Multicenter Study on the Clinical Effectiveness, Pharmacokinetics, and Pharmacogenetics of Mirtazapine in Depression.

ABSTRACT: Pharmacogenetic tests and therapeutic drug monitoring may considerably improve the pharmacotherapy of depression. The aim of this study was to evaluate the relationship between the efficacy of mirtazapine (MIR) and the steady-state plasma concentrations of its enantiomers and metabolites in moderately to severely depressed patients, taking their pharmacogenetic status into account. Inpatients and outpatients (n = 45; mean age, 51 years; range, 19-79 years) with major depressive episode received MIR for 8 weeks (30 mg/d on days 1-14 and 30-45 mg/d on days 15-56). Mirtazapine treatment resulted in a significant improvement in mean Hamilton Depression Rating Scale total score at the end of the study (P < 0.0001). There was no evidence for a significant plasma concentration-clinical effectiveness relationship regarding any pharmacokinetic parameter. The enantiomers of MIR and its hydroxylated (OH-MIR) and demethylated (DMIR) metabolites in plasma samples on days 14 and 56 were influenced by sex and age. Nonsmokers (n = 28) had higher mean MIR plasma levels than smokers (n = 17): S(+)-enantiomer of MIR, 9.4 (SD, 3.9) versus 6.2 (SD, 5.5) ng/mL (P = 0.005); R(-)-enantiomer of MIR, 24.4 (SD, 6.5) versus 18.5 (SD, 4.1) ng/mL (P = 0.003). Only in nonsmokers, plasma levels of S(+)-enantiomer of MIR and metabolites depended on the CYP2D6 genotype. Therefore, high CYP1A2 activity seen in smokers seems to mask the influence of the CYP2D6 genotype. In patients presenting the CYP2B6 *6/*6 genotype (n = 8), S-OH-MIR concentrations were higher those in the other patients (n = 37). Although it is not known if S-OH-MIR is associated with the therapeutic effect of MIR, the reduction of the Hamilton scores was significantly (P = 0.016) more pronounced in the CYP2B6 *6/*6-genotyped patients at the end of the study. The role of CYP2B6 in the metabolism and effectiveness of MIR should be further investigated.

Mechanisms involved in the maintenance of inbreeding depression in gynodioecious "Silene vulgaris" (Caryophyllaceae): an experimental investigation

