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Neuroactive Steroids and Affective Symptoms in Women Across the Weight Spectrum

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Neuroactive Steroids and Affective Symptoms in Women Across the Weight Spectrum Neuropsychopharmacology (2018) 43, 1436–1444 © 2018 American College of Neuropsychopharmacology. All rights reserved 0893-133X/18 www.neuropsychopharmacology.org Neuroactive Steroids and Affective Symptoms in Women Across the Weight Spectrum ,1 1 1 2 2 Laura E Dichtel* , Elizabeth A Lawson , Melanie Schorr , Erinne Meenaghan , Margaret Lederfine Paskal , 3 4 4 5,6 1 Kamryn T Eddy , Graziano Pinna , Marianela Nelson , Ann M Rasmusson , Anne Klibanski and 1 Karen K Miller 1 2 Neuroendocrine Unit, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA; Neuroendocrine Unit, Massachusetts General 3 Hospital, Boston, MA, USA; Eating Disorders Clinical and Research Program, Massachusetts General Hospital/Harvard Medical School, Boston, 4 5 MA, USA; The Psychiatric Institute, Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA; National Center for PTSD, Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA; 6Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA α α α α β 3 -5 -Tetrahydroprogesterone, a progesterone metabolite also known as allopregnanolone, and 5 -androstane-3 ,17 -diol, a α testosterone metabolite also known as 3 -androstanediol, are neuroactive steroids and positive GABAA receptor allosteric modulators. Both anorexia nervosa (AN) and obesity are complicated by affective comorbidities and hypothalamic–pituitary–gonadal dysregulation. However, it is not known whether neuroactive steroid levels are abnormal at the extremes of the weight spectrum. We hypothesized that serum allopregnanolone and 3α-androstanediol levels would be decreased in AN compared with healthy controls (HC) and negatively associated with affective symptoms throughout the weight spectrum, independent of body mass index (BMI). Thirty-six women were 1 : 1 age-matched across three groups: AN, HC, and overweight/obese (OW/OB). AN were amenorrheic; HC and OW/OB were studied in the follicular phase. Fasting serum neuroactive steroids were measured by gas chromatography/mass spectrometry. Mean Hamilton depression and anxiety scores were highest in AN (po0.0001). Mean serum allopregnanolone was lower in AN and OW/OB than HC (AN 95.3 ± 56.4 vs OW/OB 73.8 ± 31.3 vs HC 199.5 ± 167.8 pg/ml, p = 0.01), despite comparable mean serum progesterone. Allopregnanolone levels, but not progesterone levels, were negatively associated with depression and anxiety symptom severity, independent of BMI. Serum 3α-androstanediol levels did not differ among groups and were not associated with depression or anxiety scores, despite a significant negative association between free testosterone levels and both anxiety and depression severity. In conclusion, women at both extremes of the weight spectrum have low mean serum allopregnanolone, which is associated with increased depression and anxiety severity, independent of BMI. Neuroactive steroids such as allopregnanolone may be potential therapeutic targets for depression and anxiety in traditionally treatment-resistant groups, including AN. Neuropsychopharmacology (2018) 43, 1436–1444; doi:10.1038/npp.2017.269; published online 6 December 2017 INTRODUCTION is a potent positive allosteric modulator of GABA action at GABA receptors increasing GABA activity with 10 times Peripherally derived sex steroids, including progesterone and A the potency of benzodiazepines (King, 2013; Majewska et al, testosterone, can be converted by biosynthetic enzymes into 1986; Morrow et al, 1987). Although less potent than neuroactive steroids that reach and act in the brain, where allopregnanolone, 3α-androstanediol is also a positive they may regulate affective symptoms by modulating modulator of GABAA receptor action (Reddy, 2004). α neurotransmitter systems. The enzymes 5 -reductase and Increases in GABAA receptor activity dampen neuronal 3α-hydroxysteroid-dehydrogenase (3α-HSD) metabolize excitation and result in anxiolytic, antidepressant, and progesterone to 3α-5α-tetrahydroprogesterone (also known sedative effects in humans (Eser et al, 2006a; Eser et al, as allopregnanolone) and testosterone to 5α-androstane- 2006b; Rasmusson et al, 2006; Rupprecht and Holsboer, 3α,17β-diol (also known as 3α-androstanediol) in a parallel 1999a,b,; Sigel and Steinmann, 2012). However, little is known about whether such GABAergic neuroactive steroids manner (Figure 1) (King, 2013; Reddy, 2010). Allopregnanolone contribute to the etiopathology of affective disorders in women at the extremes of the weight spectrum, which are *Correspondence: Dr LE Dichtel, Neuroendocrine Unit, Massachusetts General Hospital, BUL457B, 55 Fruit Street, Boston, MA 02114, USA, enriched for both depression and anxiety