Selective study of sulfate and glucuronide conjugates of urinary MHPG in nervous depression. Peripheral and central influences

The determination of urinary MHPG (3-methoxy-4-hydroxyphenyl glycol) has been extensively performed to confirm the noradrenergic hypothesis of some depressions. However, owing to the double origin, central and peripheral, of this norepinephrine metabolite, the validity of total MHPG assay as an index of central noradrenergic activity may be challenged. MHPG exists in human urine in two conjugated forms, at equal amounts: sulfate and glucuronide. A number of arguments suggest that MHPG sulfate and MHPG glucuronide respectively reflect central and peripheral norepinephrine metabolism. In this work, we have selectively estimated both MHPG conjugates in 24 h-urine samples of 36 severely depressed women in view to assess the extent and frequency of central or/and peripheral norepinephrine dysfunction. On the basis of MHPG sulfate and glucuronide values, we conclude that in the examined population (6 endogenous, 19 neurotic, 11 reactive depressions) about 80% of patients exhibited a central NE functional deficit, and many of them had also a diminished sympathetic activity. Clinical symptoms related to psychic factors (melancholia) or associated to sympathetic activity changes (anxiety, retardation) respectively alter sulfate or glucuronide MHPG excretion. These data altogether validate the concept of the independent origin of the two MHPG conjugated and show that their selective assay is able to provide a more satisfactory reflection of the psychobiological state in depressed patients than total MHPG determination.     

Urinary MHPG sulfate as a marker of central norepinephrine metabolism: a commentary

Summary Measurement of total (free + conjugated) 3 methoxy-4-hydroxyphenylglycol (MHPG) in urine has long been used to assess the metabolism of central norepinephrine (NE). However, available data indicate that total MHPG is not a sensitive marker because the portion of urinary MHPG which derives from brain NE is less than was previously assumed.Several arguments support the view that central MHPG excretion is best represented by the urinary MHPG sulfate fraction. Accordingly, a new strategy has been introduced in last years, involving the separate determination of sulfate and glucuronide conjugates of MHPG as respective markers of central and peripheral NE metabolism. Various biochemical and pharmacological data obtained in healthy subjects and in patients with mental diseases support this hypothesis.     

Sulfate and glucuronide conjugates of 3-methoxy-4-hydroxyphenylglycol (MHPG) in urine of depressed patients: Central and peripheral influences

Summary A number of arguments support the hypothesis that changes in urinary levels of MHPG sulfate and MHPG glucuronide respectively reflect central and peripheral norepinephrine metabolism (NE) in man. In this line, the daily excretion of both conjugates was determined in 36 depressed women comparatively to 23 healthy women in order to assess the extent and the central or peripheral location of their possible NE dysfunction. About 80% of the patients suffering from depression (6 endogenous, 19 neurotic, 11 reactive depressions) exhibited a central NE defect, as evidenced by low MHPG sulfate, and many of them had probably also diminished sympathetic activity, as suggested by low MHPG glucuronide. Clinical symptoms possibly related to the psychic state (mood alteration) or associated to sympathetic changes (anxiety, motor activity) respectively altered sulfate or glucuronide excretion. Sulfate (S) and glucuronide (G) MHPG excretions were significantly correlated in healthy subjects (r = 0.53, p = 0.01), thus supporting the concept of the functional link between central NE activity and sympathetic function. Such a correlation was not found in depressive patients. However the lack of significant changes in the mean ratio S/G in the patient subgroups suggests that as in normal subjects, central and peripheral NE activity As a conclusion, our work shows that urinary MHPG provides in depressed patients an index of the psychobiological state, involving central and peripheral components. Any factor acting on either of both components is able to modify MHGP excretion. The separate assay of sulfate and glucuronide MHPG allows-with some limitations-to define the relative changes of central and peripheral activity. As a whole, our data indicate that in the examined population, 80% had probably a central NE hypoactivity, also associated in a large number to a sympathetic dysfunction. These observations may have valuable physiopathologic and/or therapeutic implications.Presented in part at the 5th International Catecholamine Symposium, Göteborg, Sweden, June 6, 1983, and at the meeting of the Franco Italian Psychiatric Association, Lyon, France, May 24–25, 1984.     