Summary Gynodioecy, the joint occurrence of females and hermaphrodites within natural populations, is a widely studied mating system ever since Darwin (1877). It is an exceptional mating system because continuous selection is necessary to maintain it. Since females only reproduce through ovules whereas hermaphrodites transmit genes through ovules and pollen, larger female fitness, in terms of seed output, is required to allow their maintenance. Two non-exclusive mechanisms can account for the maintenance of females. First, as females do not produce pollen they can reallocate their resources towards a higher ovule production. Second, hermaphrodites can self- and cross-fertilize whereas females are obligate outcrossers. Thus hermaphrodites should partly suffer from inbreeding depression (i.e.: the fitness decline of inbred relative to outbred individuals) and thereby produce less fit progeny than females. This thesis investigated the effects of self- and cross-fertilization of heimaphrodites over two consecutive generations. Inbreeding depression increased across the successive stages of the life- cycle (i.e.: from "seed traits" to "reproductive traits") displaying large inbreeding depression estimates (up to 0.76). This investigation not only detected large inbreeding depression estimates but also detected mechanisms involved in the maintenance of inbreeding depression. For instance cryptic self-incompatibility which is here a larger in vivo pollen performance of distant pollen compared to self-pollen; the expression of inbreeding depression especially in late life-cycle stages, and the appearance of females in the progeny of selfed hermaphrodites. The female biased sex ratio in the progeny of selfed hermaphrodites was a surprising result and could either come from the sex determining mechanisms (complex nucleo-cytoplasmic interaction(s)) and/or from inbreeding depression. Indeed, we not only got females and hermaphrodites but also partial male-sterile (PMS) individuals (i.e.: individuals with differing number of viable stamens). We detected that inbred pollen bearing plants (excluding females) have less viable stamens per flower than outbred plants. A positive correlation was detected between inbreeding depression for the number of viable stamens per flower and the difference in sex ratio between inbred and outbred individuals. A positive relationship was also detected between inbreeding depression for pollen viability and inbreeding depression for number of viable stamens per flower. Each correlation can either account for pleiotropic effects (a major gene acting on the two considered traits) or linkage disequilibrium between genes controlling each of the two related traits. If we hypothesize that these correlations are due to a major gene with pleiotropic effects, the positive relationship between inbreeding depression for number of viable stamens per flower and inbreeding depression for pollen viability showed that deleterious alleles present on a major gene coding for pollen production and viability depressed male fitness within inbred plants. The positive relationship between sex ratio difference between inbred and outbred individuals and inbreeding depression for number of viable stamens per flower indicates that (1) either number of viable stamens per flower is, in addition to inbreeding, also affected by the loci coding for sex determinism or, (2) the presence of females within the progeny of selfed hermaphrodites is a consequence of large inbreeding depression inhibiting pollen production, or (3) sex is here determined by a combination of loci coding for sex expression and inbreeding depression for male reproductive traits. In conclusion, Silene vulgaris has been shown to be a good model for understanding the evolution of mating systems that promote outbreeding. Résumé La gynodïoécie est définie comme étant la présence simultanée d'hermaphrodites et de femelles au sein de populations naturelles d'une même espèce. Ce système de reproduction a toujours fasciné le monde scientifique depuis Darwin, comme en témoigne ses écrits (1876, 1877) sur les systèmes de reproduction chez les plantes. Les femelles ne transmettent leurs gènes qu'à travers leurs ovules alors que les hermaphrodites transmettent leurs gènes à la fois par la voie mâle (le pollen) et la voie femelle (les ovules). La condition pour que la gynodïoécie se maintienne nécessite donc une fitness de la fonction femelle plus élevée chez les femelles que chez les hermaphrodites. Deux mécanismes mutuellement non exclusifs peuvent expliquer le maintien des femelles au sein de ces populations gynodioïques. D'une part, les femelles peuvent réallouer les ressources non utilisées pour la production de pollen et peuvent par conséquent produire plus d'ovules. D'autre part, la reproduction des femelles ne peut se faire que par allo-fécondation alors que les hermaphrodites, peuvent se reproduire à la fois par auto- et allo-fécondation. L'autofécondation s'accompagne en général d'une diminution de fitness de la descendance relativement à la progéniture issue d'allo-fécondation ; ce phénomène est connu sous le nom de dépression de consanguinité. Cette thèse avait pour but de mettre en évidence une éventuelle dépression de consanguinité chez Silene vulgaris, une espèce gynodioïque. Des hermaphrodites, issus de trois vallées alpines, ont été auto- et allo¬fécondés sur deux générations successives. La dépression de consanguinité pouvant s'exprimer à tous les stades de vie d'un individu, plusieurs traits de fitness, allant du nombre de graines par fruit à la production de gamètes ont été mesurés sur différents stades de vie successifs. L'estimation de la dépression de consanguinité totale atteignait des valeurs allant de 0.52 à 0.76 selon la vallée considérée, ce qui indiquerait que les hermaphrodites ont tout intérêt à limiter l'autofécondation et que les femelles ne devraient pas avoir de peine à subsister dans les vallées étudiées. Par la même occasion des mécanismes diminuant la purge potentielle du fardeau génétique, et permettant ainsi le maintien du « niveau » de dépression de consanguinité et par conséquence le maintien de la gynodïoécie ont été mis en évidence. En effet, nos résultats montrent que la dépression de consanguinité s'exprimait tard dans le cycle de vie permettant ainsi à un certain nombre individus consanguins de transmettre leurs allèles délétères à la génération suivante. D'autre part, la croissance in vivo des tubes polliniques d'auto-pollen était plus lente que celle de l'allo-pollen et donc en situation de compétition directe, les ovules devraient plutôt être issus d'allo-fécondation, diminuant ainsi les chances de purges d'allèles délétères. Enfin, l'apparition de femelles dans la progéniture d'hermaphrodites autofécondés diminue aussi les chances de purge d'allèles délétères. Il nous a été impossible de déterminer si l'apparition de femelles dans la descendance d'hermaphrodites autofécondés était due au déterminisme génétique du sexe ou si la différence de sexe ratio entre la descendance auto- et allo-fécondée était due à une éventuelle dépression de consanguinité inhibant la production de pollen. Nous avons observé que S. vulgaris ne présentaient pas uniquement des hermaphrodites et des femelles mais aussi toute sorte d'individus intermédiaires avec un nombre variable d'étamines viables. Nous avons pu mettre' en évidence des corrélations positives entre (1) la différence de sexe ratio (la proportion d'individus produisant du pollen) entre individus consanguins et non consanguins et une estimation de la dépression de consanguinité pour le nombre d'étamines viables d'individus produisant du pollen, ainsi qu'entre (2) la dépression de consanguinité pour le nombre d'étamines viables et celle estimée pour la viabilité du pollen. Chaque corrélation indique soit l'effet d'un (ou plusieurs) gène(s) pléiotropique(s), soit un déséquilibre de liaison entre les gènes. En considérant que ces corrélations sont le résultat d'effet pléiotropiques, la relation entre le nombre d'étamines viables par fleur et la viabilité du pollen, indiquerait un effet négatif de la consanguinité sur la production et la viabilité du pollen due partiellement à un gène majeur. La seconde corrélation indiquerait soit que les gènes responsables de la détermination du sexe agissent aussi sur l'expression de la fonction mâle soit que l'expression du sexe est sujette à la dépression de consanguinité, ou encore un mélange des deux. Aux regards de ces résultats, Silene vulgaris s'est avéré être un bon modèle de compréhension de l'évolution des systèmes de reproduction vers la séparation des sexes.

