Journal of Affective Disorders 116 (2009) 113116

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Journal of Affective Disorders

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d

Preliminary communication

Preliminary evidence that a functional polymorphism in type 1 deiodinase is associated with enhanced potentiation of the antidepressant effect of sertraline by triiodothyronine
Rena Cooper-Kazaz a,1, Wendy M. van der Deure b,1, Marco Medici b, Theo J. Visser b, Ana Alkelai a, Benjamin Glaser c, Robin P. Peeters b, Bernard Lerer a,
a b c

Biological Psychiatry Laboratory, Department of Psychiatry, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands Endocrinology and Metabolism Service, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

a r t i c l e

i n f o

a b s t r a c t
Background: Triiodothyronine (T3) is used to potentiate the clinical effect of antidepressant drugs. Inter-individual differences in efcacy may be related to genetically-based variability in thyroid function. Methods: DNA was obtained from 64 patients treated with sertraline plus T3 (SERT-T3, N = 35) or plus placebo (SERT-PLB, N = 29), for 8 weeks. Antidepressant efcacy was rated with the 21 item Hamilton Rating Scale for Depression (HRSD-21). Functional polymorphisms in type 1 (DIO1-C785T, DIO1-A1814G) and type 2 deiodinase (DIO2-Thr92Ala and DIO2-ORFa-Gly3Asp) were genotyped. Results: DIO1-C785T was associated with efcacy of T3 but not placebo supplementation, as indicated by the interaction of treatment, DIO1-C758T genotype and time (p = 0.04) and a stronger effect of SERT-T3 among DIO1-758T allele carriers (p = 0.01). HRSD-21 scores of DIO1758T allele carriers declined by 68.7 + 26.6% (mean + SD) over 8 weeks compared to 42.9+ 37.8% among non-carriers (p = 0.02). Discussion: DIO1 plays a key-role in T4 to T3 conversion and in clearance of the inactive metabolite, rT3. Previous data associate the DIO1-785T allele with lower DIO1 activity. This is consistent with our observation that responders to T3 supplementation had lower baseline serum T3 levels than non-responders. Depressed patients, who have a genetically determined lower T4 to T3 conversion, may be more likely to benet from T3 supplementation. 2008 Elsevier B.V. All rights reserved.

Article history: Received 31 July 2008 Revised 15 October 2008 Accepted 15 October 2008 Available online 6 December 2008 Keywords: Triiodothyronine Depression Sertraline Type 1 deiodinase Pharmacogenetics

1. Introduction The active thyroid hormone, triiodothyronine (T3), has long been used to potentiate the clinical effect of antidepressant drugs such as tricyclic antidepressants (Aronson et al., 1996; Altshuler et al., 2001) and more recently, specic serotonin

Corresponding author. Biological Psychiatry Laboratory, Department of Psychiatry, Hadassah-Hebrew University Medical Center, Ein Karem, Jerusalem 91120, Israel. Tel.: +972 2 6777185; fax: +972 2 649294. E-mail address: lerer@cc.huji.ac.il (B. Lerer). 1 These authors contributed equally to this work. 0165-0327/$ see front matter 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2008.10.019

reuptake inhibitors (Cooper-Kazaz and Lerer, 2008) in euthyroid patients. As reviewed by Cooper-Kazaz and Lerer (2008), there is considerable variability in the efcacy of the intervention. In a randomized, double blind, controlled trial (RCT) Cooper-Kazaz et al. (2007) found that concurrent administration of T3 to patients with major depressive disorder (MDD) treated with sertraline for 8 weeks, was associated with 58% remission compared to 38% remission in patients treated with sertraline plus placebo. Notwithstanding this signicant difference in efcacy, it is noteworthy that 42% of patients on the combined regimen did not achieve remission. Clinical characteristics at baseline did not identify patients destined to achieve remission;

