Brexanolone for the treatment of patients with postpartum depression.

On March 19, 2019, the United States Food and Drug Administration (FDA) approved Zulresso (brexanolone) for intravenous use for the treatment of postpartum depression (PPD) in adult women. The decision was based on three recent clinical trials following an FDA priority review and breakthrough therapy designation. Brexanolone is now available through a restricted process called the Zulresso Risk Evaluation and Mitigation Strategy Program that requires the drug to be administered by a healthcare provider in a certified healthcare facility. Brexanolone represents an important new treatment option to address treatment-resistant depressive symptoms. In this article, we discuss the current critical need for PPD treatments, the mechanisms of brexanolone action, and the efficacy and drug safety studies that led to FDA approval. Additionally, we discuss some limitations of the current formulation, specific populations of women that might benefit from this treatment, and how new drugs on the horizon may increase the ability to treat PPD in a variety of patient populations.

Long-term impact of early life events on physiology and behaviour.

This review discusses the effects of stress and nutrition throughout development and summarises studies investigating how exposure to stress or alterations in nutrition during the pre-conception, prenatal and early postnatal periods can affect the long-term health of an individual. In general, the data presented here suggest that that anything signalling potential adverse conditions later in life, such as high levels of stress or low levels of food availability, will lead to alterations in the offspring, possibly of an epigenetic nature, preparing the offspring for these conditions later in life. However, when similar environmental conditions are not met in adulthood, these alterations may have maladaptive consequences, resulting in obesity and heightened stress sensitivity. The data also suggest that the mechanism underlying these adult phenotypes might be dependent on the type and the timing of exposure.

Epigenetic mechanisms in pubertal brain maturation.

Puberty is a critical period of development during which the reemergence of gonadotropin-releasing hormone secretion from the hypothalamus triggers a cascade of hormone-dependent processes. Maturation of specific brain regions including the prefrontal cortex occurs during this window, but the complex mechanisms underlying these dynamic changes are not well understood. Particularly, the potential involvement of epigenetics in this programming has been under-examined. The epigenome is known to guide earlier stages of development, and it is similarly poised to regulate vital pubertal-driven brain maturation. Further, as epigenetic machinery is highly environmentally responsive, its involvement may also lend this period of growth to greater vulnerability to external insults, resulting in reprogramming and increased disease risk. Importantly, neuropsychiatric diseases commonly present in individuals during or immediately following puberty, and environmental perturbations including stress may precipitate disease onset by disrupting the normal trajectory of pubertal brain development via epigenetic mechanisms. In this review, we discuss epigenetic processes involved in pubertal brain maturation, the potential points of derailment, and the importance of future studies for understanding this dynamic developmental window and gaining a better understanding of neuropsychiatric disease risk.

Early life exposure to a high fat diet promotes long-term changes in dietary preferences and central reward signaling.

Overweight and obesity in the United States continues to grow at epidemic rates in large part due to the overconsumption of calorically-dense palatable foods. Identification of factors influencing long-term macronutrient preferences may elucidate points of prevention and behavioral modification. In our current study, we examined the adult macronutrient preferences of mice acutely exposed to a high fat diet during the third postnatal week. We hypothesized that the consumption of a high fat diet during early life would alter the programming of central pathways important in adult dietary preferences. As adults, the early-exposed mice displayed a significant preference for a diet high in fat compared to controls. This effect was not due to diet familiarity as mice exposed to a novel high carbohydrate diet during this same early period failed to show differences in macronutrient preferences as adults. The increased intake of high fat diet in early exposed mice was specific to dietary preferences as no changes were detected for total caloric intake or caloric efficiency. Mechanistically, mice exposed to a high fat diet during early life exhibited significant alterations in biochemical markers of dopamine signaling in the nucleus accumbens, including changes in levels of phospho-dopamine and cyclic AMP-regulated phosphoprotein, molecular weight 32 kDa (DARPP-32) threonine-75, DeltaFosB, and cyclin-dependent kinase 5. These results support our hypothesis that even brief early life exposure to calorically-dense palatable diets alters long-term programming of central mechanisms important in dietary preferences and reward. These changes may underlie the passive overconsumption of high fat foods contributing to the increasing body mass in the western world.

