change recordable in NE. In anxious depression, following light therapy, high levels of excretion of both catecholamines tended to return to normal. Ligh was found to cause opposite changes in the quantitative measures depending upon the initial value for the E:NE ratio (above or below control).

Urinary excretion of albumin and transferrin in lithium maintenance treatment: daily versus alternate-day lithium dosing schedule

Urinary excretion of albumin and transferrin was determined by means of sensitive immunochemical methods in 40 manic-depressive patients prior to and following 6 months of daily or alternate-day lithium carbonate treatment. The median dose of lithium carbonate was 700 mg in the daily treatment group and 1200 mg in the alternate-day group, the corresponding median 12-h serum lithium concentration being 0.6 mmol l-1 and 0.7 mmol l-1, respectively. Urinary excretion of albumin and transferrin was significantly elevated in the lithium-treated patients as compared to a control group (Mann-Whitney). The change in urinary albumin:creatinine and transferrin:creatinine ratios between allocation and 6 months of treatment did not correlate significantly with the lithium dosing schedule (multiple linear regression), but did correlate with total lithium carbonate dose. In conclusion, the study provides no evidence of any difference in glomerular function (permeability) in the daily and alternate-day lithium dosing schedules, and lends no support to the hypothesis that alternate-day treatment diminishes the effect of lithium on renal function.

The role of pterins in depression and the effects of antidepressive therapy

Urinary excretion of neopterins (N) and biopterins (B) was measured in 48 patients with depression before and after treatment with placebo, antidepressants, or electroconvulsive therapy (ECT), and in 26 healthy control subjects. Patients prior to and after treatment had a significantly greater neopterin/biopterin (N:B) ratio than control subjects. There was a significant correlation between N:B ratios and the severity of depression and plasma cortisol. As a raised N:B ratio implies failure to convert neopterin to biopterin, it is possible that reduced availability of tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, serotonin and dopamine, may exert rate-limiting control over the synthesis of monoamines implicated in the pathogenesis of depressive illness.

Association of biogenic amine metabolites with symptomatology in delusional (psychotic) and nondelusional depressed patients

1. The levels of the main norepinephrine, serotonin, and dopamine metabolite excretion in the urine, MHPG, 5HIAA and HVA respectively, were measured in 84 patients with major depressive disorder, 34 delusional (psychotic) and 50 nondelusional (DSM-III-R criteria). 2. Associations with the 17 items of the HDRS were evaluated using the multiple regression analysis model. In the delusional group, MHPG excretion was positively related to the scores in the items of depressed mood (p = 0.04), middle insomnia (p = 0.008) and genital symptoms (p = 0.001). 5HIAA excretion was negatively associated with late insomnia (p = 0.02), work and interests (p = 0.001) and genital symptoms (p = 0.007). HVA was positively related to agitation (p = 0.043). In the nondelusional group the only association found was between agitation and HVA excretion (p = 0.03).

Biogenic amine metabolites in delusional (psychotic) depression and melancholia subtypes of major depression

1. The levels of the urinary main metabolites of norepinephrine 3-methoxy-4-hydroxyphenylglycol (MHPG), of dopamine homovanillic acid (HVA) and of serotonin 5-hydroxyindoleacetic acid (5-HIAA) were measured in 84 patients with major depressive disorder, 34 delusional and 50 nondelusional. Melancholia subtype was also defined (N = 62). 2. MHPG was significantly higher in the delusional depressed group (p = 0.023). Female patients with delusional major depression also had significantly higher HVA excretion than female patients with non delusional major depression (p = 0.036). 5-HIAA excretion was similar in the two patient subgroups. 3. No significant differences in the three monoamine metabolites were found between the melancholic and nonmelancholic depressed patients.

Adrenomedullary function in depressed patients

In this paper from the Collaborative Depression Study (CDS)--Biological, a set of data analyses are presented which indicate that depressed states and perhaps depressed mood are associated with a greater activation of the adrenomedullary system than the sympathetic nervous system [as measured by norepinephrine (NE) and normetanephrine excretion]. For the most part this finding of predominant activation of the adrenomedullary system is seen in unipolar and not bipolar patients.

Primary early onset dysthymia, biochemical correlates of the therapeutic response to fluoxetine: II. Urinary metabolites of serotonin, norepinephrine, epinephrine and melatonin

The present study investigated pre- and post-treatment 24-h urinary metabolites of monoamines and melatonin as a function of response to treatment in primary early onset dysthymic patients. The main finding was that treatment responders had lower urinary 5-hydroxyindoleacetic acid (5-HIAA) levels prior to treatment. Following treatment, urinary 5-HIAA tended to be decreased in nonresponders and increased in responders. As well, metanephrine levels were lower and 6-sulphatoxymelatonin levels were higher in responders prior to treatment. These data support the view that there is a biological substrate for certain subgroups of dysthymia, part of which may involve serotonergic systems.

Normal urinary free cortisol and postdexamethasone cortisol in social phobia: comparison to normal volunteers

In primates, social stress is associated with activation of the hypothalamic-pituitary-adrenal (HPA) axis. Social phobia is a common, often disabling, form of pathological anxiety characterized by marked distress in situations involving possible scrutiny or evaluation. Little is known about HPA function in patients with social phobia. We examined 24-hour excretion of urinary free cortisol (UFC) in 54 patients with social phobia and post-dexamethasone cortisol levels in 64 patients with social phobia and found no evidence of HPA-axis overactivity compared to normal controls, despite pathological levels of anxiety.