Alteration of norepinephrine metabolism with desipramine and zimelidine in depressed patients

Twelve patients with a major affective disorder were treated during the depressed phase of their illness with desipramine hydrochloride and/or zimelidine hydrochloride, and urinary excretion rates of norepinephrine and its major metabolites were examined. During treatment with desipramine, daily urinary excretion of norepinephrine, 3-methoxy-4-hydroxyphenylglycol (MHPG), and vanillylmandelic acid was reduced, but urinary normetanephrine excretion was not significantly changed. In all patients, the proportion of urinary norepinephrine metabolites represented by normetanephrine was increased during desipramine treatment. Independent of treatment outcome, desipramine seemed to decrease total formation and metabolism of norepinephrine, which was reflected in decreases in the excretion rate of the catecholamine and its metabolites. These results are consistent with known actions of desipramine on the disposition of norepinephrine and represent alterations in the rate of norepinephrine formation and metabolism, resulting from inhibition of norepinephrine reuptake. Zimelidine, a new antidepressant, which is a relatively specific serotonin-uptake inhibitor, significantly reduced only urinary MHPG excretion without appearing to alter "whole-body" norepinephrine turnover. This effect of zimelidine on norepinephrine metabolism was unexpected. Current and previous findings concerning clorgyline, a relatively specific monoamine oxidase A inhibitor, suggest that three pharmacologically distinct classes of antidepressants, norepinephrine and serotonin-reuptake and monoamine oxidase type A inhibitors, all reduce central norepinephrine turnover in depressed patients.     

The influence of total sleep deprivation on urinary excretion of catecholamine metabolites in major depression

To elucidate the influence of total sleep deprivation (TSD) on catecholaminergic neurotransmission, which is assumed to be disturbed in depression, 9 depressive patients collected consecutive 24-h urine samples prior to (baseline), during (TSD) and following total sleep deprivation (post-TSD). Urine samples were analysed for total MHPG (3-methoxy-4-hydroxyphenylglycol), conjugates of MHPG (glucuronide and sulfate), excretion of HVA (homovanillic acid) and VMA (3-methoxy-4-hydroxymandelic acid). TSD increased the urinary excretion of MHPG-sulfate as a marker of the central norepinephrine metabolism and the excretion rates of VMA and HVA as indices of the peripheral catecholamine metabolism. Patients with higher VMA values prior to TSD reacted worse, and the VMA increase due to TSD was positively correlated with the response. The results demonstrate that TSD, besides acting as a stimulus on the peripheral sympathetic nervous system, influences central nervous noradrenergic neurotransmission, as reflected by the increase of MHPG-sulfate.     

Disposition and metabolism of MHPG in humans: application to studies in depression

MHPG is formed from norepinephrine metabolized throughout the body; its levels in plasma reflect total norepinephrine metabolism. Over half of the MHPG, is converted to VMA. Less than 20% of MHPG is derived from brain norepinephrine and urinary excretion of this metabolite cannot be used as a measure of brain norepinephrine metabolism. Because unconjugated MHPG is readily diffusable, there is a free exchange of this metabolite among plasma, cerebrospinal fluid, and nerve tissues (including brain and spinal cord). The CSF MHPG levels, after appropriately correction for the plasma contribution of the metabolite, reflect its rate of formation in the central nervous system.     

Effect of fluoxetine treatment on serotonin and MHPG in 32 patients with major depressive disorder

Considering the concept that depressive disorders were not only resulting from activity of one neurotransmitter, possible interactions between the noradrenergic system and a selective serotonin uptake inhibitor, fluoxetine, were investigated in order to test the hypothesis of noradrenergic or serotonergic involvement in depression. So the biological parameters (plasma and urinary MHPG, platelet serotonin) were evaluated by HPLC. The aim of this study was to evaluate the correlations between the concentrations of MHPG and serotonin in 32 melancholic patients treated by fluoxetine (20 mg/day) during a minimum of three weeks. The clinical examination with evaluation of the antidepressant effect carried out using the HDS/MES rating scale, allowed to divide the patients into three groups: responders to treatment, partial responders and non responders. In the same time, a control group of healthy subjects was investigated. ANOVA applied to platelet serotonin at day 0 showed a tendency toward heterogeneity between the three patient groups and the control group. The concentrations of serotonin in the three patients groups were highly reduced after 21 days of treatment. Concerning plasma and urinary MHPG there was non significant difference among the three patients groups at day 0 and the control groups. After treatment by fluoxetine, the results suggest that the urinary sulfate MHPG is an indicator of the metabolism of brain norepinephrine and seems to be a better turnover indicator than the plasma sulfate MHPG. The selective evaluation of sulfate and glucuronide MHPG could give a better survey of the psychobiological state of the patients than the total MHPG evaluation.     

