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Psychoneuroendocrinology 77 (2017) 122–130

Contents lists available at ScienceDirect

Psychoneuroendocrinology

jo ur nal ho me p ag e: www.elsev ier .com/ locate /psyneuen

igher serum DHEA concentrations before and after SSRI treatmentre associated with remission of major depression

hristina M. Hough a, Daniel Lindqvist a,b, Elissa S. Epel a, Molly St. Denis a,2, Victor I. Reus a

F. Saverio Bersani a,c, Rebecca Rosser a,3, Laura Mahan a,4, Heather M. Burke a,5,wen M. Wolkowitz a,1, Synthia H. Mellon d,∗,1,2

Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California, San Francisco (UCSF) School of Medicine, San Francisco, CA, USADepartment of Clinical Sciences, Section for Psychiatry, Lund University, Lund, SwedenDepartment of Neurology and Psychiatry, Sapienza University of Rome, Rome, ItalyDepartment of OB/GYN and Reproductive Sciences, UCSF School of Medicine, San Francisco, 513 Parnassus Ave., San Francisco, CA 94143-0556, USA

r t i c l e i n f o

rticle history:eceived 27 September 2016eceived in revised form8 November 2016ccepted 28 November 2016

eywords:ehydroepiandrosteroneepressionSRIntidepressant responseemission

a b s t r a c t

Background: Dehydroepiandrosterone (DHEA) and its sulfated ester DHEA-sulfate (DHEA-S), (togetherDHEA[S]), are the most abundant adrenal steroids in humans and are found in blood and the brain, wherethey function as neurosteroids with direct receptor affinities. Preclinical studies suggest that DHEA(S)has antidepressant/neuroprotective properties, and exogenously administered DHEA has shown antide-pressant efficacy in humans. Nonetheless, the role of endogenous DHEA(S) levels in major depressivedisorder (MDD) and antidepressant outcomes remains unclear.Methods: Morning fasting serum DHEA(S) concentrations were determined in 36 healthy, unmedicatedMDD adults with Hamilton Depression (HDRS) ratings ≥17, and 75 healthy controls. MDD participantsthen completed eight weeks of open-label SSRI treatment before DHEA(S) levels were re-sampled; thosewith post-treatment HDRS ratings ≤7 were classified as “Remitters.” Pre- and post-treatment DHEA(S)levels of Remitters and Non-remitters were compared, controlling for age, sex, and BMI.Results: Pre-treatment HDRS ratings did not differ between Remitters and Non-remitters (p = 0.179). Base-line DHEA levels of Remitters were significantly higher than both Non-remitters (p = 0.008) and controls(p = 0.004); baseline DHEA-S levels of Remitters were also higher than Non-remitters (p = 0.040) but didnot significantly differ from controls (p = 0.096). Non-remitters did not significantly differ from con-trols. Post-treatment DHEA(S) levels remained higher in Remitters compared to Non-remitters (DHEA:

p = 0.013; DHEA-S: p = 0.040).Conclusions: These data suggest that higher circulating DHEA(S) levels (while unmedicated and aftereight weeks of SSRI treatment) predict SSRI-associated remission in MDD. This raises the possibilitythat endogenous DHEA(S) abundance is a physiological adjunct to SSRI efficacy, as suggested by priorpreclinical and clinical studies.

© 2016 Elsevier Ltd. All rights reserved.

∗ Corresponding author.E-mail address: Sindy.Mellon@ucsf.edu (S.H. Mellon).

1 Co-senior authors.2 Present Address: Department of Psychology, Graduate School of Applied and

rofessional Psychology, Rutgers University, Piscataway, NJ, USA.3 Present Address: Department of Psychiatry, Kaiser Permanente Medical Center,edwood City, CA, USA.4 Present Address: Pennsylvania State University College of Nursing, Altoona, PA,SA.5 Present Address: Integrated Disability Evaluation System, United States Army,

ort Drum, NY, USA.

ttp://dx.doi.org/10.1016/j.psyneuen.2016.11.035306-4530/© 2016 Elsevier Ltd. All rights reserved.

1. Introduction

Major depressive disorder (MDD) is a severe and debilitating ill-ness that is estimated by the World Health Organization to affect350 million people worldwide. Despite the widespread nature andsignificant costs associated with MDD (Ferrari et al., 2013), itsunderlying etiology is still not fully understood, nor are the bio-logical predictors and mechanisms of antidepressant treatmentoutcomes. Clinical “response” is typically defined as a 50% or greater

reduction in depressive symptoms after treatment (Lecrubier,2002). “Remission,” however, is defined as post-treatment Hamil-ton Depression Rating Scale ratings ≤7 (Lecrubier, 2002), indicating