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Fig. 1. Relationship of the DI-785T allele to the effect of treatment with SERT-PLB (Panel A) and SERT-T3 (Panel B) in patients with major depression. In the SERTPLB group: T allele carriers (CT + TT genotypes), N = 17, T allele non-carriers (CC genotypes), N = 12. In the SERT-T3 group: T allele carriers (CT + TT genotypes), N = 24, T allele non-carriers (CC genotypes), N = 11. Bars show standard error of the mean. BL = Baseline.

however, patients who eventually remitted on treatment with sertraline plus T3 had lower baseline T3 levels than patients who did not. Baseline T3 levels did not differentiate between remitters and non-remitters on sertraline plus placebo. Genetic variation in different thyroid hormone pathway genes has been shown to impact signicantly on thyroid function and thyroid hormone levels in euthyroid individuals (Peeters et al., 2006). Polymorphisms in type 1 deiodinase (DIO1), which plays an important role in the production of serum T3 from T4 and in the clearance of the inactive metabolite reverse T3 (rT3), are associated with serum thyroid parameters. For instance, the DIO1-C785T polymorphism is associated with higher rT3 levels and a lower T3/rT3 ratio, pointing to lower DIO1 activity in carriers of the T allele (Peeters et al., 2003; Peeters et al., 2005a; De Jong et al., 2007). In addition, the DIO1-A1814G polymorphism is associated with a higher T3/rT3 ratio, suggesting that the DIO1-1814G variant might result in increased DIO1 activity (Peeters et al., 2003; De Jong et al., 2007). The DIO2-ORFaGly3Asp polymorphism has also been associated with serum thyroid parameters (Peeters et al., 2005b), while the DIO2Thr92Ala polymorphism has been associated with insulin resistance in some, but not all studies (Mentuccia et al., 2002; Peeters et al., 2007; Canani et al., 2005; Maia et al., 2007). In this report we explore the possibility that inter-individual differences in the efcacy of T3 as a supplement to sertraline may be related to genetically-based individual differences in thyroid function. 2. Materials and methods DNA was prospectively obtained from 64 of the 83 patients who participated in the Israeli sites of the RCT reported by

Cooper Kazaz et al. (2007). Missing DNA samples were unavailable because of technical reasons. There was no signicant difference in severity of depression or response to treatment between the patients whose DNA samples were available and those whose DNA samples were not. All patients gave written informed consent for the study, which had been approved by the Helsinki Committee (Internal Review Board) of the Hadassah-Hebrew University Medical Center and was registered on the ClinicalTrials.gov database (#NCT00158990, http://clinicaltrials.gov/ct/show/NCT00158990?order=1). The patients were treated with sertraline (50 mg/day for 1 week, then 100 mg/day if tolerated) plus T3 (20 mcg/day for 1 week, then 40mcg/day if tolerated) (SERT-T3, N = 35) or sertraline plus placebo (SERT-PLB, N = 29), for 8 weeks. Antidepressant efcacy was rated with the 21 item Hamilton Rating Scale for Depression (HRSD-21). Polymorphisms in DIO1 (DIO1-C785T [rs11206244] and DIO1-A1814G, [rs12095080]) and DIO2 (DIO2-Thr92Ala [rs225014] and DIO2-ORFa-Gly3Asp [rs12885300]) were genotyped by 5 uorogenic TaqMan assays. For all polymorphisms, we used Assays-by-Design (www.appliedbiosystems.com). PCR cycling reactions were performed in 384 wells format in a 2 l reaction volume on an ABI 9700 PCR system (Applied Biosystems Inc., Foster City, CA, USA). Results were analyzed by the ABI Taqman Prism 7900 HT using the sequence detection system 2.22 software (Applied Biosystems). Antidepressant effects of SERT-T3 and SERT-PLB were analyzed by ANOVA with repeated measures testing for a main effect of genotype on HRSD-21 and interactions with treatment; possible confounders such as sertraline and T3 dose were added where indicated as covariates. Deviation from Hardy

