Friday 21 June 2013

ROLE OF CAVEOLAE IN HEALTH & DISEASE

Introduction:
In biology, caveolae (Latin for little caves, singular: caveola), which are a special type of lipid raft, are small (50–100 nanometer) invaginations of the plasma membrane in many vertebrate cell types, especially in endothelial cells and adipocytes.
These flask-shaped structures are rich in proteins as well as lipids such as cholesteroland sphingolipids and have several functions in signal transduction. They are also believed to play a role in endocytosis, oncogenesis, and the uptake of pathogenicbacteriaand certain viruses.



REFERENCE ID: PHARMATUTOR-ART-1847
Caveolins:
Formation and maintenance of caveolae is primarily due to the protein caveolin, a 21 kD protein. There are three homologous genes of caveolin expressed in mammalian cells: Cav1, Cav2 and Cav3. These proteins have a common topology: cytoplasmic N-terminus with scaffolding domain, long hairpin transmembrane domain and cytoplasmic C-terminus. Caveolins are synthesized as monomers and transported to Golgi apparatus. During their subsequent transport through secretory pathway, caveolins associate with lipid rafts and form oligomers (14-16 molecules). These oligomerized caveolins form the caveolae. The presence of caveolin leads to the local change in morphology of the membrane.
Roles of Caveolae:
  • Caveolae can be used for entry to the cell by some pathogens and so they avoid degradation in lysosomes. However, some bacteria do not use typical caveolae but only caveolin-rich areas of the plasma membrane. The pathogens exploiting this endocytic pathway include viruses such as SV40 and polyoma virus and bacteria such as some strains of Escherichia coli, Pseudomonas aeruginosa and Porphyromonas gingivalis.
  • Caveolae have a role in the cell signaling, too. Caveolins associate with some signaling molecules (e.g. eNOS) through their scaffolding domain and so they can regulate their signaling. Caveolae are also involved in regulation of channels and in calcium signaling.
  • Caveolae also participate in lipid regulation. High levels of caveolin Cav1 are expressed in adipocytes. Caveolin associates with cholesterol, fatty acids and lipid droplets and is involved in its regulation.
  • Caveolae can also serve as mechanosensors in various cell types. In endothelial cells, caveolae are involved in flow sensation. Chronic exposure to the flow stimulus leads to increased levels of caveolin Cav1 in plasma membrane, its phosphorylation, activation of eNOS signaling enzyme and to remodeling of blood vessels. In smooth-muscle cells, caveolin Cav1 has a role in stretch sensing which triggers cell-cycle progression. 
Role of Caveolae and Caveolins in Health and Disease:-
Although they were discovered more than 50 years ago, caveolae have remained enigmatic plasmalemmal organelles. With their characteristic “flasklike” shape and virtually ubiquitous tissue distribution, these interesting structures have been implicated in a wide range of cellular functions. Similar to clathrin-coated pits, caveolae function as macromolecular vesicular transporters, while their unique lipid composition classifies them as plasma membrane lipid rafts, structures enriched in a variety of signaling molecules. The caveolin proteins (caveolin-1, -2, and -3) serve as the structural components of caveolae, while also functioning as scaffolding proteins, capable of recruiting numerous signaling molecules to caveolae, as well as regulating their activity. That so many signaling molecules and signaling cascades are regulated by an interaction with the caveolins provides a paradigm by which numerous disease processes may be affected by ablation or mutation of these proteins. Indeed, studies in caveolin-deficient mice have implicated these structures in a host of human diseases, including diabetes, cancer, pulmonary fibrosis, and a variety of degenerative muscular dystrophies.
The Multiple Faces Of Caveolae:-
Caveolae are a highly abundant but enigmatic feature of mammalian cells. They form remarkably stable membrane domains at the plasma membrane but can also function as carriers in the exocytic and endocytic pathways. The apparently diverse functions of caveolae, including mechanosensing and lipid regulation, might be linked to their ability to respond to plasma membrane changes, a property that is dependent on their specialized lipid composition and biophysical properties.