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hat very few residual symptoms of depression persist. Thisore stringent criteria has led to remission being considered the

gold standard” of treatment outcomes (Fishbain, 2009). Clinicalesponse that fails to meet standards of remission is associated witharlier relapse into a major depressive episode (MDE), greater life-ime depression chronicity, and significantly poorer psychosocialunctioning (Judd, 2001; Kennedy and Paykel, 2004; Paykel, 1998).ntidepressant efficacy studies typically report remission rates of

oughly 30–45% and response rates of roughly 50–55% (Rush et al.,006; Trivedi et al., 2006). The mechanisms related to remissionf MDD after pharmacological treatment are not currently known;owever, endogenous levels of certain steroid hormones may play

crucial role (Wolkowitz et al., 2001).Dehydroepiandrosterone (DHEA) and its sulfated ester DHEA-

ulfate (DHEA-S), together abbreviated as DHEA(S), are the mostbundant adrenal steroids in adult humans and are found in thelood and in the brain (Kroboth et al., 1999), where they function aseurosteroids with direct receptor affinities (Maninger et al., 2009;ellon, 2007). In preclinical studies, DHEA(S) has been shown to

xert several properties consistent with antidepressant or neuro-rotective effects, including neurogenesis, neurite enhancement,nti-inflammatory, anti-oxidant, and anti-glucocorticoid effectsCompagnone and Mellon, 1998; Genud et al., 2009; Lazaridis et al.,011; Maninger et al., 2009; Pinnock et al., 2009; Reddy et al.,998). Additionally, exogenously administered DHEA has shownntidepressant efficacy in humans; in some cases, subjects whochieved higher circulating DHEA(S) levels achieved better out-omes (Bloch et al., 1999; Maninger et al., 2009; Peixoto et al.,014; Rabkin et al., 2006; Schmidt et al., 2005; Wolkowitz et al.,999; Wolkowitz et al., 1997). Despite such findings with exoge-ously administered DHEA(S), the role of endogenous DHEA(S)

n neuropsychiatric illness in humans and in MDD in particular,emain unclear. Previous findings in depression have found DHEAnd/or DHEA-S concentrations to be decreased (Michael et al.,000; Mocking et al., 2015; Morgan et al., 2010; Zhu et al., 2015),

ncreased (Assies et al., 2004; Kurita et al., 2013; Morita et al., 2014;akebayashi et al., 1998), or unchanged (Fabian et al., 2001; Kuritat al., 2013; Markopoulou et al., 2009; Mocking et al., 2015; Paslakist al., 2010; Romeo et al., 1998) (also reviewed in Maninger et al.,009) in depression, compared to non-depressed controls. The rela-ionship between endogenous serum DHEA(S) levels and likelihoodf antidepressant-associated remission also remain unclear.

Several studies have examined changes in peripheral endoge-ous DHEA(S) levels over the course of antidepressant treatmentBerardelli et al., 2010; Deuschle et al., 2004; Fabian et al., 2001;siao, 2006; Markopoulou et al., 2009; Morgan et al., 2010; Moritat al., 2014; Paslakis et al., 2010; Romeo et al., 1998; Schüle et al.,009; Takebayashi et al., 1998; Zhu et al., 2015) and in relationo treatment response (Deuschle et al., 2004; Fabian et al., 2001;siao, 2006; Markopoulou et al., 2009; Morita et al., 2014; Paslakist al., 2010; Schüle et al., 2009; Takebayashi et al., 1998). How-ver, to the best of our knowledge, only three previous studiesave examined peripheral endogenous DHEA or DHEA-S levels inDD in relation to clinical response/remission after pharmaco-

ogical treatment (Fabian et al., 2001; Hsiao, 2006; Markopoulout al., 2009), and none has examined response to selective serotonineuptake inhibitors (SSRIs) specifically. These previous studiesave had mixed results, likely due to differences in medica-ions, sample size and characterization, and/or the examinationf clinical response versus remission. Previously, Markopoulout al. found that baseline DHEA levels were lower in those withreatment-resistant depression who were responders (not remit-

ers) to inpatient psychotropic treatment with various classes of

edications, including antidepressants, mood stabilizers, antipsy-hotics, benzodiazepines, and buspirone, compared to those whoid not respond to treatment (Markopoulou et al., 2009). Fabian

crinology 77 (2017) 122–130 123

et al. reported that baseline DHEA(S) levels did not differ betweenremitters and non-remitters to treatment with nortriptyline orparoxetine in a mixed inpatient and outpatient sample of elderly(≥60 years old) MDD patients, although remission to the specificclasses of antidepressants was not reported (Fabian et al., 2001).Hsiao compared baseline DHEA levels of MDD patients who remit-ted after treatment with venlafaxine to those who did not, and didnot find any significant between-group differences (Hsiao, 2006).

As previous research is limited, and as other studies have sug-gested that the mechanisms related to DHEA and antidepressant-response may differ between serotonin/SSRIs, compared to otherclasses of neurotransmitters and antidepressants (Deuschle et al.,2004; Pérez-Neri et al., 2008; Romeo et al., 1998), the currentstudy sought to assess whether baseline serum DHEA(S) levels pre-dict improvement of depression after SSRI treatment and whetherpost-treatment DHEA(S) levels are associated with improvementof depression. To accomplish this, we determined morning fast-ing serum DHEA(S) levels in 36 unmedicated adults (ages 19–65)with a current DSM-IV diagnosis of MDD, who were then treatedin an open-label manner with an SSRI for eight weeks prior to hav-ing serum DHEA(S) levels reevaluated. We predicted that higherDHEA(S) levels at both time points would be associated with bet-ter antidepressant outcome. As a secondary analysis, to compareDHEA(S) levels to norms, we also assessed serum DHEA(S) levels in75 healthy controls of similar ages.