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Weinberg equilibrium was analyzed using a 2-test. p values are two-sided throughout and considered signicant if p b 0.05. Data were analyzed using Statistica for Windows (Release 4.5). 3. Results Genotype distribution of all 4 polymorphisms was in Hardy Weinberg equilibrium (p N 0.10). The minor allele frequencies were: DIO1-785T = 0.42, DIO1-1814G = 0.09, DIO2-92Ala (allele G) = 0.41, DIO2-ORFa3Asp (allele A) = 0.30. These frequencies are similar to those reported in other populations (Peeters et al., 2003; Peeters et al., 2005a; De Jong et al., 2007). Fig. 1 shows the mean HRSD-21 scores over 8 weeks of patients treated with SERT-PLB (Panel A) or SERT-T3 (Panel B). Patients were grouped as carriers vs. non-carriers of the functional DIO1-785T allele (TT homozygotes and CT heterozygotes). Two way ANOVA with repeated measures showed that DIO1-C758T was signicantly associated with the antidepressant efcacy of T3 supplementation over the 8 week trial, as indicated by the interaction of treatment (SERT-T3, SERT-PLB), DIO1-C758T genotype (carriers/noncarriers) and time (F = 2.35; df 5, 300; p = 0.04). Separate ANOVA with repeated measures showed that SERT-T3 was signicantly more effective in carriers of the DIO1-785T allele than in non-carriers (F [genotype] = 6.96; df 1, 31; p = 0.01); F [genotype time] = 4.44; df 5, 165; p = 0.0008). Addition of mean sertraline dose and mean T3 dose as covariates did not alter the outcome of the analyses. As shown in Fig. 2, HRSD-21 scores declined by 68.7 + 26.6% (mean + SD) over 8 weeks of treatment in DIO1-758T carriers treated with SERT-T3 whereas in non-carriers the decline was only 42.9 + 37.8% (t = 2.33, df 33, p = 0.02). ANOVA with repeated measures showed no signicant relationship for DIO1-C785T and response to SERT-PLB (Fig. 1). HRSD-21 reduction over 8 weeks was 38.4 + 38.7% in DIO1-785T carriers and 34.1 + 41.2% in

non-carriers (Fig. 2). There were no signicant differences between DIO1-785T carriers (N = 41) and non-carriers (n =23) in baseline serum levels of TSH (1.83+ 0.79 vs.1.70 +1.17 mIU/ L), total T3 (112.28+ 32.24 vs. 120.49+ 45.32 ng/dL) and free thyroxine (T4) (1.07 +0.15 vs. 1.07 +0.11 ng/dL). However, responders to SERT-T3 had signicantly lower baseline T3 levels than non-responders (107.0 + 30.1 vs. 139.6 + 55.4 ng/dL, p =0.02) and baseline T3 levels were inversely correlated with change in HRSD-21 score over the treatment course in the SERTT3 group (r = 0.56, p = 0.001). The 3 other polymorphisms were analyzed in the same way as DIO1-C758T; none were associated with treatment response or with baseline TSH, total T3 or free T4 levels. 4. Discussion Our data suggest that the efcacy of T3 as an enhancer of the antidepressant effect of sertraline is inuenced by genetic factors. Carriers of the DIO1-785T allele showed a signicantly stronger response to 8 weeks of combination treatment with sertraline and T3 than non-carriers of this allele. There was no effect of the DIO1-C785T polymorphism on response to sertraline in the absence of T3 suggesting that the effect of this polymorphism is not on antidepressant response per se. DIO1 plays a key-role in the production of serum T3 from T4, and in the clearance of the inactive metabolite, rT3. Previous data (lower T3 and higher rT3 levels in carriers) suggest that the DIO1-785T allele results in a lower DIO1 activity (Peeters et al., 2003; De Jong et al., 2007). Since the polymorphism is located in the 3-untranslated region of the mRNA, a change in the stability of the mRNA may explain its functional effect. Other explanations include altered folding of the mRNA, in particular of the selenocysteine insertion sequence (SECIS), which is necessary for the incorporation of a selenocysteine residue in the catalytic center of the protein (Bianco et al., 2002). Alternatively, it may be linked to

Fig. 2. Relationship of DI-C785T genotype to percent change in HDRS-21 score over 8 weeks of treatment in patients treated with SERT-PLB (Panel A) or SERT-T3 (Panel B). Bars show standard error of the mean.