Examining the intersection of sex and stress in modelling neuropsychiatric disorders.

Sex-biased neuropsychiatric disorders, including major depressive disorder and schizophrenia, are the major cause of disability in the developed world. Elevated stress sensitivity has been proposed as a key underlying factor in disease onset. Sex differences in stress sensitivity are associated with corticotrophin-releasing factor (CRF) and serotonin neurotransmission, which are important central regulators of mood and coping responses. To elucidate the underlying neurobiology of stress-related disease predisposition, it is critical to develop appropriate animal models of stress pathway dysregulation. Furthermore, the inclusion of sex difference comparisons in stress responsive behaviours, physiology and central stress pathway maturation in these models is essential. Recent studies by our laboratory and others have begun to investigate the intersection of stress and sex where the development of mouse models of stress pathway dysregulation via prenatal stress experience or early-life manipulations has provided insight into points of developmental vulnerability. In addition, examination of the maturation of these pathways, including the functional importance of the organisational and activational effects of gonadal hormones on stress responsivity, is essential for determination of when sex differences in stress sensitivity may begin. In such studies, we have detected distinct sex differences in stress coping strategies where activational effects of testosterone produced females that displayed male-like strategies in tests of passive coping, but were similar to females in tests of active coping. In a second model of elevated stress sensitivity, male mice experiencing prenatal stress early in gestation showed feminised physiological and behavioural stress responses, and were highly sensitive to a low dose of selective serotonin reuptake inhibitors. Analyses of expression and epigenetic patterns revealed changes in CRF and glucocorticoid receptor genes in these mice. Mechanistically, stress early in pregnancy produced a significant sex-dependent effect on placental gene expression that was supportive of altered foetal transport of key growth factors and nutrients. These mouse models examining alterations and hormonal effects on development of stress pathways provide necessary insight into how specific stress responses can be reprogrammed early in development resulting in sex differences in stress sensitivity and neuropsychiatric disease vulnerability.

Role of the corticotropin-releasing factor receptor type 2 in the control of food intake in mice: a meal pattern analysis.

The actions of corticotropin-releasing factor (CRF) and related peptides are mediated by two receptors (CRF(1) and CRF(2)). The respective role of each subtype in the control of food intake remains poorly known. In the present study, we examined the quantity and microstructure of ingestive behavior of knockout (KO) mice lacking CRF(2) receptors and their wild-type (WT) littermates. Under basal conditions, CRF(2) KO mice showed increased nocturnal food intake, evident as an increased zenith in circadian cosinor analysis of food intake. Microstructure analysis revealed that this greater food intake reflected increased meal size, rather than meal frequency, suggesting a decreased satiating value of food. Following acute restraint stress, CRF(2) KO mice showed an intact immediate anorectic response with increased latency to eat and decreased meal size. However, CRF(2) deletion abolished the prolonged phase of restraint-induced anorexia. CRF(2) KO mice did not differ from WT controls in feeding responses to food deprivation or injection of ghrelin receptor agonists. Independent of genotype, food deprivation increased food intake, with dramatic changes in meal size, meal frequency, water : food ratio and eating rate. Acyl-ghrelin or BIM-28131, a potent ghrelin analog, dose-dependently stimulated food intake by increasing meal size (ghrelin, BIM-28131) and meal number (BIM-28131), while slowing the average eating rate (BIM-28131) similarly in WT and KO mice. These results suggest that the CRF(2) receptor is involved in the control of meal size during the active phase of eating and following acute exposure to stress.

CNS region-specific oxytocin receptor expression: importance in regulation of anxiety and sex behavior.