2. Methods

2.1. Subjects

Thirty-six unmedicated adults (ages 19–65; 24 females, 12males) with current MDD completed an eight-week, open-labellongitudinal study of SSRI treatment, as part of a larger cross-sectional study of MDD (NCT00285935). Data from 75 healthycontrol subjects (ages 21–69; 46 females, 29 males) from thislarger cross-sectional study were included in secondary analyses,comparing DHEA(S) levels of control subjects to those of MDD sub-jects, including comparisons with Remitters (Week 8 HDRS ≤7)and Non-remitters separately. All subjects who completed eightweeks of SSRI treatment and who had serum DHEA(S) levels avail-able were included in the analyses. Three MDD subjects did nothave follow-up serum samples due to difficulty with venipuncture;these subjects were included in analyses of baseline but not post-treatment DHEA(S). Additionally, the DHEA value for one controlsubject was more than five standard deviations from the mean andwas excluded from DHEA (but not DHEA-S) analyses.

Subjects were recruited by flyers, bulletin board notices,Craigslist postings, newspaper ads, and (in the case of MDD sub-jects) clinical referrals. The Committee on Human Research of theUniversity of California, San Francisco (UCSF) approved the studyprotocol. All study participants gave written informed consent toparticipate in this study and were compensated for participating;MDD subjects additionally received free antidepressant treatment.

Depressed subjects were diagnosed with MDD, without psy-chotic features, according to the Structured Clinical Interview forDSM IV-TR Axis I Disorders (SCID) (First, 1997) (which was the DSMversion in use at the time of the study) with a current 17-itemHamilton Depression Rating Scale (HDRS) (Hamilton, 1960) rat-ing of ≥17. All diagnoses were confirmed by clinical interview witha Board-Certified psychiatrist. Depressed subjects were excludedfor presence of the following: bipolar disorder, psychotic symp-

toms during their current major depressive episode, history ofpsychosis outside of a mood disorder episode, any eating disor-der or post-traumatic stress disorder (PTSD) within one month ofentering the study, and substance abuse or dependence (includ-

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24 C.M. Hough et al. / Psychoneur

ng alcohol) within six months of entering the study. Co-morbidnxiety disorders (except PTSD) were allowed if MDD was consid-red the primary diagnosis. Control subjects had no history of anySM-IV-TR Axis I disorder, also confirmed by SCID interview. Fur-

her, study participants had no acute illnesses or infections, chronicnflammatory disorders, neurological disorders, or any other major

edical conditions considered to be potentially confoundinge.g. cancer, HIV, diabetes, history of cardiovascular disease ortroke, etc.), as assessed by history, physical examinations andoutine blood screening. All subjects were free of psychotropic

edications (including antidepressants), hormone supplements,teroid-containing birth control or other potentially interferingedications, and had not had any vaccinations, for at least sixeeks prior to enrollment in the study; additionally, none were

aking vitamin supplements above the U.S. recommended dailyllowances (e.g. 90 mg/day for Vitamin C). Short-acting sedative-ypnotics were allowed as needed up to a maximum of three timeser week, but none within one week prior to participation. Prior toach study visit, all subjects had to pass a urine toxicology screen forrugs of abuse (marijuana, cocaine, amphetamines, phencyclidine,piates, methamphetamine, tricyclic antidepressants, and barbitu-ates) and a urine test for pregnancy in women of child-bearingge.

.2. Procedures

Subjects were admitted as outpatients to the UCSF Clinical andranslational Science Institute between the hours of 0800 and 1100,aving fasted (except water) since 2200 h the night before. Subjectsere instructed to sit quietly and relax for 25–45 min before blood

amples were obtained for hormone assessment and routine clin-cal labs. The severity of depressive symptoms was then rated inepressed subjects using the 17-item HDRS (Hamilton, 1960). Eachating session was conducted with two raters present who scoredithin one point of each other; if this was not achieved, a consensus

ating was determined.Following this baseline visit, thirty-six subjects received eight

eeks of open-label outpatient treatment with an SSRI antidepres-ant. The first 28 subjects were treated with sertraline, as this wasnitially the only SSRI to be studied. The remaining eight subjects

ere treated under a separate but otherwise identical protocol thatllowed treatment with any SSRI (two with sertraline, two withuoxetine, two with citalopram, and two with escitalopram) asetermined to be clinically appropriate by the study psychiatrist.he decision regarding the specific SSRI prescribed was made basedn clinical grounds such as medical history, family history, andotential side effects. The prescriber and HDRS raters were blindo serum DHEA(S) levels. Outpatient compliance with the med-cation regimen, as well as clinical evaluations and assessmentsf drug tolerability, were assessed by a telephone check-in at thend of Week 1 and an in-person check-in at the end of Week 4nd Week 8, at which time pill counts were performed. Thirteenf the subjects additionally had plasma antidepressant concentra-ions assessed at Week 4 and Week 8; in each of these subjects,lasma antidepressant concentrations were in the expected clini-al range for that antidepressant, suggesting excellent compliance.edication dosages increased over the course of treatment as toler-

ted and as warranted by clinical response. Sertraline dosing beganith 25 mg per day and increased to a maximum of 200 mg per

ay; fluoxetine and citalopram dosing began with 10 mg per daynd increased to a maximum of 40 mg per day; escitalopram dos-ng began with 10 mg per day and increased to a maximum of 20 mg

er day. See Table 1 for further information regarding SSRI dosing.t the end of the eight weeks of SSRI treatment, MDD subjects weregain rated with the HDRS and had blood re-drawn for steroid hor-one levels. Subjects with post-treatment HDRS ratings ≤7 were

crinology 77 (2017) 122–130

classified as “Remitters,” while those with post-treatment HDRSratings >7 were classified as “Non-remitters” (Lecrubier, 2002).