Caveolae-Associated Signaling In Health And Disease:-
Lipid rafts are planar aggregates of specific lipids that organize the membrane into domains with unique phase behaviours. Caveolae, considered a subcategory of lipid rafts, are 60-80 nm membrane invaginations stabilised by caveolin and PTRF-Cavin. Both microdomains are considered to harbour key signal transduction molecules. The overall aim of the present proposal is to unveil the function of caveolae and lipid rafts in the cardiovascular and urogenital systems. To do this, genetically modified animals, with perturbed function of receptors and proteins of relevance for formation and trafficking of caveolae/rafts, are utilized. An additional approach is depletion of membrane cholesterol, which disrupts both microdomains. Albeit less specific, this allows critical comparisons with human tissue.
Specific aims include-
i) to assess how receptor signaling is influenced by caveolae,
ii) to examine what role PTRF-Cavin plays in arterial function,
iii) to test whether caveolae-dependent trafficking affects vascular function, and
iv) to probe the possibility that bladder over activity following outlet obstruction is due to increased caveolae density.
The studies will provide in-depth understanding of the role of caveolae in cardiovascular and urogenital physiology. Novel therapeutic targets for treatment of hypertension, atherogenesis, erectile-, and bladder dysfunction may be discovered.
The Role Of Caveolae In Endothelial Cell Dysfunction With A Focus On Nutrition And Environmental Toxicants:-
Complications of vascular diseases, including atherosclerosis, are the number one cause of death in Western societies. Dysfunction of endothelial cells is a critical underlying cause of the pathology of atherosclerosis. Lipid rafts, and especially caveolae, are enriched in endothelial cells, and down-regulation of the caveolin-1 gene may provide protection against the development of atherosclerosis. There is substantial evidence that exposure to environmental pollution is linked to cardiovascular mortality, and that persistent organic pollutants can markedly contribute to endothelial cell dysfunction and an increase in vascular inflammation. Nutrition can modulate the toxicity of environmental pollutants, and evidence suggests that these affect health and disease outcome associated with chemical insults. Because caveolae can provide a regulatory platform for pro-inflammatory signaling associated with vascular diseases such as atherosclerosis, we suggest a link between atherogenic risk and functional changes of caveolae by environmental factors such as dietary lipids and organic pollutants. For example, we have evidence that endothelial caveolae play a role in uptake of persistent organic pollutants, an event associated with subsequent production of inflammatory mediators. Functional properties of caveolae can be modulated by nutrition, such as dietary lipids (e.g. fatty acids) and plant-derived polyphenols (e.g. flavonoids), which change activation of caveolae associated signaling proteins. The following review will focus on caveolae providing a platform for pro-inflammatory signaling, and the role of caveolae in endothelial cell functional changes associated with environmental mediators such as nutrients and toxicants, which are known to modulate the pathology of vascular diseases.
The Cell Surface in Health and Disease :-
The properties of the plasma membrane rely on the specialisation of the plasma membrane into microdomains of specific function. We are studying two types of surface microdomains: caveolae, a specialised domain of the cell surface with a distinct structure, and clathrin-independent endocytic carriers (CLICs), that form the major endocytic pathway in mammalian cells. Caveolae have been implicated in regulation of cell growth and in maintaining the balance of lipids in the cell. In addition, caveolins, the major membrane proteins of caveolae, and cavins, a newly discovered family of caveolar coat proteins, have been implicated in a number of disease states including tumour formation, lipodystrophies, and muscular dystrophy. To study caveolae function, we are using caveola-null mice, cells lacking caveolins and/or cavins, and zebrafish embryos. These systems are also being used to study the role of caveolae in muscle and the molecular changes associated with muscular dystrophy.
Lipid Rafts and Caveolae in the Terminal Differentiation of Epidermal Keratinocytes:-
The epidermal barrier resides in the protective, semipermeable stratum corneum (SC) that permits terrestrial life. An intact SC is crucial to maintain a barrier that prevents the loss of fluids, electrolytes and other molecules from within the body and, at the same time, prevents penetration by microorganisms, toxic materials and UV radiation. SC permeability barrier function is provided by lipid bilayer lamellae surrounding apoptotic corneocytes, the so-called “bricks-and-mortar model”. The intercellular spaces are filled with lipid lamellae build from a mixture of ceramides, free sterols, and free fatty acids made by the secretion of lamellar bodies (LB) at the level of the stratum corneum/stratum granulosum (SC/SG) junction. LB originates from the tubulo-vesicular elements of the trans- Golgi network, where lipids and proteins are sorted for secretion.