Origin of free 3-methoxy-4-hydroxyphenylethyleneglycol in rat cerebrospinal fluid

Summary The origin of free 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG, a major metabolite of norepinephrine) in rat cerebrospinal fluid (CSF) was investigated using brain and spinal cord perfusions with artificial CSF, electrical stimulation of the locus coeruleus (LC) and the technique of retrograde cell labelling with horseradish peroxidase (HRP). The rates of appearance of MHPG into ventricular-cisternal and lumbar-cisternal perfusates were about 12.4 and 19.2 ng/hour respectively. Probenecid (200 mg/kg i.p.) did not alter the MHPG output in either preparation. Intravenous administration of 3g MHPG did not substantially enhance the outflow of the metabolite in the ventricular-cisternal perfusate, indicating that MHPG found in the perfusate is of central origin. Maximal activation of central norepinephrine (NE)-containing neurons of the LC by electrical stimulation induced a 50% increase of MHPG levels in the ventricular-cisternal perfusate. In addition HRP was found to be retrogradely transported from the lateral ventricle to these LC-neurons.These findings indicate that MHPG in CSF originates, at least in part from NE of nerve terminals adjacent to the cerebral ventricles, which have their origin in the LC. We calculated that the fraction of MHPG formed in the central nervous system, that was released into the CSF was about 34%. It is concluded that MHPG in CSF is a measure for changes in central NE turnover and that a considerable portion is dependent upon the activity of LC neurons.     

Dopamine metabolism and disposition in schizophrenic patients. Studies using debrisoquin

Debrisoquin sulfate, a monoamine oxidase inhibitor that does not enter the brain, was administered to 23 schizophrenic subjects. Plasma, cerebrospinal fluid (CSF), and urine samples were obtained before and during debrisoquin administration and were assayed for their content of norepinephrine and dopamine metabolites, ie, 3-methoxy-4-hydroxyphenylglycol (MHPG), homovanillic acid (HVA), and dihydroxyphenylacetic acid. The severity of the patient's schizophrenic symptoms was also assessed with several types of rating scales. During debrisoquin administration there were significant reductions in plasma, urine, and CSF MHPG levels. Regression analyses suggested that the reduction in CSF MHPG level was probably due to the reduction in plasma MHPG level, which contributes to the CSF MHPG pool. Debrisoquin administration was not associated with changes in CSF HVA level, although it did produce marked reductions in plasma and urinary HVA and dihydroxyphenylacetic acid levels. Significant correlations between plasma and CSF concentrations of HVA were noted during, but not before, debrisoquin administration. Before debrisoquin administration there were trends toward positive relationships between symptom severity and plasma HVA concentrations, which became stronger and statistically significant during debrisoquin administration. These data suggest that debrisoquin may be used as a research tool to create a condition in which measures of HVA in peripheral body fluids reflect dopamine system function and metabolism within the central nervous system.     

Urinary 3-methoxy-4-hydroxyphenylglycol sulfate excretion in seventy-three schoolchildren with minimal brain dysfunction syndrome

Although many authors have studied the urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG) of minimal brain dysfunction (MBD) children to explore a possible mechanism for this disorder, the mechanism remains unclear. The present study extends the determinations of urinary MHPG X SO4 in MBD schoolchildren to a larger sample to determine whether or not the function of central norepinephrine (NE) of MBD children is normal. 24-hr urinary excretion of MHPG X SO4 was determined in 73 schoolchildren with MBD and 57 normal controls. MGPG X SO4 level was significantly lower in the MBD children than in the control group. 38 of these children received an open trial of methylphenidate and the urine specimen was examined blindly. The children with marked improvement showed significant decrease in urinary MHPD X SO4 while the nonresponders showed no change, but rather a slight increase. This was also demonstrated in a second drug trial in which eight MBD children received Chinese herbal medicine. The authors compare the clinical data with the biochemical findings and point out that the MBD children developed hypoactivity of central NE, especially those with positive genetic factors in their family history.     