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another, as yet unidentied functional polymorphism. In the present study, the DIO1-785T allele predisposed to stronger antidepressant effects of T3 addition to sertraline. This is consistent with our observation that responders to T3 supplementation had lower baseline serum T3 levels than non-responders and that improvement in depression in patients treated with SERT-T3 was inversely correlated with baseline total T3 levels. Our ndings suggest that patients, who have a genetically determined lower T4 to T3 conversion, may be more likely to benet from T3 addition. An alternative explanation would be that more depressed people have lower T3 values, but this is not supported by the data. There was no correlation between baseline Hamilton depression scale scores and baseline T3 levels (r = 0.06). Furthermore, severity of depression at baseline was not signicantly associated with response to treatment. Although DIO1 is essential for serum T3 production, DIO1C785T was not associated with serum T3 levels in this study. This might be due to the confounding effect of variable concentrations of T4 and T4-binding proteins, combined with a relatively small sample size. The serum T3/rT3 ratio is therefore a more sensitive marker of peripheral thyroid hormone metabolism and thus of DIO1 activity (Bianco et al., 2002, Peeters et al., 2003). Unfortunately, no data on rT3 levels were available in this study. Sample size is an important reservation that should be noted when considering these ndings. The minor allele frequency of the DIO1-A1814G polymorphism was 9% so that differences in effect less than 20% could not have been detected in this sample. The inuence of multiple testing on our results should also be considered. We performed 4 independent analyses of variance to test the hypothesis that the 4 polymorphisms examined would inuence response to combination treatment with sertraline and T3. The observed signicance of the DIO1-C785T genotype main effect on treatment response (p = 0.01) was marginally stronger than that required by Bonferroni correction for the number of independent tests performed (p = 0.0125). Although these ndings must be considered preliminary and require replication in other samples, the C785T polymorphism in DIO1 and additional polymorphisms in other thyroid hormone pathway genes could result in a pharmacogenetic strategy to identify potential responders to T3 supplementation of antidepressant treatment.
Role of funding source Funding for this study was provided in part by grants from the Stanley Medical Research Institute (to BL and RCK) and from the National Institute for Psychobiology in Israel and the Prof Milton Rosenbaum Endowment Fund for Research in the Psychiatric Sciences (to RCK) and from the Netherlands Organization of Scientic Research (NWO) Research Institute for Diseases in the Elderly (grant 014-93-015 to WMvdD). These funding sources had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. Conict of interest None of the authors have any conict of interest to declare with regard to this paper.