THE DYNAMICS OF LAMELLAR BODIES SECRETION-
LB secreted at the SC/SG junction, fuse with the apicalplasma membrane (APM) of the outermost SG cell, creatingthus a cholesterol/glycosphingolipid-enriched lipid raft-like domain. This secretion happens at low rates under normal conditions allowing a sufficient delivery of LB content, enough to maintain barrier function. However, immediately following acute barrier abrogation, an orchestrated sequence of responses occurs rapidly to restore the barrier function to its basal level. Among these, the instant secretion (within 30 minutes) of the preformed LB from the outermost SG takes place.
Application of either monensin or brefeldin A, known inhibitors of exocytosis and organellogenesis delay barrier recovery by affecting LB secretion and content respectively. While the signaling events that regulate LB formation/secretion are not yet fully understood, a decline in cation gradients across the epidermis (i.e. calcium and potassium) stimulates the initial secretion of LB that occurs in response to barrier disruption. Nevertheless, the secreted lipids “dumped” from LB-fusion with the AMP at the SG/SC are processed into lipid bilayers by secretory phopholipase A2 (sPLA2), steroidsulfatase (SSase), acid sphingomyelinase (aSMase) and glucocerebrosidase in the SC. Surprisingly, we recently found that aSMase delivered to the SC interstices is expressed in the raft domain fraction of the epidermis.
THE LIPID RAFT HYPOTHESIS-
Simons and van Meer back in 1988 described lipid rafts domains as dynamic, localized assemblies of cholesterol and sphingolipids within the plasma membrane. Caveolae represent a subclass of those rafts and are enriched in caveolin proteins, a family of three (cav-1 to -3) small molecular weight (18-24 kDa) proteins, that cycle between the trans-Golgi network and the plasma membrane (i.e. the natural flow of LB). Caveolin proteins form homo- and hetero-oligomers, which directly bind to cholesterol, required for the insertion of caveolae into membranes. Cav-1 possesses a ‘scaffolding domain’ that interacts with signal transduction molecules. Not only is this domain required to form multivalent homo-oligomers with other cav proteins, but it also mediates the interaction of cav-1 with non-cav proteins, such as the G-subunits, Ha-Ras, Src family kinases and eNOS. Consequently, cav-1 acts as molecular ‘Velcro’ where signal transduction complexes are bound in the inactivated state. Among the 3 cav proteins, cav-1 has been reported to be essential for caveolae formation. However, neither caveolin (1-3) knockout (-/-) mice show major abnormalities in their phenotype.
Many functions have been attributed to lipid rafts/ caveolae, and recently a role of caveolin-1 in lamellar body assembly, trafficking and function was suggested. This could indicate a role of cavolin-1 and caveolae formation in epidermal barrier permeability
homeostasis. Studies in methyl-cyclodextrin-treated mice show that disruption of lipid rafts leads to alterations in plasma membrane dynamics necessary for adequate lamellar body secretion at the SG/SC interface. In addition, studies in caveolin-1 knockout mice and monensin-treated mice demonstrate the importance of caveolin-1insertion into lipid rafts and caveolae formation in barrier restoration. Next to an
important role of caveolae in lamellar body secretion and terminal differentiation, preliminary data also suggest a role in establishing cell-cell contacts and adherens junction formation.

Age-Related Changes of Caveolin-1 Expression : A New Role for Caveolins:-
In biological terms, caveola are a specialized type of small invaginations (50-100 nanometers) in the plasma membrane of several vertebrate cells that participate in the regulation of a considerable quantity of cellular functions. At cardiovascular level, they are present in almost all cardiac cells including smooth muscle cells, endothelial cells, myocyte, fibroblasts and macrophages. Caveola were discovered between 1953 and 1955 by Palade and Yamada, who demonstrated the presence of gallbladders that were not related to clathrin in endothelial cells and epithelial cells of the gallbladder. Since then, these cellular structures were studied in order to know their normal functioning and, more recently, in which way their alterations are involved in different pathologies. The organization and function of caveola are given by coat proteins, called caveolins, and adaptation proteins, called cavins. Caveolin, with its three isoforms (caveolin-1, caveolin-2, and caveolin-3), form the backbone and are highly integrated in their function. Caveolin-1 and 2 are present in most of the cardiovascular system cells, while caveolin-3 is present in the smooth muscle, striated and cardiac cells. On the other hand, cavins act as regulators of caveolin functioning.
