By N. Ugolf. Hesston College.

So it is worth raphe nuclei) large enough to make sufficient RNA for label- discussing the uses to which such arrays have already been ing is difficult purchase mildronate 500mg overnight delivery. Better labeling put mildronate 500 mg with mastercard, and the uses to which neuropsychopharmacologists methods buy mildronate mastercard, dyes, and detection devices are being developed. In fact, the amount of total RNA needed for an array experi- Few investigators have used arrays to study brain so far, ment has already fallen well below 1 g, and should ap- preferring instead to look at mammalian cell lines and tu- proach 1 ng shortly. In addition, many workers have focused on Each array experiment will let an investigator look simul- yeast (45,46) or prokaryotes (47,48) because their genomes taneously at thousands of transcripts including those encod- are small and have been completely sequenced. Conse- ing enzymes involved in energy metabolism, receptors, G quently, every protein-encoding gene can be arrayed and proteins, second messengers, and ion channels, to name a examined. In addition, there will be many species represented on the not-too-distant future. Meanwhile, experiments can be big arrays, the actions of which are unknown. These have between task will be to assign them functions (see below). Consider, for example, the work that could be data have developed quickly. In spite of this, the supply of done to understand the mechanism(s) of action of selective arrays has not kept up with demand, and demand should serotonin reuptake inhibitors (SSRIs) and the reason for increase dramatically if the goal of using arrays is to compare their delayed onset of action in depressed patients. As is many conditions and then mine the data systematically for known, SSRIs increase the availability of serotonin (5-hy- patterns of gene expression. Thus, as stated earlier, costly droxytryptamine, 5-HT) to presynaptic and postsynaptic products are unlikely to gain wide acceptance, and glass receptors, of which there are at least 14 subtypes (50). For Among these, 5-HT1A receptors on serotoninergic raphe this reason, I now discuss their production and use. Some sets of cDNAs have been se- anxiety, inhibit serotonin secretion. Conversely, desensitiza- quence verified and are ideal to use for preparing arrays; tion of 5-HT1A receptors, which could result from elevated others have not been validated and are less useful. To make 5-HT levels in the synaptic space following SSRI adminis- arrays, plasmid DNA is prepared from gridded sets of clones tration, may have the opposite effect—an increase in 5-HT to be printed, and (typically) the 3′ end of each cDNA is release by raphe neurons, and chronic stimulation of 5-HT amplified by PCR. The purified PCR products are then receptors in regions such as the hippocampus, amygdala, spotted using a robotic arrayer. Many thousands of 100- M spots type I and type II (42). In the former, two samples are can be printed on a single glass microscope slide (see ref. This is because the relationship between be labeled with a different fluorescent dye that could, in the amount of transcript in a mixture and the intensity of turn, be visualized with a different laser. Presently, most the fluorescent spot it produces is a complex one—in- commercial readers have only two lasers, but four-color in- fluenced by labeling efficiency, hybridization and wash con- struments have already appeared on the market. To achieve this goal, in a two-sample experi- duces. Pools of cell-line RNAs have been used as standards mined for each spot, and the relative abundance of the two for human work. It would be useful if a central source of input RNAs can then be estimated. NORMALIZING RATIOS Since it is difficult, if not impossible, to measure the amount of RNA used to produce a labeled probe, normalizing the signals from the source RNAs is essential. The housekeeping set needs to be defined empirically, and in looking for candi- dates to include in such a set, few genes have been found that have constant expression levels. When small arrays are employed, on the other hand, the size and composition of the gene set used for normaliza- tion are very important. Just as a reference standard is ur- gently needed now, a normalization set supplied by a central site would be quite valuable. To perform microarray experiments, RNA is puri- fied from two or more samples of cultured cells or dissected tis- QUALITY CONTROL sues. Inthe exam- ple given, the dye cy5, which fluoresces red, was used to label probe from sample 1; and the dye cy3, which fluoresces green, While we have methods to assess the quality of DNA se- was used to label probe from sample 2. The labeled products are quence data, for example, there is no generally accepted mixed and hybridized to the spots on the microarray. Following a wash step, the array is scanned and the signals from the red method for establishing the quality of an array study. If an RNA species is more spite of this, there are some controls that can be built into abundant in sample 1than 2, the resulting spot will be red; in an array. As noted earlier, scientists are arraying DNAs gen- the reverse case, the spot will be green. When the RNA is equally abundant in the two samples, the spot is yellow. See color version erated by PCR from plasmid templates.