The oxytocin receptor (OTR) is differentially expressed in the CNS. Because there are multiple mechanisms by which the OTR can be transcriptionally induced, we hypothesized that differences in OTR expression may be explained by activation of distinct signal transduction pathways and may be critical for the control of anxiety and sex behaviors. To determine the regulation and functional significance of this expression, we infused female rats with modifiers of protein kinases before assaying for behavior and oxytocin receptor binding. In the ventromedial nucleus of the hypothalamus (VMH), estrogen-dependent induction of oxytocin receptors required protein kinase C activation, and oxytocin infused here promoted female sex behavior but had no effect on anxiety. In contrast, dopamine controlled tonic oxytocin receptor expression in the central nucleus of the amygdala (cAmyg) through activation of protein kinase A, and oxytocin infused here was anxiolytic but had no effect on female sex behavior. Therefore, we have identified brain region-specific regulation of the OTR in the VMH and cAmyg. Distinct signal transduction pathways regulating receptor expression and binding in each brain region may mediate in part the ability of oxytocin to exert these differential behavioral effects.

Mice deficient for corticotropin-releasing hormone receptor-2 display anxiety-like behaviour and are hypersensitive to stress.

Corticotropin-releasing hormone (Crh) is a critical coordinator of the hypothalamic-pituitary-adrenal (HPA) axis. In response to stress, Crh released from the paraventricular nucleus (PVN) of the hypothalamus activates Crh receptors on anterior pituitary corticotropes, resulting in release of adrenocorticotropic hormone (Acth) into the bloodstream. Acth in turn activates Acth receptors in the adrenal cortex to increase synthesis and release of glucocorticoids. The receptors for Crh, Crhr1 and Crhr2, are found throughout the central nervous system and periphery. Crh has a higher affinity for Crhr1 than for Crhr2, and urocortin (Ucn), a Crh-related peptide, is thought to be the endogenous ligand for Crhr2 because it binds with almost 40-fold higher affinity than does Crh. Crhr1 and Crhr2 share approximately 71% amino acid sequence similarity and are distinct in their localization within the brain and peripheral tissues. We generated mice deficient for Crhr2 to determine the physiological role of this receptor. Crhr2-mutant mice are hypersensitive to stress and display increased anxiety-like behaviour. Mutant mice have normal basal feeding and weight gain, but decreased food intake following food deprivation. Intravenous Ucn produces no effect on mean arterial pressure in the mutant mice.

NGF, cyclic AMP, and phorbol esters regulate oxytocin receptor gene transcription in SK-N-SH and MCF7 cells.

Oxytocin receptor (OTR) gene transcription has predominantly been thought to be regulated by estrogen. However, the continuous presence of receptors in certain brain regions after gonadectomy suggests the existence of alternate mechanisms of regulation. We have cloned and sequenced 4 kb of 5'-flanking DNA of the rat OTR gene and identified an internal segment which was absent in the initial publication of this promoter sequence. Sequence analysis of this segment, as well as of a novel upstream region, revealed the presence of a CRE as well as several other potential regulatory elements, including AP-1, AP-2, AP-3, AP-4 sites, an ERE, and a half-SRE (SRE/2). The effects of phorbol 12-myristate 13-acetate (PMA), forskolin, and NGF treatment on this promoter were tested in transfection experiments in MCF7 and SK-N-SH cells. Transcription of the full-length OTR promoter was induced by forskolin and by the phorbol ester PMA, and a synergistic (17-fold) effect was observed in MCF7 cells treated with both agents. Receptor binding studies using the OTR antagonist 125I-labeled ornithine vasotocin, and Western blot analyses of OTRs in MCF7 cells, showed that PMA and forskolin also increased the density of endogenous human oxytocin receptors. Mutational analyses of the CRE and half-SRE sites in this promoter indicated that these elements function as enhancers and support forskolin and NGF effects, respectively, on transcription. These studies have identified a novel region of the rat OTR promoter containing elements which impart cAMP and/or phorbol ester inducibility of OTR gene transcription. A potential role of the PKA and/or PKC pathways in OTR gene regulation is suggested.

Cloning, novel promoter sequence, and estrogen regulation of a rat oxytocin receptor gene.