Alpha1b-adrenergic receptors control locomotor and rewarding effects of psychostimulants and opiates.

Drugs of abuse, such as psychostimulants and opiates, are generally considered as exerting their locomotor and rewarding effects through an increased dopaminergic transmission in the nucleus accumbens. Noradrenergic transmission may also be implicated because most psychostimulants increase norepinephrine (NE) release, and numerous studies have indicated interactions between noradrenergic and dopaminergic neurons through alpha1-adrenergic receptors. However, analysis of the effects of psychostimulants after either destruction of noradrenergic neurons or pharmacological blockade of alpha1-adrenergic receptors led to conflicting results. Here we show that the locomotor hyperactivities induced by d-amphetamine (1-3 mg/kg), cocaine (5-20 mg/kg), or morphine (5-10 mg/kg) in mice lacking the alpha1b subtype of adrenergic receptors were dramatically decreased when compared with wild-type littermates. Moreover, behavioral sensitizations induced by d-amphetamine (1-2 mg/kg), cocaine (5-15 mg/kg), or morphine (7.5 mg/kg) were also decreased in knock-out mice when compared with wild-type. Ruling out a neurological deficit in knock-out mice, both strains reacted similarly to novelty, to intraperitoneal saline, or to the administration of scopolamine (1 mg/kg), an anti-muscarinic agent. Finally, rewarding properties could not be observed in knock-out mice in an oral preference test (cocaine and morphine) and conditioned place preference (morphine) paradigm. Because catecholamine tissue levels, autoradiography of D1 and D2 dopaminergic receptors, and of dopamine reuptake sites and locomotor response to a D1 agonist showed that basal dopaminergic transmission was similar in knock-out and wild-type mice, our data indicate a critical role of alpha1b-adrenergic receptors and noradrenergic transmission in the vulnerability to addiction.