Be- has yet to be fully explored discount 250 mg mildronate with amex, but recent reviews suggest it cause vouchers are used to support treatment goals discount mildronate 250mg on line, thera- may have a modest effect size of 0 buy mildronate visa. These restrictions impose con- siderable program costs over and above the costs of the vouchers. The delay between the time the reinforcement SUMMARY (purchase of goods or services) is provided and the time that the behavior being reinforced (abstinence, as evidenced No medications are currently approved by the Food and by a drug-free urine) occurs may decrease the value to the Drug Administration (FDA) for cocaine dependence, but patient (but not the actual program cost) of the reinforce- we have developed several leads for medications based on ment. The efficacy of CM in studies with cocaine-depen- our understanding of the neurobiology and clinical phe- dent patients also appears to be considerably more modest nomenology of stimulants. Based on neurobiological abnor- at best than in the earlier studies. Iguchi and his colleagues malities in dopamine receptors and transporters after (102) compared voucher-based CM used to reinforce either chronic stimulant use, studies have examined both dopa- drug-free urine samples (UA group) or treatment plan tasks mine agonists and antagonists, but not shown clinical effi- (TP tasks) and a no-voucher standard treatment group cacy. Based on clinical phenomenology, antidepressants (STD) during methadone maintenance treatment. The have been tried in depressed cocaine abusers who may re- value of the vouchers was set considerably lower than in duce their cocaine use with desipramine, other tricyclics, other studies of CM and did not increase in value for succes- serotonin reuptake inhibitors, and bupropion. Among unse- sive drug-free urine samples or completion of therapeutic lected stimulant abusers these antidepressants may be quite tasks. The authors also did not use the CRA that Higgins limited, but when depressive symptoms are reduced, cocaine has used, although their TP intervention included many of abstinence also appears to follow. There were no significant main effects (CBF) defects also appear to be relatively common among of treatment group on rates of drug-free urine samples. These CBF defects in cocaine abusers may respond changed in either the UA or STD groups, whereas they to antistroke medications, and this potential for remediation increased over time in the TP group. Finally, CM is not builds on a rapidly evolving field of stroke pharmacother- effective for all patients—for example, 10 of 19 (53%) CM- apy. Although increasing the value, schedule, cocaine administration as a surrogate efficacy assessment. Considering that drug-dependent tient randomized clinical trials, these laboratory settings patients continue illicit drug use despite extremely high im- have been helpful in assessing medical safety during cocaine mediate and longer-term costs, increasing patient internal interactions. Neuroimaging of cerebral blood flowand of Chapter 102: Pathophysiology and Treatment of Cocaine Dependence 1471 'receptor' binding also holds promise for medication devel- dependence: neurobiology and pharmacotherapy. Elevated striatal With all of these pharmacotherapies the behavioral plat- dopamine transporters during acute cocaine abstinence as mea- form for their delivery is critical in retaining the patient in sured by [123I]beta-CIT SPECT. Am J Psychiatry 1998;155(6): treatment and maintaining compliance with the medica- 832–834. As a behavioral disorder, stimulant dependence is 8. Effect of chronic cocaine quite responsive to contingency management using a variety abuse on postsynaptic dopamine receptors. Serotonergic mecha- purchase prosocial goods and services are the most common nisms of cocaine effects in humans. Psychopharmacology 1995; reinforcer used to initiate and maintain stimulant-free ur- 119:179–185. Dopaminergic one-to-one fixed ratio initially, with a progressive increase responsivity during cocaine abstinence. Noradrenergic dys- as longer periods of abstinence are attained. The major regulation during discontinuation of cocaine use in addicts. Arch problem with this approach has been maintaining absti- Gen Psychiatry 1994;51:713–719. The pharmacology of cocaine developing a mechanism to obtain these types of reinforcers related to its abuse. A more typical time limited between dopamine transporter protein alleles and cocaine- therapy for clinical programs is cognitive behavioral therapy. Neuropsychopharmacology 1994;11(3): Cognitive behavioral therapies have been examined in con- 195–200. Elevated central pressants, and have shown interesting additive effects (32). Am J Psychiatry 2000;157: For example, at 1-year follow-up after a 3-month treatment 1134–1140. Regional cerebral and the cognitive therapy showed more sustained abstinence blood flowimproves with treatment in chronic cocaine polydrug than those who got either therapy alone. Pharmacotherapy of cerebral ischemia in cocaine treatments may also be most useful for abstinence initiation, dependence. Cerebral blood flow havioral therapy approaches (32). Overall, the long-term in chronic cocaine users: a study with positron emission tomog- outcome at 1 year is substantially enhanced by the use of raphy. Selective inhibition of cocaine seeking behavior by a partial dopamine D3 receptor agonist.