Urinary MHPG and clinical symptoms in patients with unipolar depression

The relationship between levels of urinary 3-methoxy-4-hydroxyphenylglycol (MHPG) and symptom scores on the Hamilton Rating Scale for Depression was examined in 31 patients with unipolar depression. Patients with either low MHPG or high MHPG showed significant sleep disturbance in the form of early morning awakening. Patients with mid-range or high MHPG showed decreased work and activities. Endogenomorphy factor scores represented a blend of these findings.

Relationship between 3-methoxy-4-hydroxyphenylglycol and suicide

Urinary 3-methoxy-4-hydroxyphenylglycol (MHPG) levels in 53 depressed women were compared to current suicidal thoughts or activity. Comparisons were also made between MHPG and past suicide attempts, number of past attempts, and seriousness of the worst attempt. There was a weak trend for current but not past suicidality to be associated with decreased MHPG levels.

Effects of tricyclic antidepressant treatment on tyramine-O-sulfate excretion in depressed patients

The urinary excretion of tyramine-O-sulfate following an oral load of tyramine (Tyramine Challenge Test, 'TCT') was measured in a group of fourteen inpatients with unipolar and bipolar major depressive episode. TCT was done both during a pretreatment baseline period and following four weeks of treatment with tricyclic antidepressants. The change in TCT values after treatment correlated with improvement in depression. The previously described ability of TCT to discriminate between endogenous and nonendogenous depressed patients was confirmed at baseline. However, following tricyclic antidepressant treatment, TCT values were not significantly different between endogenous and nonendogenous patients.

Age, alcoholism and depression are associated with low levels of urinary melatonin

Two normal control populations, separated by 8,000 miles and 24 degrees of latitude, had similar six-month mean values for overnight urinary melatonin concentrations. These values were significantly higher than six-month values for depressed subjects and abstinent alcoholic subjects, while the means for the two clinical populations were similar. Age and urinary melatonin concentration in the control and clinical populations were inversely related, but the slopes of the linear regression equations were ten times steeper for the control populations than for the clinical populations. Differences in age and sex distributions accounted for some of the differences in values between controls and the clinical populations, although controls still differed from the clinical populations, even after sex and age were factored out. The disparate slopes for age and melatonin concentrations may contribute to some of the conflicting findings of studies comparing populations of different ages. The total melatonin content in the samples from alcoholic subjects, but not the depressed subjects, was lower than that for controls. The difference in the urinary melatonin concentration between the controls and the two patient groups was not accounted for by difference in duration of urine collection period, hours of sleep or body weight.

Changes in norepinephrine output following light therapy for fall/winter seasonal depression

Recurrent fall/winter depressions that remit during spring and summer have been called Seasonal Affective Disorders (SAD) (Wehr and Rosenthal 1989). The pathophysiology of SAD, its relationship to nonseasonal affective disorders, and the mechanism of action of light therapy, which is effective in treating SAD, remain to be elucidated (Depue et al 1989; Jacobsen et al 1987; James et al 1986; Joseph-Vanderpool et al 1991; Skwerer et al 1988, Terman et al 1989). Norepinephrine (NE) may play a role in the mechanisms of action of many antidepressant treatments (Schildkraut 1965) that alter NE metabolism (Schildkraut et al 1964 and 1965) and decrease the urinary output of NE and its metabolites, i.e., "whole-body NE turnover" (WBNET) (Golden et al 1988; Potter et al 1988). The present study explored whether light therapy also reduces the urinary output of NE and its metabolites.

Is the tyramine test for depressive illness useful in elderly patients?

There were no significant differences in tyramine sulphate excretion following tyramine ingestion between elderly depressed, demented or control patient groups, in contrast with younger subjects where this test is a trait marker for unipolar endogenous depression. There are inherent problems in urine collection studies in the elderly and the results may have been influenced by the medication that elderly patients have to take for other disorders. This study suggests that the tyramine test is unlikely to be of clinical usefulness in the over 65 age group.

Thyrotropin responses to TRH and MHPG excretion before and after an electroconvulsive therapeutic course in depressed patients

1. TSH response to TRH, and urinary MHPG were investigated before and after an ECT course in 12 female patients with endogenous depression. 2. The changes caused by ECT treatment on these parameters were not significant. 3. A positive correlation (r = 0.75, p = 0.005) was found between the changes in TSH response and the changes in urinary MHPG excretion.

Learned helplessness and urinary MHPG levels in unipolar depression

OBJECTIVE

Studies of the learned helplessness paradigm in laboratory animals show increased central noradrenergic activity following exposure to uncontrollable stressors. In clinical studies, depressed patients as a group report higher perceptions of helplessness and powerlessness. The authors examined the relationship between perceptions of powerlessness and noradrenergic activity in depressed patients.

METHOD

Twenty drug-free patients (12 women and 8 men) meeting DSM-III criteria for major depressive disorder were given the Kobasa Hardiness Questionnaire, which contains subscales measuring feelings of powerlessness, security, and alientation. Concurrently, 24-hour urine samples were collected for measurement of urinary MHPG.

RESULTS

Significant correlations were found between MHPG levels and total hardiness scores as well as between MHPG levels and total powerlessness scores but not between MHPG levels and total security or total alientation scores.

CONCLUSIONS

These results suggest that depressed patients with high urinary output of MHPG are more likely to show the cognitive features of learned helplessness.