2.3. Steroid measurement

Serum was collected into serum separator tubes for steroidassay. Assays were performed in two separate batches based onrecruitment phases (2006–2008 and 2011–2014). The first batchconsisted of 15 MDD (7 Remitters, 8 Non-remitters) and 20 controlsamples, and was assayed by radioimmunoassay (DHEA: Diagnos-tic Systems Laboratories, Inc., Webster, TX; DHEA-S: DiagnosticProducts Corporation, Los Angeles, CA; cortisol: Siemens Med-ical Solutions Diagnostics, Los Angeles, CA). Intra-assay CV forDHEA, DHEA-S and cortisol was 3.2%, 7.8% and 3.4%, respectively;inter-assay CV for DHEA, DHEA-S and cortisol was 3.6%, 9.7%and 5.5%, respectively. The second batch consisted of 21 MDD (6Remitters, 15 Non-remitters) and 55 control samples, and wasassayed by Human ELISA (DHEA: American Laboratory ProductsCo., Salem, NH; DHEA-S and cortisol: Immulite 2000, SiemensHealthcare Global, Erlangen, Germany). Intra-assay CV for DHEA,DHEA-S and cortisol was 5.6%, 7.6% and 5.6%, respectively; inter-assay CV for DHEA, DHEA-S and cortisol was 6.9%, 9.7% and 7.7%,respectively. The use of two different assay batches necessitateda change in assay labs and methods over the course of the study.As noted below, batch was entered as a covariate in all analyses.DHEA was measured in ng/dL with a reportable range of 0.37–-30.0 ng/mL. DHEA-S was measured in �g/dL with a reportablerange of 15–1000 �g/dL. Cortisol was measured in �g/dL with areportable range of 1–50 �g/dL. Lab personnel who performed theassay were blind to demographic and clinical data.

2.4. Statistical analyses

All statistical analyses were performed using Statistical Packagefor the Social Sciences (SPSS) v.22 (IBM Corp., Armonk, NY). All testswere 2-tailed with an alpha = 0.05. Comparisons of demographicand clinical characteristics between-groups were performed usingKruskall Wallis, Mann-Whitney U, and Chi-Square tests. Non-parametric tests were used (Mann-Whitney U, Kruskal-Wallis,Chi-Square, and Spearman’s Correlations, as appropriate), sinceDHEA(S) levels were non-normally distributed. Age, sex, and bodymass index (BMI) were defined a priori as possible confoundersdue to their reported impact on DHEA(S) (Kroboth et al., 1999)and were corrected for in all analyses by utilizing residual valuesof DHEA(S); additionally, as DHEA(S) was analyzed in two sepa-rate assay batches, all analyses were also corrected for assay batch.Cohen’s d effect sizes were calculated using residual data.

To assess whether pre- and post-treatment DHEA(S) levels wererelated to SSRI-associated remission, pre-treatment DHEA(S) lev-els were compared between Remitters and Non-remitters, as werepost-treatment DHEA(S) levels. Since the majority, but not all sub-jects received sertraline, sensitivity analyses were performed, onlyincluding those subjects who were prescribed sertraline; all resultsremained unchanged. Secondarily, differences in DHEA(S) levelsbetween controls and both groups of MDD subjects (Remittersand Non-Remitters) were explored to determine the relationshipof the MDD hormone levels of those with controls. To determinethe specificity of the association of DHEA(S) with SSRI-associatedremission, and to examine the relationship of related steroids, pre-and post-treatment cortisol levels were compared using the same

statistical methods used in DHEA(S) analyses. Receiver operatingcharacteristic (ROC) curve analyses were performed using residualdata to calculate area under the curve (AUC) of significant between-group findings.

C.M. Hough et al. / Psychoneuroendocrinology 77 (2017) 122–130 125

Table 1Demographics and clinical characteristics of the sample.

All MDD(n = 36)

Remitters(n = 13)

Non-remitters(n = 23)

Remitters vs.Non-remitters

Controls(n = 75)

Three GroupComparison

Age(years; M ± SD)

37.92 ± 12.11 37.77 ± 12.60 38.00 ± 12.11 U = 138.5p = 0.717

37.33 ± 13.29 �2 = 0.35p = 0.840

Sex(% females)

66.7 61.5 69.6 �2 = 0.24p = 0.624

61.3 �2 = 0.53p = 0.768

Ethnicity(% Caucasian)

83.3 84.6 82.6 �2 = 0.02p = 0.877

70.7 �2 = 2.09p = 0.352

Body Mass Index(kg/m2; M ± SD)

26.78 ± 5.00 24.03 ± 12.60 28.34 ± 4.59 U = 71.0p = 0.010

24.48 ± 4.60 �2 = 14.07p = 0.001*,a

Tobacco Use(% tobacco users)

30.6 30.8 30.4 �2 = 0.00p = 0.983

8.0 �2 = 9.54p = 0.008*,b

Years of education(M ± SD)

16.17 ± 2.11 16.38 ± 1.94 16.04 ± 2.23 U = 138.0p = 0.697

16.73 ± 1.83 �2 = 2.03p = 0.362

HDRS pre-treatment(M ± SD)

19.50 ± 3.01 18.92 ± 3.04 19.83 ± 3.01 U = 109.5p = 0.179

– –

HDRS post-treatment(M ± SD)