Effect of ventral noradrenergic bundle transection and locus coeruleus lesions on urinary 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) excretion in the rat

Urinary 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) excretion was determined in rats after central noradrenergic pathway interruption by ventral bundle transection or by locus coeruleus (LC) lesions. The transection prevented an increase in urinary MHPG that occurred in sham-operated animals, an effect that was presumed to be due to loss of cerebrospinal fluid (CSF). Electrolytic lesioning of the LC, which was not attended by loss of CSF, had no effect on baseline MHPG excretion but diminished the response to subsequent administration of the alpha-adrenergic blocking agent, phenoxybenzamine (PBZ). Since the contribution of brain MHPG to total urinary MHPG is small, the observed effects of these procedures are most likely due to disrupted central regulation of peripheral sympathetic nerve activity.     

Plasma levels of tumor necrosis factor-alpha in patients with panic disorder: effect of alprazolam therapy

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.     

Urinary 3-methoxy-4-hydroxyphenylglycol in affective and schizophrenic patients. Behavior and symptom correlates

The relations between urinary 3-methoxy-4-hydroxyphenylglycol, (MHPG) excretion, ward behavior in two environments (dayroom and gym), and symptomatology were examined in 58 psychiatric inpatients. In the total patient sample, idiosyncratic behaviors and body activity correlated positively with MHPG levels. Among depressed patients MHPG correlated negatively with eating lunch in the dayroom and positively with self-reported appetite loss, suggesting that appetite disturbance in major depression may be due to high norepinephrine turnover. The results support the utility of naturalistic observation instruments in exploring the relations between psychopathology and biological substrates.     

Effect of low-dose clorgyline on 24-hour urinary monoamine excretion in patients with rapidly cycling bipolar affective disorder

Effects of clorgyline on urinary excretion of norepinephrine, dopamine, tyramine, and their major metabolites, 5-hydroxyindoleacetic acid and phenylethylamine, were studied in four women who suffered from primary, bipolar affective disorder. All patients had rapid mood cycles and were nonresponsive to lithium carbonate. During placebo administration, a strong correlation was found between the excretion rates of norepinephrine and dopamine and their respective metabolites. Clorgyline, 5 to 10 mg every or every other day, reduced overall-body norepinephrine turnover by 55% and increased tyramine but did not alter 5-hydroxyindoleacetic acid, phenylethylamine, or p-hydroxyphenylacetic acid excretion. These findings demonstrate the clinical actions of low-dose clorgyline and clorgyline's specificity as a monoamine oxidase A (MAO-A) inhibitor in vivo in humans, as well as the effects of specific MAO-A inhibition on monoamine metabolism.     

Stimulants, urinary catecholamines, and indoleamines in hyperactivity. A comparison of methylphenidate and dextroamphetamine

Children with attention deficit disorder with hyperactivity were given either methylphenidate hydrochloride or dextroamphetamine sulfate to compare the effects on urinary excretion of catecholamines, indoleamines, and phenylethylamine (PEA). Methylphenidate's effects were distinctly different from those of dextroamphetamine. After methylphenidate administration, both norepinephrine (NE) and normetanephrine (NMN) concentrations were significantly elevated, and there was a 22% increase in excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG). In contrast, after dextroamphetamine treatment, MHPG excretion was significantly reduced and NE and NMN values were unchanged. Excretion of dopamine and metabolites was unchanged by either drug. Urinary PEA excretion was not significantly changed after methylphenidate treatment, but increased 1,600% in response to dextroamphetamine. Methylphenidate treatment did not significantly alter serotonin or 5-hydroxyindoleacetic acid excretion. Effects of dextroamphetamine were not tested.     

Dexamethasone suppression test and urinary MHPG X SO4 determination in depressive disorders

The Dexamethasone Suppression Test (DST) was performed in 64 depressed inpatients, in 48 schizophrenics, and in 20 normal controls. Thirty-four percent of depressive inpatients were found to escape from dexamethasone suppression significantly higher than either schizophrenics (13%) or normal subjects (5%). Among subgroups, bipolar and unipolar endogenous depression patients had much higher abnormal rates for the DST (59% and 48%, respectively) than nonendogenous cases (8%). DST results were also found to be positively correlated with patients' Hamilton scores. These findings suggested that DST could be helpful in diagnosis, discrimination of subtypes, and in assessment of severity of symptoms. In 32 of the 64 depressed inpatients, urinary MHPG X SO4 excretion was determined and compared with 21 normal controls. Bipolar patients (n = 7) had less MHPG X SO4 excretion than unipolar endogenous patients (n = 16). Excretion was positively correlated with cortisol level at 17 hr after dexamethasone administration in 32 depressive inpatients, especially in the unipolar subgroup. A trend toward negative correlation, though not statistically significant, was found in bipolar depression between cortisol levels at 17 hr after dexamethasone administration and urinary MHPG X SO4 excretion. This may indicate that some differences in norepinephrine (NE) metabolism may exist between unipolar and bipolar depression, leading to differing correlations between deviation of central NE function and hypothalamus-pituitary-adrenal (HPA) axis in different subgroups of depression.     

