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Molecular Psychiatry (2008) 13, 800–812 & 2008 Nature Publishing Group All rights reserved 1359-4184/08 $30.00 www.nature.com/mp ORIGINAL ARTICLE Polymorphisms in inflammation-related genes are associated with susceptibility to major depression and antidepressant response M-L Wong, C Dong, J Maestre-Mesa and J Licinio Department of Psychiatry and Behavioral Sciences, Center on Pharmacogenomics, University of Miami Miller School of Medicine, Miami, FL, USA There are clinical parallels between the nature and course of depressive symptoms in major depressive disorder (MDD) and those of inflammatory disorders. However, the characterization of a possible immune system dysregulation in MDD has been challenging. Emerging data support the role of T-cell dysfunction. Here we report the association of MDD and antidepressant response to genes important in the modulation of the hypothalamic–pituitary– adrenal axis and immune functions in Mexican Americans with major depression. Specifically, single nucleotide polymorphisms (SNPs) in two genes critical for T-cell function are associated with susceptibility to MDD: PSMB4 (proteasome b4 subunit), important for antigen processing, and TBX21 (T bet), critical for differentiation. Our analyses revealed a significant combined allele dose–effect: individuals who had one, two and three risk alleles were 2.3, 3.2 and 9.8 times more likely to have the diagnosis of MDD, respectively. We found associations of several SNPs and antidepressant response; those genes support the role of T cell (CD3E, PRKCH, PSMD9 and STAT3) and hypothalamic–pituitary–adrenal axis (UCN3) functions in treatment response. We also describe in MDD increased levels of CXCL10/IP-10, which decreased in response to antidepressants. This further suggests predominance of type 1 T-cell activity in MDD. T-cell function variations that we describe here may account for 47.8% of the attributable risk in Mexican Americans with moderate MDD. Immune function genes are highly variable; therefore, different genes might be implicated in distinct population groups. Molecular Psychiatry (2008) 13, 800–812; doi:10.1038/mp.2008.59; published online 27 May 2008 Keywords: TBX21; PSMB4; major depression; genetic; SNP; cytokine Introduction in which a sustained focus on the threatening stimulus, fear-related behaviors and stereotyped Major depressive disorder (MDD) is a common and states of cognition and affect are matched with complex disorder of unknown etiology that affects indices of physiological hyperarousal, such as activa- about 15% of the population.1 Despite recent scien- tion of the hypothalamic–pituitary–adrenal (HPA) tific advances and its enormous social costs,2 MDD axis and sympathetic activation, and inhibition of is still currently thought to be a gene-environment counterproductive neurovegetative functions during disorder of polygenic nature with a descriptive life-threatening situations.5,6 Depression-like symp- diagnosis and no known biomarkers.1 Although the toms have been associated with activation of the HPA contributions of immune mediators to the pathophysio- axis, sympathetic nervous system and inflammatory logy and treatment of psychiatric disorders may be response characterized by hypercortisolaemia,7 increased traced back to over 80 years with the work of Nobel central corticotropin-releasing hormone (CRH)8–10 and laureate Julius Wagner-Jauregg,3 evidence from clin- norepineprhine11,12 functions, increased numbers of ical and basic research have recently supported a role peripheral leukocytes, positive acute phase proteins for dysregulation of the immune system in MDD.4 and proinflammatory cytokines.13 Both acute stress and MDD are states of hyperarousal, We and others have proposed a role for proin- flammatory cytokines in the pathophysiology of Correspondence: Dr M-L Wong, Department of Psychiatry and MDD, with activation of the immune system and of Behavioral Sciences, Center on Pharmacogenomics, School of the cellular immune response.14,15 Even though still Medicine at the University of Miami, 1580 NW 10th Avenue, underexplored in MDD, the T-cell arm of the immune Room 633-A, Miami, FL 33136, USA. system has been emerging as the centerpiece of the E-mail: [email protected] Received 5 February 2008; revised 10 April 2008; accepted 14 continued debate over the role of the immuno- April 2008; published online 27 May 2008 mediators in depression.15,16 Data supporting either Inflammation-related genes in major depression M-L Wong et al 801 a predominance of cytokine-producing helper T-cells, (Table 1). We also conducted multiplex assays of 21 type 1 (Th1) or type 2 (Th2) have accumulated. The circulating cytokines in a subset of our patients. overactivity of the hallmarks of Th1 immunity, such