Deletion of CREB-Regulated Transcription Coactivator 1 Induces Pathological Aggression, Depression-Related Behaviors, and Neuroplasticity Genes Dysregulation in Mice.

BACKGROUND: Mood disorders are polygenic disorders in which the alteration of several susceptibility genes results in dysfunctional mood regulation. However, the molecular mechanisms underlying their transcriptional dysregulation are still unclear. The transcription factor cyclic adenosine monophosphate (cAMP) response element binding protein (CREB) and the neurotrophin brain-derived neurotrophic factor (BDNF) have been implicated in rodent models of depression. We previously provided evidence that Bdnf expression critically rely on a potent CREB coactivator called CREB-regulated transcription coactivator 1 (CRTC1). METHODS: To further evaluate the role of CRTC1 in the brain, we generated a knockout mouse line and analyzed its behavioral and molecular phenotype. RESULTS: We found that mice lacking CRTC1 associate neurobehavioral endophenotypes related to mood disorders. Crtc1(-/-) mice exhibit impulsive aggressiveness, social withdrawal, and decreased sexual motivation, together with increased behavioral despair, anhedonia, and anxiety-related behavior in the novelty-induced hypophagia test. They also present psychomotor retardation as well as increased emotional response to stressful events. Crtc1(-/-) mice have a blunted response to the antidepressant fluoxetine in behavioral despair paradigms, whereas fluoxetine normalizes their aggressiveness and their behavioral response in the novelty-induced hypophagia test. Crtc1(-/-) mice strikingly show, in addition to a reduced dopamine and serotonin turnover in the prefrontal cortex, a concomitant decreased expression of several susceptibility genes involved in neuroplasticity, including Bdnf, its receptor TrkB, the nuclear receptors Nr4a1-3, and several other CREB-regulated genes. CONCLUSIONS: Collectively, these findings support a role for the CRTC1-CREB pathway in mood disorders etiology and behavioral response to antidepressants and identify CRTC1 as an essential coactivator of genes involved in mood regulation.

Dépression, suicide assisté et vieillissement: cas clinique et commentaires = Depression, assisted suicide and ageing: case report and comments

L'hôpital de jour de psychiatrie de l'âge avancé du centre hospitalier universitaire Vaudois (CHUV), en Suisse, prend en charge ambulatoirement les personnes âgées souffrant de troubles psychiatriques. Cet article relate la première expérience de notre équipe d'une patiente qui est décédée à domicile via l'assistance au suicide alors qu'elle était suivie dans notre service pour un épisode dépressif sévère, de probables troubles cognitifs et un trouble de la personnalité émotionnellement labile de type borderline. Cette pratique d'assistance au suicide, autorisée par la loi suisse sous certaines conditions, est reprécisée et quelques directives médicoéthiques professionnelles sont présentées, avec un accent sur la capacité de discernement. © 2010 Elsevier Masson SAS. Tous droits réservés. The old age psychiatric daycare hospital of the Vaud University Hospital (CHUV), in Switzerland, follows up on elderly ambulatory patients with psychiatric disease. This article relates our team's first time experience with a patient who, while she was being treated in our unit for severe depression, cognitive symptoms and a borderline personality disorder, died at home via a suicide organization. Assisted suicide, allowed by the Swiss law, is also discussed in this article and, in addition, a few professional medico-ethics directives, with an emphasis on decision-making capacity are presented. © 2010 Elsevier Masson SAS. All rights reserved.

Correlates of insomnia in patients with social phobia: role of depression and anxiety.

The severity of insomnia and the relationships between social fear, anxiety, depression and insomnia were examined in 179 patients with social phobia. Two-thirds of our sample had insomnia. Depression, anxiety, social anxiety, and insomnia were positively correlated. General and social anxiety contributed to insomnia when accounting for depression.

