(PSYCHIATRIC TIMES) - Most important, antidepressants do not work as quickly or as effectively as the original monoamine hypothesis would suggest. Monoamine action also does not explain much of the clinical activity of diverse mood stabilizers (lithium [Eskalith, Lithobid], valproic acid [Depakote, Depakene], carbamazepine [Carbatrol, Tegretol]), and some atypical antipsychotics. In addition, the monoamine theory fails to account for recent evidence concerning structural changes within the brain that are associated with affective illness in both humans and animal models.
A more recent conceptualization of mood disorders and their treatment invokes the phenomenon of human brain plasticity, in which the brain is capable of adapting to many circumstances—both external (ie, environmental) and internal (ie, hormones, neurotransmitters, and neurotrophic growth factors). The constant remodeling of the brain is probably responsible for memory formation and the ability to learn motor programs, as well as complex behavioral strategies. A well-known finding that suggested such brain restructuring was that London taxi drivers had larger gray matter volumes in their brains' posterior hippocampi than age-matched controls; this correlated positively with time spent driving a taxi.1 Brain complexity and adaptability also allows for things to go wrong, which sometimes can result in a mood disorder.
CHANGES IN BRAIN ANATOMY
Human imaging studies show that major depression correlates with decreased hippocampal volume. The magnitude of the change in hippocampal volume is directly proportional to the length of illness.2 Up to a 19% loss in hippocampal volume may occur in patients with severe, untreated depression.3 A reduction in hippocampal volume is also observed in patients who have posttraumatic stress disorder.4
Such hippocampal changes may explain the memory impairment that is seen in patients with severe depression (the hippocampus has long been known to be important in intact memory function and emotional processing). In addition, the hippocampus has a role in hypothalamic-pituitary-adrenal axis functioning, which is often impaired in patients with severe major depression.
Animal studies have suggested that anatomical changes in the adult hippocampus may result from atrophy of neurons and a reduction of neurogenesis. Chronically exposing rodents to physical stress or exposing primates to psychological stress causes atrophy of carbonic anhydrase 3 pyramidal neurons in the hippocampus5 that is partly mediated by excessive levels of glucocorticoids.6
However, the results of postmortem studies in humans with depression have been less clear. Most cellular and morphological postmortem studies in humans with depression have focused on cortical brain structures, where there have been some reported reductions in the size of neuronal cell bodies and number of glia.7,8 Anatomical studies of the human hippocampus are scarce, although 1 study of post- mortem findings collected from 19 patients with major depression compared with 21 control subjects found that the average soma size of pyramidal neurons was significantly reduced in the major depression group.
Imaging studies from patients who have bipolar disorder also demonstrate significant brain volume reductions, but with considerable variability among studies. Some investigators have reported decreased volume in medial temporal lobe structures, with a greater effect on the amygdala (15.6%) than on the hippocampus (5.3%).9 Others have found decreases in subgenual prefrontal cortex volume10 or in the corpus collosum.11
Antidepressant medications seem able to regrow the hippocampus, in part by stimulating the production of new neurons in the hippocampus from stem cells that reside there.12 These findings are consistent with the slow clinical action of antidepressants, which usually does not begin for 1 to 2 weeks and can take up to 8 weeks for full effect.
The question then arises of how depression or severe stress might decrease neuronal size and numbers, and how treatment may reverse that atrophy and possibly result in neurogenesis. Research is focusing on the downstream effects of mood stabilizers and antidepressants, including the modulation of intracellular signaling, gene expression, and neural plasticity. Signaling seems to serve to maintain the pathways. Molecular and cellular dysfunction, either because of signaling problems or other issues, might result in destabilization of mood and the associated neurovegetative abnormalities observed in unipolar and bipolar affective disorders.13
Neurotransmission begins when "first messenger" neurotransmitters (eg, monoamines, such as serotonin, norepinephrine, and dopamine, or other transmitters, such as acetylcholine and glutamate) are released from a presynaptic terminal. The neurotransmitter then binds to and activates postsynaptic receptors that modify properties of the postsynaptic cell.
These postsynaptic receptors are large protein molecules that are embedded in the lipid neuronal membrane on the receiving neuron's surface. For most monoamines, these receptors are in the guanine-protein-coupled receptor family (which are sometimes called "metabotropic" receptors as opposed to the other main family of receptors called "ion channel" receptors).
When a guanine-protein (G-protein) receptor is occupied by its specific neurotransmitter, it changes shape and releases a G-protein.14 This G-protein second messenger system, in turn, activates enzymes in the neuronal cytoplasm (particularly protein kinases), which add phosphate groups to a variety of proteins within the receiving neuron and set in motion a complex molecular cascade that ultimately turns on genes and DNA in the receiving neuron. Phosphorylation is key to second messenger system function.
Other second messengers
There are two related second messenger systems that seem particularly important. The first is the phosphoinositol system, which helps regulate the level of calcium in the cytoplasm of neurons (which is very low).
In contrast, calcium is present in high concentrations in seawater and in our bloodstream. That is not mere coincidence, since it represents an attempt at maintaining the mechanisms that worked in the ocean environment before animals transitioned to land. Yet, intracellular levels of calcium are low—0.0001 of that outside the cell. Careful regulation of calcium levels may be required for nature to use phosphorylation as an efficient way to regulate intracellular activities, since very high levels of calcium would cause calcium phosphate to form, interfering with the enzymatic action needed to add or cleave off phosphate groups.15
Another messenger system that works with G-proteins is the adenylate cyclase, or cyclic adenosine monophosphate (cAMP), second messenger system. The cAMP response element binding (CREB) protein is a transcription factor that can mediate the actions of the cAMP system, again primarily through phosphorylation. Protein kinases are known to phosphorylate and activate CREB proteins. All this is important, since the cAMP cascade and CREB protein may represent the pathway by which serotonin and norepinephrine antidepressants do their work.16
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