Conjugated HVA increase in rat urine after insulin-induced hypoglycemia: Involvement of central dopaminergic structures but not of adrenal medulla

Summary To examine the possible contribution of Rat adrenal medulla to urinary DOPAC and HVA, we have studied these compounds in adrenals and urine under insulin-induced (5 IU/kg) hypoglycemic stimulation.In the urine samples collected over 16-hour-period following the intravenous insulin injection, there was a great increase in E, NE and their methoxylated derivatives MN and NMN, without change in DA, DOPAC, MHPG and free HVA excretion. In addition, there was a pronounced increase in urinary HVA conjugates (glucuronide and sulfate). Only very low amounts of DOPAC (10±2ng/gland; 0.05% of catechols) and no detectable amounts of HVA (<3 ng/gland) were found in adrenal glands, without no significant change two hours after insulin, thus suggesting that Rat adrenal glands are not meaningful sources for urinary HVA and DOPAC.Since free HVA and total MHPG excretion remained unchanged, HVA contribution from sympathetic neurons seems unlikely in our study.In contrast, highly increased levels of conjugated HVA-and at a lesser extent of conjugated DOPAC-have been found in the striatum, which appears to be the most likely source of urinary HVA increment. The dopaminergic activation following insulin affected too the hypothalamus but not the nucleus accumbens. The role of such central dopaminergic activation has been discussed in terms of feeding behavior.     

Alterations in motor activity, sleep, and biochemistry in a cycling manic-depressive patient.

Biochemical and electrophysiological factors were studied longitudinally in a rapidly cycling manic-depressive patient. Slow changes in mood, motor activity, sleep, and urinary norepinephrine levels during the course of each depressed and manic episode are reported, as well as rapid alterations in many variables at the time of mood switch. Urinary concentrations of norepinephrine and its metabolite, 3-methoxy-4-hydroxyphenyl glycol (MHPG) were significantly lower in depression than in mania; norepinephrine but not MHPG excretion increased prior to the switch. We postulate that the slow behavioral and biological changes preceding switches in this patient are an important manifestation of the cyclic process in manic-depressive illness.     

Studies on the utility of urinary 3,4-dihydroxyphenylethylene-glycol (DHPG) measurement

1. The utility of urinary DHPG measurement as an index of NE function was evaluated in an animal model by determining its excretion following pharmacological manipulations that are known to alter noradrenergic activity.

2. Acute desipramine (DMI) administration (10 mg/kg i.p.b.i.d.) significantly reduced urinary DHPG (−26%) but not MHPG (−18%) excretion.

3. Acute yohimbine administration (5 mg/kg i.p.b.i.d.) significantly increased urinary DHPG and MHPG levels to a similar extent (+46%).

4. These findings suggest that urinary DHPG levels also provide a sensitive indicator reflecting changes in NE neuronal activity. Further, DHPG may be a better measure of NE metabolism than MHPG to assess the efficiency of the NE neuronal uptake system.     

Reduction of norepinephrine turnover by serotonergic drug in man

Zimelidine (ZIM), a relatively specific serotonin reuptake inhibitor, was administered to 12 hospitalized healthy young male volunteers. Chronic but not acute ZIM caused a modest (23%) but significant elevation of plasma norepinephrine (NE) measured in the standing but not in the supine position. The 24-hr urinary excretion of NE itself was unchanged on chronic drug, whereas "whole-body" NE turnover was reduced by 1 week of ZIM, as evidenced by lowered excretion rates (both individually and summed with NE) of the metabolites 3-methoxy-4-hydroxyphenylglycol (MHPG), normetanephrine (NM), and vanillylmandelic acid. Lack of effect of ZIM on the NM/MHPG excretion ratio (which is increased by desipramine) indicated that ZIM and its major metabolite, horzimelidine (NZIM) are not acting by NE reuptake blockade. These data are consistent with modulating serotonergic influence on the noradrenergic system. Reduction of NE turnover and increasing the efficiency of the NE neurotransmission may be a common pathway of all clinically effective antidepressant treatments.