The neuroanatomical model of post-stroke depression: towards a change of focus?

One third of all stroke survivors develop post-stroke depression (PSD). Depressive symptoms adversely affect rehabilitation and significantly increase risk of death in the post-stroke period. One of the theoretical views on the determinants of PSD focuses on psychosocial factors like disability and social support. Others emphasize biologic mechanisms such as disruption of biogenic amine neurotransmission and release of proinflammatory cytokines. The "lesion location" perspective attempts to establish a relationship between localization of stroke and occurrence of depression, but empirical results remain contradictory. These divergences are partly related to the fact that neuroimaging methods, unlike neuropathology, are not able to assess precisely the full extent of stroke-affected areas and do not specify the different types of vascular lesions. We provide here an overview of the known phenomenological profile and current pathogenic hypotheses of PSD and present neuropathological data challenging the classic "single-stroke"-based neuroanatomical model of PSD. We suggest that vascular burden due to the chronic accumulation of small macrovascular and microvascular lesions may be a crucial determinant of the development and evolution of PSD.

Macrophage migration inhibitory factor is critically involved in basal and fluoxetine-stimulated adult hippocampal cell proliferation and in anxiety, depression, and memory-related behaviors.

Intensive research is devoted to unravel the neurobiological mechanisms mediating adult hippocampal neurogenesis, its regulation by antidepressants, and its behavioral consequences. Macrophage migration inhibitory factor (MIF) is a pro-inflammatory cytokine that is expressed in the CNS, where its function is unknown. Here, we show, for the first time, the relevance of MIF expression for adult hippocampal neurogenesis. We identify MIF expression in neurogenic cells (in stem cells, cells undergoing proliferation, and in newly proliferated cells undergoing maturation) in the subgranular zone of the rodent dentate gyrus. A causal function for MIF in cell proliferation was shown using genetic (MIF gene deletion) and pharmacological (treatment with the MIF antagonist Iso-1) approaches. Behaviorally, genetic deletion of MIF resulted in increased anxiety- and depression-like behaviors, as well as of impaired hippocampus-dependent memory. Together, our studies provide evidence supporting a pivotal function for MIF in both basal and antidepressant-stimulated adult hippocampal cell proliferation. Moreover, loss of MIF results in a behavioral phenotype that, to a large extent, corresponds with alterations predicted to arise from reduced hippocampal neurogenesis. These findings underscore MIF as a potentially relevant molecular target for the development of treatments linked to deficits in neurogenesis, as well as to problems related to anxiety, depression, and cognition.

Alexithymia and depression in eating disorders.

We compared alexithymia and depression ratings for non-hospitalized women meeting DSM-IV criteria for anorexia nervosa (n=32) and bulimia nervosa (n=32) to ratings for healthy women (n=74). Alexithymia was evaluated by the Toronto Alexithymia Scale (TAS-20) and depression by the Hospital Anxiety and Depression Scale (HAD). TAS and HAD scores were significantly higher in anorexic compared to bulimic patients, although these two scales were significantly and positively correlated (r=0.53, P=0.001). After taking depression into account as a confounding variable, rates of alexithymia did not vary according to the type of eating disorder (anorexia or bulimia).

Stressful life events and neuroticism as predictors of late-life versus early-life depression.