et al., J Clin Endocrinol Metab. 2008;93:307581). In our study sample, the A allele of rs2235544 was signicantly associated with better response to treatment in the sertraline plus T3 group (p = 0.038). The two polymorphisms (rs2235544 and rs11206244) were in linkage disequilibrium ( D V= 1.0, R2 = 0.76). ANOVA with repeated measures showed a strong progressive effect of the haplotype allele A-rs2235544/Trs11206244 over time (p b 0.001). References
Altshuler, L.L., Bauer, M., Frye, M.A., Gitlin, M.J., Mintz, J., Szuba, M.P., Leight, K.L., Whybrow, P.C., 2001. Does thyroid supplementation accelerate tricyclic antidepressant response? A review and meta-analysis of the literature. Am. J. Psychiatry 158, 16171622. Aronson, R., Offman, H.J., Joffe, R.T., Naylor, C.D., 1996. Triiodothyronine augmentation in the treatment of refractory depression. A meta-analysis. Arch. Gen. Psychiatry 53, 842848. Bianco, A.C., Salvatore, D., Gereben, B., Berry, M.J., Larsen, P.R., 2002. Biochemistry, cellular and molecular biology, and physiological roles of the iodothyronine selenodeiodinases. Endocr. Rev. 23, 3889. Canani, L.H., Capp, C., Dora, J.M., Meyer, E.L., Wagner, M.S., Harney, J.W., Larsen, P.R., Gross, J.L., Bianco, A.C., Maia, A.L., 2005. The type 2 deiodinase A/G (Thr92Ala) polymorphism is associated with decreased enzyme velocity and increased insulin resistance in patients with type 2 diabetes mellitus. J. Clin. Endocrinol. Metab. 90, 34723478. Cooper-Kazaz, R., Apter, J.T., Cohen, R.T., Karagichev, L., Muhammed-Moussa, S., Grupper, D., Drori, T., Newman, M.E., Sackeim, H.A., Glaser, B., Lerer, B., 2007. Combined treatment with sertraline and liothyronine in major depression: a randomized, double-blind, placebo-controlled trial. Arch. Gen. Psychiatry 64, 679688. Cooper-Kazaz, R., Lerer, B., 2008. Efcacy and safety of triiodothyronine supplementation in patients with major depressive disorder treated with specic serotonin reuptake inhibitors. Int. J. Neuropsychopharmacol. 11, 685699 [Electronic Publication: Nov 30, 2007]. De Jong, F.J., Peeters, R.P., den Heijer, T., van der Deure, W.M., Hofman, A., Uitterlinden, A.G., Visser, T.J., Breteler, M.M., 2007. The association of polymorphisms in the type 1 and 2 deiodinase genes with circulating thyroid hormone parameters and atrophy of the medial temporal lobe. J. Clin. Endocrinol. Metab. 92, 636640. Maia, A.L., Dupuis, J., Manning, A., Liu, C., Meigs, J.B., Cupples, L.A., Larsen, P.R., Fox, C.S., 2007. The type 2 deiodinase (DIO2) A/G polymorphism is not associated with glycemic traits: the Framingham Heart Study. Thyroid 17, 199202. Mentuccia, D., Proietti-Pannunzi, L., Tanner, K., Bacci, V., Pollin, T.I., Poehlman, E.T., Shuldiner, A.R., Celi, F.S., 2002. Association between a novel variant of the human type 2 deiodinase gene Thr92Ala and insulin resistance: evidence of interaction with the Trp64Arg variant of the beta-3-adrenergic receptor. Diabetes 51, 880883. Peeters, R.P., van Toor, H., Klootwijk, W., de Rijke, Y.B., Kuiper, G.G., Uitterlinden, A.G., Visser, T.J., 2003. Polymorphisms in thyroid hormone pathway genes are associated with plasma TSH and iodothyronine levels in healthy subjects. J. Clin. Endocrinol. Metab. 88, 28802888. Peeters, R.P., van den Beld, A.W., van Toor, H., Uitterlinden, A.G., Janssen, J.A., Lamberts, S.W., Visser, T.J., 2005a. A polymorphism in type I deiodinase is associated with circulating free insulin-like growth factor I levels and body composition in humans. J. Clin. Endocrinol. Metab. 90, 256263. Peeters, R.P., van den Beld, A.W., Attalki, H., Toor, H., de Rijke, Y.B., Kuiper, G.G., Lamberts, S.W., Janssen, J.A., Uitterlinden, A.G., Visser, T.J., 2005b. A new polymorphism in the type II deiodinase gene is associated with circulating thyroid hormone parameters. Amer. J. Physiol., Endocrinol. Metab. 289, E75E81. Peeters, R.P., van der Deure, W.M., Visser, T.J., 2006. Genetic variation in thyroid hormone pathway genes: polymorphisms in the TSH receptor and the iodothyronine deiodinases. Eur. J. Endocrinol. 155, 655662. Peeters, R.P., van der Deure, W.M., van den Beld, A.W., van Toor, H., Lamberts, S.W., Janssen, J.A., Uitterlinden, A.G., Visser, T.J., 2007. The Asp727Glu polymorphism in the TSH receptor is associated with insulin resistance in healthy elderly men. Clin. Endocrinol. 66, 808815.

Note added in proof Recently, it was shown that another DIO1 polymorphism, rs2235544, is associated with T3 concentration (Panicker A.