9.53 ± 5.09 4.62 ± 1.34 12.30 ± 4.23 U = 0.00p < 0.001*

– –

Current MDE Length(months; M ± SD)

70.87 ± 124.68 46.55 ± 117.91 83.55 ± 128.77 U = 108.5p = 0.310

– –

Lifetime DepressionChronicityc (months;adjusted M ± SD)

123.05 ± 118.00(n = 35)

106.49 ± 112.30(n = 12)

139.61 ±112.14

F = 0.68p = 0.414

– –

Final SSRI Dosed

(mg/day; M ± SD)108.33 ± 36.84 105.77 ± 27.30 109.78 ± 41.79 U = 141.0

p = 0.763– –

* Significant at the p < 0.05 level.a Post-hoc analyses indicate that the BMI of Non-remitters was significantly higher than that of controls (p < 0.001); BMI of Remitters did not differ from controls (p = 0.663).b Post-hoc analyses indicate that tobacco use was more prevalent in both Remitters (p = 0.017) and Non-remitters (p = 0.006), in comparison to controls.

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d Final SSRI Dose is based on dose-equivalency of sertraline (Preskorn, 2009).

. Results

.1. Participant characteristics

Demographic and clinical characteristics of the sample are sum-arized in Table 1. Remitters and Non-remitters did not differ in

aseline HDRS scores, age, sex, years of education, race, currentobacco use, lifetime depression chronicity, length of current MDDpisode, or final SSRI dose (based on dose-equivalency of sertralinePreskorn, 2009)). Non-remitters had significantly higher BMI thanoth Remitters (p = 0.009) and controls (p < 0.001); Remitters’ BMIid not differ from controls (p = 0.663). Controls were well-matchedo both Remitters and Non-remitters in regards to age, sex, yearsf education, and race. Tobacco use was more prevalent in bothemitters (p = 0.017) and Non-remitters (p = 0.006), in comparisono controls.

.2. DHEA(S) and remission of MDD

In comparison to Non-Remitters, Remitters had significantlyigher pre-treatment DHEA and DHEA-S levels (DHEA: U = 70.0,

= 0.008, Cohen’s d = 1.11; DHEA-S: U = 87.0, p = 0.040, Cohen’s = 0.83; Fig. 1). Pre-treatment DHEA(S) showed good predic-ive ability in separating Remitters from Non-Remitters (DHEA:UC = 0.766, p = 0.009; DHEA-S: AUC = 0.709, p = 0.040). At thend of eight weeks of SSRI treatment, DHEA and DHEA-S levelsemained significantly higher in Remitters compared to Non-emitters (DHEA: U = 63.0, p = 0.013, Cohen’s d = 0.98; DHEA-S:

= 74.0, p = 0.040, Cohen’s d = 0.67; Fig. 1). DHEA(S) levels after SSRIreatment continued to significantly distinguish these two groupsDHEA: AUC = 0.758, p = 0.014; DHEA-S: AUC = 0.715, p = 0.039).

ensitivity analyses were performed, only including those subjectsho were prescribed sertraline and results remained unchanged.roup means and standard deviations of DHEA(S) levels are pre-

ented in Table 2.

ted means and standard deviations were calculated using analysis of covariance

3.3. DHEA(S) and absolute improvement of MDD severity

Correlational analyses showed that absolute improvement inHDRS ratings (across all MDD subjects) was not significantly asso-ciated with pre-treatment DHEA (rho = −0.081, p = 0.639; Fig. 2a)or DHEA-S levels (rho = −0.288, p = 0.088; Fig. 2b). Improvement inHDRS ratings was, however, significantly associated with higherpost-treatment DHEA (rho = −0.432, p = 0.012; Fig. 2c) and DHEA-Slevels (rho = −0.590, p < 0.001; Fig. 2d).

There was no significant change in pre-to-post-treatmentDHEA or DHEA-S levels in the whole group (p = 0.922 and 0.469,respectively), Remitters (p = 0.422 and 0.522, respectively), or inNon-remitters (p = 0.681 and 0.601, respectively). Further, changesin DHEA(S) were not significantly correlated with changes in HDRS(p = 0.717 and 0.589, respectively).

3.4. Comparisons with healthy controls

There were no group differences in baseline DHEA and DHEA-Slevels between controls and all MDD subjects (DHEA: U = 1181.0,p = 0.336, Cohen’s d = 0.31; DHEAS: U = 1221.0, p = 0.416, Cohen’sd = 0.22). However, power calculations indicate that an effect sizeof 0.57 or greater would be necessary to detect differences ina sample of this size, with a power of 0.80. When comparingbaseline DHEA(S) levels of controls to those of Remitters andNon-remitters separately, Remitters had significantly higher base-line DHEA than controls (U = 242.0, p = 0.004, Cohen’s d = 0.98;AUC = 0.748, p = 0.004) and a trend toward the same relationshipwith DHEA-S (U = 346.0, p = 0.096, Cohen’s d = 0.56; AUC = 0.645,p = 0.096); Fig. 3. Levels of DHEA and DHEA-S did not differ sig-

nificantly between Non-remitters and controls (DHEA: U = 763.0,p = 0.455, Cohen’s d = 0.17; DHEA-S: U = 850.0, p = 0.917, Cohen’sd = 0.03; Fig. 3). Group means and standard deviations of DHEA(S)levels are presented in Table 2.