Functionally, caveola participate in cellular signalling and in the regulation of vesicular transport kinetics, fulfilling in this way numerous activities. Signalling function is produced thanks to the high concentration of receptors and intracellular molecules in the place of invagination, which allow an efficient signal transduction. Among other functions, caveola are inhibitors of the activity of the endothelial enzyme nitric oxide synthase (eNOS) while interacting and form a complex eNOS/caveolin-1 that decreases the formation of nitric oxide (NO). In this way, caveolin-1 is an important regulator of NOS functioning. Alterations of these proteins, in different pathologies, produce modifications in NO metabolism, as it is the case of diabetes, in which the overexpression of caveolin-1 generates a negative regulation of the eNOS activity. In the same way it was demonstrated that aging is associated with an increase in the expression of caveolin-1 in human fibroblasts and the reduction of these caveolins in senescent fibroblasts is able to reverse its phenotype to a level of activity similar to the one of young cells.
In situations of hypovolemia, the activation of NO system during the haemorrhage is an important compensatory mechanism. In this sense, in this current issue of the Argentine Journal of Cardiology, considered an interesting hypothesis while studying in which way this system of adaptation could be altered with the advancing age and they try to explain these changes with the modifications in caveolin functioning. The authors demonstrate that there is a lower expression of eNOS in the group of adult animals compared with young ones. This was not correlated with the enzyme activity, as it was expressed by the authors, eNOS activity was similar both in adult and young animals. This last piece of information is opposed to the idea of aging associated with an eNOS negative regulation while increasing the expression of caveolin-1. This controversy makes Arreche et al. results more interesting, while arranging the caveolin association/dissociation phenomenon with the eNOS, as although having lower expression of protein, the activity is not modified, probably as a dissociation of the eNOS with caveolin. However, in their study, the authors did not measure the expression and the activity of caveolin-1, which would have helped to answer, at least partially, this question. Surely, this question would be answered in future works.
On the other hand, a state of hypovolemia affects not only to myocyte, but also the vascular component. In this sense, caveola are important regulators of the vascular tone, due to their capacity of modulating eNOS activity. Therefore, it would be interesting to evaluate the eNOS answer, at vascular endothelial level, during acute haemorrhage and also considering aging.
It is clear that there are many questions concerning this interesting topic, particularly in which way could some pathologic states that are often associated with aging as diabetes or hypertension in the adaptive response of NO, associated with hypovolemia and in relation with caveola activity affect. This is important as there is a growing interest about the role of caveola and its structural protein, caveolin-1, in the normal and pathological functioning of the cardiovascular system.
The Role of Caveolin-1 in Prostate Cancer: Clinical Implications:-
Caveolin-1 (cav-1) is a major structural component of caveolae, which are specialized plasma membrane invaginations involved in multiple cellular processes such as molecular transport, cell adhesion and signal transduction. Although under some conditions cav-1 may suppress tumorigenesis, cav-1 is associated with and contributes to malignant progression through various mechanisms. Specific proteins such as receptor tyrosine kinases, serine/threonine kinases, phospholipases, G protein-coupled receptors and Src family kinases are localized in lipid rafts and caveolar membranes, where they interact with cav-1 through the cav-1 scaffolding domain; the activities mediated by this domain result in the generation of platforms for compartmentalization of discrete signaling events. A high level of intracellular cav-1 expression is associated with metastatic progression of human prostate cancer and other malignancies, including lung,renaland esophageal squamous cell cancers.
Virulent prostate cancer cell lines reportedly secrete biologically active cav-1 protein in vitro, and cav-1 promotes prostate cancer cell viability and clonal growth. The cancer-promoting effects of secreted cav-1 include antiapoptotic activities similar to those observed following enforced expression of cav-1 within the cells. In addition to showing cav-1-mediated autocrine activities, a recent study showed that recombinant cav-1 protein is taken up by prostate cancer cells and endothelial cells in vitro and that recombinant cav-1 increases angiogenic activities both in vitro and in vivo by activating Akt- and/or nitric oxide synthase-mediated signaling. Moreover, significantly higher serum cav-1 levels have been documented in men with prostate cancer than in men with benign prostatic hyperplasia and also in patients with elevated risk of cancer recurrence after radical prostatectomy.