Expression of the oxytocin receptor (OR) gene in vivo is known to be regulated by estradiol (E2). We have cloned and sequenced 4 kilobase (kb) of 5'-flanking DNA of the rat OR gene and identified an internal segment of 1260 nucleotides that was absent in an initial publication of this promoter and an additional 2 kb of upstream sequence. This novel internal region is located between two large tg nucleotide repeats. PCR amplification using genomic DNA verified that this sequence is present in the rat genome. To explain transcriptional effects of E2, a palindromic estrogen response element (ERE) that is active is estrogen receptor binding was identified within this new sequence, approximately 4 kb 5' of the translational start site. The ability of E2 to enhance transcription of this promoter was tested in transfection experiments in MCF7 cells. E2 only weakly induced transcription of a truncated construct. Mutational analysis of the ERE in the context of a basal promoter indicated that it functions as an enhancer, and that mutation of two bases eliminates this activity. Further support of the efficacy of this response was shown in mobility gel shift assays in which the OR ERE bound estrogen receptor present in uterine extracts. Receptor binding studies using 125I-ornithine vasotocin in MCF7 cells revealed that E2 dramatically up-regulated endogenous ORs. Western blot analysis confirmed this increase in OR protein with E2 treatment of MCF7 cells. These studies have identified a novel region of the rat OR promoter containing an upstream palindromic ERE that imparts E2 inducibility of OR gene transcription.

Regulation of oxytocin receptor messenger ribonucleic acid in the ventromedial hypothalamus by testosterone and its metabolites.

Oxytocin receptor (OR) binding in the ventromedial hypothalamus (VMH) is regulated by testosterone (T) and its metabolites, estrogen (E2) and dihydrotestosterone (DHT). Previous studies have reported that OR binding increases in the VMH in castrated male rats when they are replaced with T or E2 compared to that in vehicle-treated animals. DHT alone had no effect on OR binding, but when given in combination with E2 appeared to have a synergistic effect. This study was designed to determine whether these effects of steroid hormones on OR binding in the VMH are associated with changes in OR messenger RNA (mRNA) expression. Male rats were castrated or sham operated and given T propionate (TP), E2 benzoate (EB), DHT plus EB, or an oil vehicle. OR mRNA was assessed using a rat complementary RNA OR probe and in situ hybridization techniques. OR binding to tissue slices was quantified autoradiographically using an OR antagonist, [125I]d(CH2)5[Tyr(Me)2,Thr4,Tyr-NH2(9)] ornithine vasotocin. These experiments showed that TP and EB increased both OR mRNA and OR binding in the VMH significantly above levels in vehicle-treated animals. However, animals given both EB and DHT exhibited significantly lower OR mRNA expression and OR binding in the VMH compared to those in animals treated with TP or EB alone. These data indicate that increases in VMH OR binding in response to gonadal steroids are accompanied by changes at the mRNA level that correspond well in magnitude and direction with those in the OR-binding sites.

Oxytocin receptor mRNA expression in the ventromedial hypothalamus during the estrous cycle.

Changes in OR mRNA expression in the ventromedial hypothalamus (VMH) in relation to the estrous cycle were measured by in situ hybridization with a rat oxytocin receptor (OR) probe. Binding studies have localized ORs to various brain regions, and have detected a high density of receptors in the VMH, a nucleus containing large numbers of estrogen responsive neurons. Previous studies in this lab have reported a significant increase in OR mRNA expression in the VMH in ovariectomized rats treated with estrogen. The present study was designed to determine whether changes in steroid hormone levels across the estrous cycle result in induction of OR mRNA expression. Autoradiographic studies revealed differences in OR mRNA expression in the rostral and caudal as well as medial and lateral aspects of the VMH. OR mRNA levels were highest in the caudal portion of the vIVMH on the afternoon (16:00 hr) of proestrus. The rostral region exhibited a high level of expression in the ventrolateral region of the VMH on the morning (9:00 hr) of proestrus and in the dorsomedial region of the VMH on the afternoon of proestrus. Little or no OR mRNA expression was evident in the rostral or caudal VMH on the morning or evening of diestrus. These results support previous findings which showed a regulation of OR binding by gonadal steroids and suggest that this may be due to altered expression of the OR gene. These effects suggest a possible role of ORs in the oxytocin stimulated release of luteinizing hormone.