126 C.M. Hough et al. / Psychoneuroendocrinology 77 (2017) 122–130

Fig. 1. Pre- and Post-treatment DHEA(S) in Remitters and Non-remitters.DHEA and DHEA-S levels were significantly higher in Remitters compared to Non-remitters before SSRI treatment (p = 0.008 and 0.040, respectively) and after SSRI treatment(p = 0.013 and 0.040, respectively). DHEA was measured in ng/dL and DHEA-S was measured in �g/dL. Data represent residual values after correcting for age, sex, BMI, andDHEA(S) assay batch, therefore, values may be positive or negative.

Table 2Mean steroid concentrations and group comparisons.

Remitters(n = 13)

Non-remitters(n = 23)

Remitters vs.Non-remitters

Controls(n = 75)

Controls vs.Remitters

Controls vs.Non-Remitters

Pre-treatment(Baseline) DHEA(ng/dL; M ± SD)

12.49 ± 8.12 6.17 ± 3.69 U = 70.0p = 0.008*

6.45 ± 4.38a U = 242.0p = 0.004

U = 763.0p = 0.455

Pre-treatment(Baseline) DHEA-S(�g/dL; M ± SD)

207.46 ± 134.92 157.30 ± 83.47 U = 87.0p = 0.040*

159.00 ± 89.40 U = 346.0p = 0.096

U = 850.0p = 0.917

Post-treatment DHEA(ng/dL; M ± SD)

10.54 ± 7.26 5.73 ± 3.432 U = 63.0p = 0.013*

– – –

Post-treatmentDHEA-S (�g/dL;M ± SD)

200.44 ± 120.58 162.95 ± 115.852 U = 74.0p = 0.040*

– – –

Pre-treatment(Baseline) cortisol(�g/dL; M ± SD)

11.91 ± 5.89 8.08 ± 3.23 U = 115.0p = 0.267

9.68 ± 6.00 U = 415.0p = 0.394

U = 762.0p = 0.400

Post-treatment cortisol(�g/dL; M ± SD)

10.91 ± 5.53 8.24 ± 3.19b U = 111.0p = 0.501

– – –

Means presented reflect raw data, however, group comparisons were run on residual data corrected for age, sex, BMI and DHEA(S) assay batch.*

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Significant at the p < 0.05 level.a n = 74.b n = 20.

.5. Cortisol and remission of MDD

To determine the specificity of the association of DHEA(S) withSRI-associated remission, and to examine the relationship ofelated steroids, pre- and post-treatment cortisol levels were com-ared, also correcting for age, sex, BMI and assay batch. There wereo significant differences in pre- or post-treatment cortisol levelsetween Remitters and Non-remitters; comparisons with healthyontrols were also not significant. Statistics are presented in Table 2.

. Discussion

To the best of our knowledge, this is the first study to examinendogenous serum DHEA(S) levels specifically in relation to SSRI-

induced remission of MDD. We found that pre-treatment, as wellas post-treatment, serum DHEA(S) levels were higher in MDD sub-jects who achieved remission during eight weeks of SSRI treatmentcompared to those who did not achieve remission; these relation-ships were of a large effect size and remained significant when onlyincluding participants who were taking sertraline (n = 30). Similarrelationships were not found with cortisol, suggesting that DHEA(S)concentrations specifically were related to MDD remission.

As reviewed in the Introduction, three previous studies exam-ined baseline circulating DHEA(S) levels in relation to likelihood

of antidepressant-associated response/remission, with somewhatmixed results. Markopoulou et al. found that baseline DHEA levelswere lower in those who went on to respond to inpatient phar-macotherapy with a variety of psychotropics, including thyroid

C.M. Hough et al. / Psychoneuroendocrinology 77 (2017) 122–130 127

Fig. 2. Spearman correlations between pre- and post-treatment DHEA(S) and absolute change in HDRS Depression Severity over the eight weeks of treatment (Week 8 minusBaseline).D esiduam s didp

mbapsrrwptfi(

HEA was measured in ng/dL and DHEA-S was measured in �g/dL. Data represent ray be positive or negative. The outlier with the greatest decrease in HDRS rating

ost-hoc exclusion of that subject and as the analyses were non-parametric.

edications, antidepressants, mood stabilizers, antipsychotics,enzodiazepines, and buspirone; response to antidepressantslone was not reported (Markopoulou et al., 2009). The com-arability of these previous findings with those of this currenttudy is limited, however, as it (i) was specifically in treatment-esistant depression, (ii) examined clinical response rather thanemission, (iii) included participants with comorbid diagnoses thatere exclusionary in the present study (e.g. bipolar, PTSD, bulimia,

sychosis), (iv) included inpatient subjects, and (v) the medica-

ion interventions involved different classes of drugs. Fabian et al.ound no differences in baseline DHEA(S) levels when compar-ng remitters and non-remitters to treatment with nortriptylinea tricyclic antidepressant) or paroxetine (an SSRI) in elderly MDD

l values after correcting for age, sex, BMI, and DHEA(S) assay batch, therefore, data not significantly affect the results, as results were not significantly changed with

patients (Fabian et al., 2001); however, response to these twomedications were not examined separately, making it unknownwhether the relationship between remission and DHEA(S) levelsdiffered between the two classes of antidepressants. Additionally,the study by Fabian et al. differed from ours in that it (i) was lim-ited to elderly MDD patients (60+ years of age), (ii) employed adifferent classification of remission (post-treatment HDRS ≤ 10),(iii) involved 12 weeks of treatment rather than eight, (iv) includedinpatient subjects, and (v) many subjects were taking multiple

medications throughout the study (Fabian et al., 2001). Hsiao com-pared baseline DHEA levels of those who remitted after treatmentwith venlafaxine (a serotonin-norepinephrine reuptake inhibitor[SNRI]) to those who did not remit and did not find any signifi-