BACKGROUND: The occurrence of depression in younger adults is related to the combination of long-standing factors such as personality traits (neuroticism) and more acute factors such as the subjective impact of stressful life events. Whether an increase in physical illnesses changes these associations in old age depression remains a matter of debate. METHODS: We compared 79 outpatients with major depression and 102 never-depressed controls; subjects included both young (mean age: 35 years) and older (mean age: 70 years) adults. Assessments included the Social Readjustment Rating Scale, NEO Personality Inventory and Cumulative Illness Rating Scale. Logistic regression models analyzed the association between depression and subjective impact of stressful life events while controlling for neuroticism and physical illness. RESULTS: Patients and controls experienced the same number of stressful life events in the past 12 months. However, in contrast to the controls, patients associated the events with a subjective negative emotional impact. Negative stress impact and levels of neuroticism, but not physical illness, significantly predicted depression in young age. In old age, negative stress impact was weakly associated with depression. In this age group, depressive illness was also determined by physical illness burden and neuroticism. CONCLUSIONS: Our data suggest that the subjective impact of life stressors, although rated as of the same magnitude, plays a less important role in accounting for depression in older age compared to young age. They also indicate an increasing weight of physical illness burden in the prediction of depression occurrence in old age.

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: rationale and design of a randomized controlled trial.

BACKGROUND: A few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. However, there is a lack of controlled studies in this area and to date no study of adequate quality on brief psychodynamic psychotherapy for depression during short inpatient stay exists. The present article describes the protocol of a study that will examine the relative efficacy, the cost-effectiveness and the cost-utility of adding an Inpatient Brief Psychodynamic Psychotherapy to pharmacotherapy and treatment-as-usual for inpatients with unipolar depression. METHODS/DESIGN: The study is a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 130 consecutive adult inpatients with unipolar depression and Montgomery-Asberg Depression Rating Scale score over 18 will be recruited. The study is carried out in the university hospital section for mood disorders in Lausanne, Switzerland. Patients are assessed upon admission, and at 1-, 3- and 12- month follow-ups. Inpatient therapy is a manualized brief intervention, combining the virtues of inpatient setting and of time-limited dynamic therapies (focal orientation, fixed duration, resource-oriented interventions). Treatment-as-usual represents the best level of practice for a minimal treatment condition usually proposed to inpatients. Final analyses will follow an intention-to-treat strategy. Depressive symptomatology is the primary outcome and secondary outcome includes measures of psychiatric symptomatology, psychosocial role functioning, and psychodynamic-emotional functioning. The mediating role of the therapeutic alliance is also examined. Allocation to treatment groups uses a stratified block randomization method with permuted block. To guarantee allocation concealment, randomization is done by an independent researcher. DISCUSSION: Despite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. This study is the first to address the issue of the economic evaluation of inpatient psychotherapy. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ACTRN12612000909820).

Die Krankheit Depression kann jeden treffen [In Process Citation].

The survey "Datenerhebung zur Depression in der Allgemeinbevölkerung" was conducted from fall 2010 to spring 2011 on several online platforms. The results show that there is a considerable timespan between the appearance of initial symptoms of depression and the first diagnosis of a patient. Intervention at early stages of the disease can reduce a potentially long time of suffering and can lead to the successful treatment of depression. General practitioners play an important role as the link between patient and psychiatrist.

The Brief Psychiatric Rating Scale (version 4.0) factorial structure and its sensitivity in the treatment of outpatients with unipolar depression.

The 24-item Brief Psychiatric Rating Scale (BPRS, version 4.0) enables the rater to measure psychopathology severity. Still, little is known about the BPRS's reliability and validity outside of the psychosis spectrum. The aim of this study was to examine the factorial structure and sensitivity to change of the BPRS in patients with unipolar depression. Two hundred and forty outpatients with unipolar depression were administered the 24-item BPRS. Assessments were conducted at intake and at post-treatment in a Crisis Intervention Centre. An exploratory factor analysis of the 24-item BPRS produced a six-factor solution labelled "Mood disturbance", "Reality distortion", "Activation", "Apathy", "Disorganization", and "Somatization". The reduction of the total BPRS score and dimensional scores, except for "Activation", indicates that the 24-item BPRS is sensitive to change as shown in patients that appeared to have benefited from crisis treatment. The findings suggest that the 24-item BPRS could be a useful instrument to measure symptom severity and change in symptom status in outpatients presenting with unipolar depression.