as interferon-g (IFNg), tumor necrosis factor-a or Methods interleukin-1 (IL-1),17 or predominant Th2 patterns Genetic study of production supported by increased levels of IL-6, IL-10 or IL-1316 have continued to fuel this discus- Study population. This study was approved by the sion. At least two fundamental processes may institutional review boards of the University of contribute to the role of the T-cell arm of adaptive California Los Angeles and the University of Miami, immunity in MDD: T-cell programmed differentiation and it has been registered in the public database and antigen processing. ClinicalTrials.gov (NCT00265292). The study Naive CD4 þ T lymphocytes proliferate and differ- population consisted of 284 depressed Mexican entiate into two main lineages defined by distinct Americans enrolled in a pharmacogenetic study cytokine profiles18 after encountering antigen-carry- of antidepressant treatment response as previously ing dendritic cells in secondary lymphoid organs. described.26,27 We also studied 331 control The balance of two main subtypes of cytokine- individuals recruited from the same Mexican- producing Th1/Th2 determines the immune response American community in Los Angeles and studied to pathogens. Clinically, Th1 patterns of cytokine by the same bilingual clinical research team. Controls production are associated with inflammation and for our genomic studies were in general good health autoimmune disease, whereas Th2 patterns are but were not screened for medical or psychiatric related to allergic responses and asthma.19 Th1 cell- illness. All patients were Mexican-American men and lineage commitment is controlled by the key trans- women aged 21–68 years, with a current episode of criptional factor TBX21 (Tbet),20 which is rapidly major depression as diagnosed by DSM-IV (Diagnostic produced early in Th1 differentiation and gradually and Statistical Manual of Mental Disorders, decreases at later stages.21 TBX21 has the ability to 4th edn).28 In our study, all Mexican-American simultaneously drive Th1 genetic programs and subjects had at least three grandparents born in repress the development of the opposing Th2 Mexico.26 All patients had comprehensive subset; it may also redirect fully polarized Th2 cells psychiatric and medical assessments. We used into Th1 cells. diagnostic and ratings instruments that have been Proteasomes (prosome, macropain) are the major fully validated in English and Spanish, and intracellular extralysosomal organelle for protein conducted all assessments in the subject’s primary degradation and a central source of antigenic peptides language. in the endogenous pathway; they are utilized in major Inclusion criteria included DSM-IV diagnosis of histocompatibility complex molecules class I current, unipolar major depressive episode, with a 21- (MHC1) antigen processing and protein degradation. item Hamilton Depression Rating Scale (HAM-D21)29 Proteasomes are highly abundant in the cytosol and score of 18 or greater with item number 1 (depressed nucleus and are organized as multiunit protease mood) rated 2 or greater. There was no anxiety complexes. Protein degradation is central to threshold for inclusion. Subjects with any primary many important biological functions, including axis I other than MDD (for example, dementia, cell-cycle progression, apoptosis, synaptic reorgani- psychotic illness, bipolar disorder, adjustment dis- zation, DNA repair, normal immune surveillance order), electroconvulsive therapy in the past 6 months mechanisms and immune response networks. or previous lack of response to desipramine or Disruption of the proteasomal degradation pathway fluoxetine were excluded. As anxiety can be a has been implicated in a wide range of human manifestation of depression, patients who met criteria disorders; immune abnormalities include the devel- for depression and also anxiety disorder were not opment of CD8 þ T lymphocytes and MHC1 excluded. Exclusion criteria included active medical molecules, and MHC1-restricted antigen presentation illnesses that could be etiologically related to the have been described in mice lacking proteasome ongoing depressive episode (for example, untreated subunits.22 Independent lines of research have hypothyroidism, cardiovascular accident within the supported the role of protein synthesis/degradation past 6 months, uncontrolled hypertension or dia- in MDD-like neuropsychiatric symptoms in autoim- betes), current, active suicidal ideation with a plan mune disorders23 and in the central actions of and strong intent, pregnancy, lactation, current use of antidepressant drugs.24 medications with significant central nervous system We used a combination strategy consisting of activity, which interfere with electroencephalography genetic analyses and functional