The concept of expression and secretion of cav-1 by prostate cancer cells in malignant progression is unique. The autocrine and paracrine activities of cav-1 mediated through the activation of Akt and/or nitric oxide synthase signaling may lead to pervasive engagement of the local tumor microenvironment, involving but not limited to the proangiogenic activities previously documented.
Mechanisms of Cav-1-mediated Oncogenic Activities in Prostate Cancer:-
Overexpression of cav-1 was reported in various malignancies, including cancer of the colon, kidney,bladder, lung, pancreas and ovary, and in some types of breast cancer. The level of cav-1 expression may depend on the tumor type and stage; for example, high cav-1 levels were reported in late or advanced squamous cell carcinoma and in metastatic prostate cancer. These results have led many investigators to attempt to identify cav-1-related oncogenic pathways for various malignancies. Although cav-1 activities impinge on various oncogenic pathways and can inhibit or activate these pathways, depending on the cell type and context, the results of multiple studies now indicate that Akt activation has an important role in cav-1-mediated oncogenic functions in prostate cancer. The first demonstration of a direct association between cav-1 expression and Akt indicated that the overexpression of cav-1 increased binding to and inhibited the serine/threonine phosphatases, PP1 and PP2A, in human prostate cancer cells. These interactions, which were likely mediated through cav-1 binding to a cav-1 scaffolding domain-binding site on PP1 and PP2A and inhibition of their activities, led to significantly increased levels of phospho-Akt and sustained activation of downstream oncogenic Akt targets. Findings from a recent independent study supported this mechanism and further showed that the putative oncogene inhibitor of differentiation-1 induced Akt activation by promoting the binding activity of cav-1 and PP-2A. It is important to consider that the activation of Akt has been previously associated with prostate cancer and is clearly one of the most important oncogenic activities that underlie prostate cancer progression. It is worthwhile to consider the idea that activated Akt contributes to the expression and secretion of multiple growth factors (GFs) that have important roles in the growth, survival and progression of prostate cancer cells through autocrine and paracrine activities. The molecular mechanisms that may connect cav-1 upregulation to GF expression and secretion through the activation of Akt are worthy of future investigation.
Secreted Cav-1 as a Biomarker and Therapeutic Target:-
The expression and secretion of cav-1 by prostate cancer cells presents an opportunity for the development of cav-1-based biomarkers for prostate cancer. We previously developed an immunoassay for measuring serum cav-1 levels and showed that the median serum cav-1 level in men with clinically localized prostate cancer was significantly higher than that in healthy control men (that is, in those with normal findings on digital rectal examination and serum prostate-specific antigen levels of ≤1.5 ng ml−1 over a period of 2 years) and in men with clinical benign prostatic hyperplasia. Further, in a larger population study in men with a serum prostate-specific antigen of >10 ng ml−1, high pretreatment levels of cav-1 in the serum were associated with a shorter time to biochemical recurrence (defined as a serum prostate-specific antigen level of ≥0.2 ng ml−1 on two consecutive measurements). High pretreatment serum cav-1 levels were established using a cutoff determined by using the minimum P-value method.
These initial clinical and basic laboratory study results, together with those of pathology-based tissue analysis, show the potential of serum cav-1 as a prognostic biomarker for the identification of men with clinically aggressive prostate cancer. Specifically, the pretreatment serum cav-1 concentration may be used to identify men with clinically significant prostate cancer who are likely to experience a rapid recurrence of the cancer following radical prostatectomy. Although further studies are necessary to validate these results, it is conceivable that serum cav-1 analysis would contribute to the identification of the subset of the men undergoing localized therapy for presumed localized disease who would benefit from neoadjuvant or adjuvant therapy, for example, local radiotherapy, localized biologic therapy, androgen-deprivation therapy and/or targeted systemic therapy.
We have considered, in addition to the potential use of serum cav-1 analysis as a prognostic biomarker for clinically aggressive prostate cancer, the possibility that secreted cav-1 is a therapeutic target for prostate cancer. Our recent studies revealed that systemic treatment of mice with cav-1 antisera significantly reduced the development and growth of primary site tumors and metastases in both orthotopic and experimental metastasis mouse models of prostate cancer. These studies further showed that metastatic prostate cancer cells may survive and grow partly through the uptake of secreted cav-1. As targeted systemic antibody therapy has been used successfully to treat specific malignancies, the development of cav-1-targeted antibody therapy should be further pursued as a potential therapy for prostate cancer.