Sex differences in and effects of estrogen on oxytocin receptor messenger ribonucleic acid expression in the ventromedial hypothalamus.

In situ hybridization techniques were used in the present study to detect hypothalamic expression of the oxytocin receptor (OR) gene. Binding studies have localized OR to various brain regions and have detected a high density of receptors in the ventromedial hypothalamus (VMH), a documented target of estrogen action. This study was designed to compare levels of OR messenger RNA (mRNA) in the VMH of male and female rats and to study the effects of estrogen treatment on mRNA levels in the VMH of female rats. After cloning a rat OR gene from a genomic testes library, a probe was generated for use in in situ hybridization assays to evaluate sex differences in OR mRNA expression in the VMH. In addition, ovariectomized females were treated with estrogen, and VMH OR mRNA expression was compared with that in ovariectomized or intact females. The results of these studies showed that male rats expressed higher levels of OR mRNA in the VMH than females. Estrogen-treated ovariectomized females exhibited significantly greater expression in the VMH than either oil-treated or intact females. These results support binding studies that have shown oxytocin binding in the VMH to be regulated by gonadal steroids and suggest that estrogen may either directly or indirectly regulate transcription of the OR gene.

CNS oxytocin receptor mRNA expression and regulation by gonadal steroids.

A genomic clone was used to generate a rat oxytocin receptor (OTR) probe for in situ hybridization studies in order to monitor changes in expression of OTR mRNA in the CNS of male and female rats in brain regions reported to be rich in OTR binding. This probe predominantly detects expression in the ventromedial hypothalamus (VMH). Quantitatively greater expression of OTR mRNA was more evident in the male VMH than in that of the female. OTR mRNA expression in the VMH is also enhanced in gonadectomized rats treated with either estrogen or testosterone. Previous studies of VMH OTR mRNA expression during the estrous cycle revealed a role of estrogen in proestrous OTR mRNA expression and also provided evidence for progesterone's modulatory effect on OTR expression. A related study which examined OTR mRNA expression during gestation, parturition, and lactation further supported the regulation of the OTR by gonadal steroids, as a pronounced induction of expression occurred at parturition when estrogen levels were highest. These results support previous studies which have documented the regulation of OTR binding by gonadal steroids and suggest that this regulation may be the result of altered expression of the OTR gene. Induction of OTRs in anatomically distinct regions of the VMH may be important in promoting OT'ergic neurotransmission required for sexual behavior or the induction of gonadotropin release by OT, which requires estrogen and progesterone priming. The anatomical variation in OTR mRNA localization and its restricted detection in the VMH by this probe suggests potential CNS OTR heterogeneity.

Distribution of messenger RNA for the vasopressin V1a receptor in the CNS of male and female rats.

The distribution of cells expressing mRNA encoding a vasopressin V1a receptor (V1aR) was examined in Long-Evans male and female rats by in situ hybridization using a [35S]cRNA probe. Specific hybridization to the vasopressin V1aR mRNA was evident in cells of the frontal cortex, piriform cortex, internal granular layer and the medial, dorsal, ventral and lateral portion of the anterior olfactory nucleus, zona limitans of the islands of Calleja, suprachiasmatic nucleus, CA1, CA2, CA3 and dentate gyrus of the hippocampus, paraventricular hypothalamic nucleus, ventromedial hypothalamic nucleus, arcuate nucleus, lateral habenular nucleus, and the molecular and granular cell layers of the cerebellum. The cerebellum, olfactory nucleus and the dentate gyrus appeared to be the most intensely labeled areas, while all other areas exhibited a lower level of expression. The anatomical distribution and the amount (as measured by optical density) of V1aR mRNA labeling was identical between male and female rats. This indicates that unlike the vasopressin gene itself, the expression of the vasopressin V1aR mRNA does not exhibit sexual dimorphism. These data demonstrate a wide spread distribution in the expression of the vasopressin V1aR mRNA in the CNS of male and female rats. This information on the anatomical distribution of the V1aR mRNA when combined with data concerning the anatomical distribution of the V1a binding sites, provides new information on the possible pre- and post-synaptic location of these neuropeptide receptors.