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A locus for bipolar deficiency as cause of the flushing reaction to alcohol in Japa- affective disorder on chromosome 4p order mildronate 250mg on line. Support for the possible aldehyde dehydrogenase genotypes and alcoholism in Chinese locus on chromosome 4p15 for bipolar affective disorder mildronate 250 mg otc. Ann Neurol 1993; susceptibility genes in bipolar affective disorder—evidence for 34:752–754 best order for mildronate. Grigoroiu-Serbanescu M, Martinez M, Nothen MM, et al. Pat- diseases: analysis of SNPs around APOE in Alzheimer disease. On the interpretation of association studies in 100. Hablotype relative risks: an eary reliable Engl J Med 1994;330:962–967. Statistical properties of the haplotype relative risk. The sins of the fathers and mothers: Genomic linkage disequilibrium: the insulin gene region and insulin-de- imprinting in mammalian development. A conditional inference framework for chiatry 1999;56:1019–1031. Anticipation in Swed- tests of linkage and/or association. Am J Hum Genet 1998;63: ish families with bipolar affective disorder. Birth-cohort changes association between bipolar disorder and MAOA gene polymor- in manic and depressive disorders in relatives of bipolar and phisms. The problem of anticipation in pedigrees of dystro- der. Statistical pitfalls in detecting ses of the MAOA gene in bipolar affective disorder by using age-at-onset anticipation: the role of correlation in studying family based controls. Am J Med Genet 1997;74(5): repeats in schizophrenia and bipolar disorder. Confirmation gene in bipolar affective disorder by association studies, meta- of association between expanded CAG/CTG repeats and both analyses and sequencing of the promoter. Am J Med Genet 1999; schizophrenia and bipolar disorder. Detection of expanded CAG repeats in bipolar affective disorder using the and linkage studies with lithium responsive bipolar disorder. CAG repeat expansions bipolar disorder and MAOA gene polymorphisms: results of a in bipolar and unipolar disorders. Direct detection MAOA gene and bipolar affective disorder. Am J Hum Genet of novel expanded trinucleotide repeat in the human genome. Am J Med Genet 1997;19: of large CAG/CTG trinucleotide repeats in schizophrenia and 494–496. A triplet repeat on 17q in the promoter region of MAOA gene and mood disorders. NEMEROFF Over the past three decades, considerable progress has been agent, elevated depressed mood and inhibited monoamine made in our understanding of the biology of depressive degradation by the enzyme, monoamine oxidase; imipra- disorders. Still, there are a great number of unanswered mine, a tricyclic compound originally studied as an antipsy- questions regarding the relative roles specific biological sys- chotic, had potent antidepressant effects and blocked the tems may play in pathogenesis. This debate in part reflects reuptake of norepinephrine (and to some extent serotonin) a number of methodologic factors: a possibly over broad into presynaptic neurons. Although a low norepinephrine state was the corner- longitudinal studies. Indeed, more recent data have pointed to biological heterogeneity of norepinephrine activ- ity in depression with some patients demonstrating low and BACKGROUND others apparently elevated activity (5). Serotonin (5-HT) theories, in contrast, have emphasized decreased production Although Freud put forth a hypothesis for understanding or reuptake in depression. Research over the among others: elevated corticotropin-releasing hormone past 40 years has done much to point to likely 'culprits' (CRH); elevated acetylcholine activity; increased amino- that are involved in the etiology of the disorder as well as butyric acid (GABA) levels; excessive glucocorticoid activity in the mediation of treatment response; these have been in psychotic major depression; hippocampal volume loss, reviewed several times recently (1,2). These have in turn led to or been with particular emphasis first on norepinephrine and later associated with a number of new biological hypotheses re- serotonin. The basis for invoking these systems rested largely garding why some individuals become depressed or develop on a number of pharmacologic observations that have been specific symptoms.

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