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Depression, Anhedonia, and Psychomotor Symptoms: The Role of Dopaminergic Neurocircuitry


Dan J. Stein, MD, PhD


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CNS Spectr. 2008;13(7):561-565

 

Faculty Affiliation and Disclosure

Dr. Stein is professor in and chair of the Department of Psychiatry and Mental Health at the University of Cape Town in South Africa, and is also on faculty at the Mount Sinai School of Medicine in New York City.

Faculty Disclosures: Dr. Stein has received grant support/honoraria from AstraZeneca, Eli Lilly, GlaxoSmithKline, Lundbeck A/S, Orion, Pfizer, Pharmacia, Roche, Servier, Solvay, Sumitomo, and Wyeth.

Funding/Support: Dr. Stein receives support from the Medical Research Council of South Africa.

Authors’ note: This case is based on an amalgam of the author’s experience.

Abstract

The heterogeneity of major depression suggests that multiple neurocircuits and neurochemicals are involved in its pathogenesis. Anhedonia and psychomotor symptoms are, however, particularly characteristic features of major depression and may provide insights into its underlying psychobiology. Importantly, these symptoms appear to be mediated by dopaminergic mesolimbic and mesostriatal projections, the function of which is, in turn, influenced by key gene variants and environment stressors. Indeed, there is growing evidence of the way in which the dopaminergic system is associated with cognitive-affective disturbances in depression, and provides a useful target for therapeutic interventions. At the same time, a range of other systems are likely to contribute to the psychobiology of this condition.

Case Report

Rachel is a 43-year-old woman who presented for treatment to her primary care physician. She complained of depressed mood, not finding pleasure in her life, and of feeling slower and slower. She had a range of other classical symptoms of depression, including poor concentration, decreased appetite, and insomnia. On mental status examination, her speech was slowed, and there was evidence of psychomotor retardation. Her primary care physician initiated bupropion, increasing the dosage to 100 mg TID. After several weeks of treatment, she demonstrated a good response to treatment. Rachel was particularly delighted to report that she was enjoying life again, and had the sense that she was moving around more quickly and more responsively.

Cognitive-Affective Neuroscience

Depression is a heterogenous condition characterized by multiple symptoms and subtypes. Different symptoms (eg, poor concentration, disturbed sleep) and subtypes (eg, melancholic, seasonal) are likely mediated by different neurocircuitry and neurochemistry,1-3 and may or may not be present, in any particular individual with depression. Depression may be characterized by an increase or a decrease in certain of its symptoms (eg, hyperphagia, hypophagia), further complicating attempts to explore its psychobiology.

Nevertheless, anhedonia—or loss of pleasure—appears to be a particularly central feature of major depression.4-6 Reward is mediated by dopaminergic projections to the nucleus accumbens, suggesting that mesolimbic neurocircuitry plays a crucial role in the pathogenesis of depression.7,8 Furthermore, other dopaminergic projections (ie, mesostriatal, mesocortical) may play a role in mediating additional symptoms of depression that appear to lie at the core of this disorder (eg, psychomotor symptoms, loss of motivation)9,10 and its melancholic subtype.11    

Neuroanatomy/Neurochemistry

Basic research on the brain reward and motivation systems and animal models of anhedonia and psychomotor symptoms12-15 have provided a foundation for investigating the role of dopaminergic and associated neurocircuitry in the pathogenesis of depression. Complementary work16,17 has shown that neurological lesions in this circuitry can result in anhedonia or psychomotor symptoms. Finally, neuroimaging studies9,10,18-22 of anhedonic and psychomotor symptoms in depression have contributed to delineating the neurocircuitry and neurochemistry of this disorder.