128 C.M. Hough et al. / Psychoneuroendocrinology 77 (2017) 122–130

Fig. 3. Baseline (pre-treatment) DHEA(S) levels in Remitters, Non-remitters, and controls.B = 0.00h whenm I, and

catciiteti

ioDcstRcscpHeep2w2e2thmddp

aseline DHEA levels of Remitters were significantly higher than Non-remitters (pigher than Non-remitters (p = 0.040), with a trend toward the same relationship

easured in �g/dL. Data represent residual values after correcting for age, sex, BM

ant differences between these groups (Hsiao, 2006). Though therere many similarities between the present study and that by Hsiao,here are certain key differences that could explain the discrepan-ies between those findings and our own. The study by Hsiao (i)nvolved 12 weeks of treatment rather than eight, perhaps impact-ng the classification of Remitters; (ii) did not correct for BMI,hough they acknowledge the effects of BMI on DHEA levels (Mazzat al., 1999); (iii) imposed a shorter medication-free period prioro baseline measurement (two weeks rather than six); and (iv)nvolved the use of a different class of antidepressants (i.e. SNRIs).

Though the primary aim of the present study was to exam-ne DHEA(S) levels in MDD subjects before and after undergoingpen-label SSRI treatment, we additionally examined whetherHEA(S) levels changed after SSRI treatment and whether thehange in DHEA(S) levels related to the change in depressioneverity. We did not find any significant changes in pre-to-post-reatment DHEA(S) levels in the whole MDD sample or in theemitters or Non-remitters separately, nor did we find a significantorrelation between change in DHEA(S) and change in depressioneverity. Several studies have examined the association betweenhange in DHEA(S) levels and clinical improvement after antide-ressant treatment (Deuschle et al., 2004; Fabian et al., 2001;siao, 2006; Markopoulou et al., 2009; Morita et al., 2014; Paslakist al., 2010; Romeo et al., 1998; Schüle et al., 2009; Takebayashit al., 1998), several of which have reported decreases in pre-to-ost treatment DHEA(S) levels in depressed patients (Schüle et al.,009; Takebayashi et al., 1998; Zhu et al., 2015), at least in thoseho responded to treatment (Deuschle et al., 2004; Fabian et al.,

001; Hsiao, 2006; Morita et al., 2014; Paslakis et al., 2010; Schület al., 2009); however, findings are mixed (Markopoulou et al.,009; Morgan et al., 2010; Romeo et al., 1998). The reasons forhese inconsistencies are uncertain, however, few of these studiesad similar designs to ours, including differences in age groups,edication status, measurements of improvement, etc., making

irect comparisons difficult. One more potential reason for these

iscrepant findings may be the differences in the classes of antide-ressants used in each study (as discussed in the Introduction).

8) and controls (p = 0.004). Baseline DHEA-S levels of Remitters were significantly compared to controls (p = 0.096). DHEA was measured in ng/dL and DHEA-S wasDHEA(S) assay batch, therefore, data may be positive or negative.

In addition to examining differences in DHEA(S) levels in Remit-ters and Non-remitters, we explored the relationship of thesehormone levels to absolute changes in HDRS. We found that,whereas baseline DHEA(S) levels were not significantly associatedwith absolute changes in HDRS, Week 8 DHEA(S) levels were sig-nificantly associated with absolute changes in HDRS. Though thereasons for the differences in these measures are not known, remis-sion indicates the absence of significant depressive symptoms andis considered the “gold standard” outcome (Fishbain, 2009). Fur-ther larger scale studies will be needed to validate the differencesin these measures.

In addition to examining differences in DHEA(S) levels inMDD subjects, we further explored differences between depressedindividuals and healthy controls. Previous findings in depressionhave found DHEA and/or DHEA-S concentrations to be decreased(Michael et al., 2000; Mocking et al., 2015; Morgan et al., 2010;Zhu et al., 2015), increased (Assies et al., 2004; Kurita et al., 2013;Morita et al., 2014; Takebayashi et al., 1998), or unchanged (Fabianet al., 2001; Kurita et al., 2013; Markopoulou et al., 2009; Mockinget al., 2015; Paslakis et al., 2010; Romeo et al., 1998) (also reviewedin Maninger et al., 2009) in depression in comparison to non-depressed controls. There is no simple way of reconciling thesediscrepant findings; however, it is likely that participant demo-graphics (including age and gender), comorbid psychiatric andmedical conditions, medication status, and time of blood collec-tion are relevant. The current study did not find any significantdifferences in DHEA or DHEA-S levels between MDD and healthycontrol subjects; however, MDD subjects who went on to becomeRemitters after SSRI treatment had significantly higher baselineDHEA(S) levels when compared to controls. Non-remitters’ base-line DHEA(S) levels did not differ from healthy controls, suggestingthat baseline DHEA(S) levels may be related to prognosis ratherthan diagnosis of MDD per se.