symptoms. Tel: +1 617 726 3870, Fax: +1 617 726 5072, Small studies have suggested that both cerebrospinal fluid E-mail: [email protected] (CSF) and serum allopregnanolone levels may be low in Received 22 May 2017; revised 24 August 2017; accepted 27 October patients with major depressive disorder (MDD) and post- 2017; accepted article preview online 1 November 2017 traumatic stress disorder (PTSD) as compared with healthy Neuroactive steroids and affective symptoms LE Dichtel et al 1437 O O O H 5 -reductaseH 3 -HSD H H H H H H H O O HO H H 3 ,5 -Tetrahydroprogesterone Progesterone 5 -Dihydroprogesterone (Allopregnanolone) OH OH OH H 5 -reductaseH 3 -HSD H H H H H H H O O HO H H 5 -Androstane-3 ,17 -diol 5 -Dihydrotestosterone Testosterone (3 -Androstanediol) Figure 1 Metabolism of progesterone to allopregnanolone (top row) and testosterone to 3α-androstanediol (bottom row), demonstrating parallel enzymatic pathways via 5α-reductase and 3α-hydroxysteroid dehydrogenase (3α-HSD). controls (Rasmusson et al, 2006; Romeo et al, 1998; Strohle limited; two studies, one in women alone and one in both et al, 1999; Uzunova et al, 1998). Girdler et al (2012) sexes combined, reported higher levels of allopregnanolone additionally noted decreased conversion of progesterone to in obese than normal-weight individuals without considera- allopregnanolone in women with a history of depression. tion of comorbid psychiatric symptomatology (Menozzi Moreover, results from three small studies suggest that et al, 2002; Monteleone et al, 2003). However, all these pharmacological antidepressant therapy with selective ser- studies were limited by the use of immunoassays to measure otonin reuptake inhibitors (SSRIs) may increase allopregna- allopregnanolone levels, which are particularly vulnerable to nolone levels in CSF, serum, and postmortem brain, cross-reactivity with similarly structured steroid hormone implying a possible mechanistic role in depression etiology metabolites (Cheney et al, 1995a; Siekmann, 1979). Addi- and recovery (Agis-Balboa et al, 2014; Romeo et al, 1998; tionally, while some studies exclude women on oral contra- Strohle et al, 1999; Uzunova et al, 1998). One such study ceptives (Monteleone et al, 2001; Monteleone et al, 2003) and showed that SSRI treatment in depressed subjects led to an control for the follicular phase of the menstrual cycle increase in CSF allopregnanolone levels and that these levels (Menozzi et al, 2002; Monteleone et al, 2001; Monteleone positively correlated with improvement in depressive symp- et al, 2003), others (Galderisi et al, 2003) do not specify these toms in the absence of changes in the levels of precursors, conditions, which are critical in the assessment of neuroac- such as progesterone (Uzunova et al, 1998). In another study, tive steroids. drug-naive outpatients with MDD demonstrated significant Given the sex steroid deficiency in AN, as well as the high increases in serum allopregnanolone levels with SSRI rates of AN-associated MDD, we hypothesized that allo- treatment (Romeo et al, 1998). In a third study, serum pregnanolone and 3α-androstanediol levels would be lower allopregnanolone levels increased with ‘clinically effective’ in women with AN than age-matched lean and overweight/ antidepressant administration (Strohle et al, 1999). Studies obese women; we also hypothesized that levels of allopreg- α have shown that the administration of 3α-androstanediol nanolone and 3 -androstanediol would be inversely asso- reduces depressive behaviors in male and female mice (Frye ciated with severity of depression and anxiety across the and Walf, 2009). However, there are no data in humans on three groups, independent of weight. We therefore measured the testosterone metabolite 3α-androstanediol in relation to serum levels of the neuroactive steroids allopregnanolone α – mood disorders. and 3 -androstanediol using gas chromatography mass Anorexia nervosa (AN) and overweight/obesity (OW/OB) spectrometry (GC-MS) performed after separation of the are both complicated by high rates of comorbid depression steroids of interest by high pressure liquid chromatography and anxiety. AN in women is complicated by depression (HPLC) in women across the weight spectrum and and/or anxiety in 450% of cases. Seven percent of obese investigated the relationship between these neuroactive adults have depression; 43% of adults with depression are steroids and affective symptom severity. obese (Bredella et al, 2014; Herzog et al, 1996). In women, increasing BMI has been associated with MDD and suicidal ideation, and the diagnosis of obesity has been shown to MATERIALS AND METHODS confer a 37% increased risk of an MDD diagnosis in women Subjects according to US National Survey data (Carpenter et al, 2000). Given the deficiency of gonadal hormonal substrates in This study
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