Anhedonia, for example, was positively correlated with ventromedial prefrontal cortex and negatively correlated with amygdala/ventral striatal activity in response to happy stimuli (Figure 1).19 In another study,20 trait anhedonia was positively correlated to ventromedial prefrontal cortex activity during the processing of positive information, and inversely correlated with anterior caudate volume (Figure 2). Psychomotor symptoms have also been associated with frontal and caudate abnormalities in depression,9,10,23 and fatigue may involve related regions.2,24



Molecular imaging studies8,25,26 provide partial support for the role of the dopaminergic system in mediating depression, particularly depression with psychomotor symptoms.27-29 Functional brain imaging during a dopaminergic challenge has emphasized that dopaminergic circuitry is involved in altered reward processing in anhedonia (Figure 3).30 Electroconvulsive therapy and prefrontal transcranial magnetic stimulation result in increased dopamine release,8,31 and deep brain stimulation to the reward circuitry is able to relieve anhedonia in treatment-resistant depression.32



Depression involves a range of other circuits and chemicals, and the extent to which anhedonia, psychomotor symptoms, and other features associated with reduced positive affect are specifically linked to dopaminergic dysfunction is debatable.33,34 Several other systems and molecules that play an important role in mediating depression intersect closely with the dopaminergic system; these include serotonin,35 glutamate,36 opioids,37 the hypothalamic-pituitary-adrenal axis,38 and neurotrophic factors.39,40 However, certain depressive symptoms may be more specifically linked to one of these systems.2,41

Gene/Environment

The heritability of anhedonia and psychomotor symptoms deserves further study.42,43 Response to early maternal separation and to other stressors is mediated in part by dopaminergic circuitry,15,44 and dopaminergic gene variants and their interactions with environmental stressors play a role in the pathogenesis of depression.45,46 Still, a range of other gene-environment mechanisms are also likely to play a role in this condition.47,48 Research on the relationship between dopaminergic receptor variants, cortico-striatal activation, and responsivity to reinforcers,49 may ultimately be relevant to understanding the pathogenesis of depression.

Evolutionary Approaches

A range of evolutionary theories have been put forward to explain anhedonia and psychomotor symptoms in depression.50,51 Nesse,50 for example, notes that low mood increases ability to cope with situations in which effort to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort. Similarly, others51 have argued that depression represents an adaptive response to the perceived threat of exclusion from important social relationships. Some evolutionary theories have focused specifically on the importance of anhedonia.52

Clinical Implications

DSM-IV-TR Diagnosis

Anhedonia and psychomotor symptoms seem to be particularly core features of major depression, and also characterize its melancholic subtype.5,9,53 Other important symptoms of depression may also fall under the rubric of reduced positive affect (eg, lack of energy).33 Nevertheless, it is important to emphasize that symptoms such as anhedonia and psychomotor symptoms occur in a broad range of other medical conditions, including psychotic disorders, Parkinson’s disease, and cocaine withdrawal.

Assessment/Evaluation

There are a number of scales of anhedonia including the Snaith-Hamilton Pleasure Scale, the Fawcett-Clark Pleasure Capacity Scale, and the Revised Chapman Physical Anhedonia Scale, and these do not completely overlap.54 The Salpêtrière retardation rating scale, the CORE Assessment of Psychomotor Change, and the Motor Agitation and Retardation Scale, are observer-rated measures to assess psychomotor abnormalities, and a range of more sensitive experimental performance measures is also available.10,55

Pharmacotherapy/Psychotherapy

Dopaminergic agents have a useful role to play in the treatment of depression and treatment-resistant depression.8,56,57 Both dopamine agonists and low-dose atypical antipsychotics (which increase extracellular levels of dopamine and norepinephrine, but not serotonin, in the prefrontal cortex) appear effective in the pharmacotherapy of treatment-resistant depression.2 Although effective antidepressants tend to be useful across the range of depressive symptoms, there is some evidence10,33 that dopaminergic agents are particularly useful for reduced positive affect and for psychomotor symptoms.

Conclusion

Depression is universally described as a “down” rather than an “up” feeling. Similarly, there is a common association between depression, anhedonia (feeling down), and psychomotor retardation (slowing down). There is growing evidence that dopaminergic mesolimbic and mesostriatal projections play an important role in mediating these symptoms. Functioning of the dopamine system is impacted on by particular gene variants as well as environmental stressors, and also by its interactions with a range of other systems. As always, researchers hope that a better understanding of these mechanisms will ultimately lead to better treatments.

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