Though specific pathways by which DHEA(S) levels may relate toSSRI-induced remission are not known, possible mechanisms may

be postulated. Prior experiments in adult rats by Pinnock et al. haveshown that DHEA, administered subcutaneously, can increase theefficacy of fluoxetine-induced neurogenesis in the dentate gyrus

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C.M. Hough et al. / Psychoneur

y rendering fluoxetine doses that were previously ineffective toe as effective as a dose four times greater (Pinnock et al., 2009).his finding suggests that DHEA may have a synergistic effect withuoxetine, promoting hippocampal neurogenesis, at least in rats.o the extent this is true in humans with MDD as well, it is plausi-le that DHEA may augment SSRIs’ ability to promote hippocampaleurogenesis, thereby increasing the likelihood of inducing remis-ion.

One limitation of the present study is the use of a relativelymall sample, although, we had more than sufficient power toetect the effect sizes of our main comparisons, which ranged from.67–1.11. However, our between-group comparisons with cortisolere generally underpowered, with observed effect sizes ranging

rom 0.23–0.60. Additional limitations of the present study includei) the use of multiple SSRIs, though sensitivity analyses revealed nohange in findings when only examining subjects taking sertraline;ii) the sole use of SSRIs, which may limit generalizability to otherlasses of antidepressants; (iii) the open-label nature of the antide-ressant therapy, which can confound drug response with placeboesponse (though an open-label design more closely resembleslinical settings); (iv) the assessment of antidepressant remissionfter eight weeks of treatment, rather than additionally includingonger duration time points; and (v) the use of single time-pointnd single time-of-day (morning) blood draws for DHEA(S) deter-ination pre- and post-SSRI treatment, which fails to account for

iurnal and day-to-day fluctuations. Strengths of the present studynclude (i) our use of well-characterized, rigorously diagnosed,hysically healthy, unmedicated MDD subjects; (ii) a minimum six-eek medication-free period before baseline; (iii) an eight-week

eriod of antidepressant treatment that was verified by pill countsn all subjects and by plasma antidepressant assays in a subset; andiv) the use of a single class of antidepressant medication to increaseample homogeneity.

. Conclusions

The present study suggests that higher circulating DHEA(S)evels (both while unmedicated and after eight weeks of SSRIreatment) are associated with remission of depression after SSRIreatment. Due to our modest sample size and somewhat con-icting prior findings in the literature, these data bear replicationith a larger sample. These data indicate that endogenous DHEA(S)

bundance may be a physiological adjunct to SSRI efficacy, as sug-ested by prior preclinical and clinical studies (Bloch et al., 1999;aninger et al., 2009; Pinnock et al., 2009; Rabkin et al., 2006;

chmidt et al., 2005; Wolkowitz et al., 1999; Wolkowitz et al., 1997).hould these findings be replicated, serum DHEA(S) levels couldepresent a novel biomarker for depression remission with SSRIntidepressants, although our small-scale study was not designedo establish sensitivity or specificity of DHEA(S) as a biomarker inndividual patients. Additional future clinical trials might furtherxamine whether exogenously administered DHEA can serve as aseful adjunct to SSRI treatment.

onflict of interest

The authors report no conflict of interest.

inancial support

This study was funded by grants from the National Institute

f Mental Health (NIMH) (Grant Number R01-MH083784), the’Shaughnessy Foundation, the Tinberg family, and grants from

he UCSF Academic Senate, and the UCSF Research Evaluationnd Allocation Committee (REAC). This project was also sup-

crinology 77 (2017) 122–130 129

ported by National Institutes of Health/National Center for ResearchResources (NIH/NCRR) and the National Center for AdvancingTranslational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number UL1 RR024131. The University of VirginiaCenter for Research in Reproduction Ligand Assay and Analy-sis Core is supported by the Eunice Kennedy Shriver NICHD/NIH(NCTRI) Grant P50-HD28934. Author DL was supported by theSwedish Research Council (registration number 2015-00387),Marie Sklodowska Curie Actions, Cofund (Project INCA 600398),the Swedish Society of Medicine, the Söderström-Königska Foun-dation, the Sjöbring Foundation, OM Persson Foundation and theprovince of Scania (Sweden) state grants (ALF). None of the grant-ing or funding agencies had a role in the design and conduct of thestudy; collection, management, analysis and interpretation of thedata; and preparation, review, or approval of the manuscript. TheCo-Principal Investigators, OMW, ESE, and SHM, had full access toall of the data in the study and take responsibility for the integrityof the data and the accuracy of the data analysis. The contents ofthis publication are solely the responsibility of the authors and donot necessarily represent the official views of the NIH.

Contributors

Authors SHM, OMW, ESE, and VIR were responsible for studyconcept and design. CMH, LM, RR, HMB, VIR, OMW, and SHM con-tributed to the acquisition of data. CMH performed initial dataanalysis and interpretation of findings. DL and FSB assisted in per-forming data analysis. OMW, SHM, VIR, DL, MS, and FSB assisted ininterpretation of findings. CMH drafted the manuscript. All authorscritically reviewed content and approved the final manuscript.

Acknowledgements

The authors gratefully acknowledge the assistance of KevinDelucchi, PhD, Phuong Hoang, and Alanie Lazaro (all at UCSF); theMendoza Lab of the University of California, Davis; the nursingand other staff of the UCSF CTSI Clinical Research Center, the UCSFPNE Lab volunteer research assistants and, of course, the researchparticipants.

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