Cell-Specific Dual Role of Caveolin-1 in Pulmonary Hypertension:
Pulmonary hypertension (PH) is a rare but a devastating disease with high morbidity and mortality rate. The reported prevalence is 15–52 cases/million and the incidence is thought to be 2.4–7.6 cases/million/year. A wide variety of cardiopulmonary diseases, collagen vascular and autoimmune diseases, chronic thromboembolism, HIV, portal hypertension, drug toxicity, and myeloproliferative diseases are known to lead to PH. In primary pulmonary arterial hypertension (PAH), currently labeled as idiopathic PAH, the underlying etiology is not clear and about 6% of patients in this group have a family history of the disorder. Multiple signaling pathways and inflammation have been implicated in the pathogenesis of PH. Endothelial dysfunction may be an important triggering factor leading to an imbalance between vasorelaxation and vasoconstriction and deregulation of cell proliferation leading to vascular remodeling and PH with subsequent cell migration and neointima formation. Loss of bioavailability of nitric oxide (NO) and prostacyclin (PGI2) , upregulation/activation of proliferative molecules such as endothelin-1 (ET1) , platelet-derived growth factor (PDGF) , serotonin, survivin, cyclin D1, tyrosine-phosphorylated signal transducer and activator of transcription 3 (PY-STAT3) , RhoA/Rho kinase, and anti-apoptotic molecules such as Bcl2 and Bcl-xLhave been reported in PH. In addition, increased elastase activityand increased production of matrix metalloproteinase2 (MMP2) occur in PH. Recent studies have shown a strong link between heterozygous germline mutations in bone morphogenic protein receptor type II (BMPRII), a member of TGFβ superfamily and pulmonary arterial hypertension (PAH). Mutation of BMPRII has been reported in 70% of heritable PAH, 26% IPAH, and 6% of patients with congenital heart defect and associated PAH. However, only about 20% of people with this mutation develop PAH, indicating that environmental and/or other genetic factors may be involved in the development of the disease. Furthermore, recent studies have shown reduction in the expression of BMPRII protein in both monocrotaline (MCT) and the hypoxia models of PH. In addition, mutations of activin-like receptor kinase 1 (ALK1) and endoglin, both belonging to TGFβ superfamily, have been reported in patients with hereditary hemorrhagic telangiectasia, and some of these patients develop PAH.
Regardless of the underlying etiology, the main features are endothelial dysfunction, impaired vascular relaxation response, deregulated cell proliferation and impaired apoptosis, vascular remodeling, narrowing of the lumen, elevated PA pressure, and right ventricular hypertrophy with subsequent right heart failure and premature death. Despite major advances in the understanding of the disease process, a cure is not yet in sight. Current therapy has improved the quality of life but has not had a significant effect on the mortality rate. Loss of endothelial caveolin-1, a cell membrane protein is well documented in experimental and clinical forms of PH. Recent studies indicate that in addition to the loss of endothelial caveolin-1, there is enhanced expression of caveolin-1 in smooth muscle cells with proliferative activity and subsequent neointima formation. Thus, caveolin-1 may play a key role in the pathogenesis of PH, and its activity may depend on cell type and the disease stage.
Endothelial Caveolin-1 in Pulmonary Hypertension :-
Disruption of Endothelial Cell Membrane and Loss of Caveolin-1-
Loss of endothelial caveolin-1 has been reported in clinical and experimental forms such as monocrotaline (MCT) and myocardial infarction models of PH.The MCT model has been extensively studied to understand the pathogenesis of PH. A single subcutaneous injection of MCT in rats injures endothelial cells within 24–48 hrsand PH is observed at 10–14 days after MCT. In this model the disruption of endothelial caveolae associated with progressive loss of caveolin-1 occurring as early as 48 hrs after MCT, is a major feature seen before the onset of PH. In addition to the loss of caveolin-1, there is reduction in the expression of other endothelial cell membrane proteins known to colocalize with caveolin-1 such as Tie2 (endothelium-specific tyrosine kinase receptor of angiopoietin 1), platelet endothelial cell adhesion molecule (PECAM) 1, and both subunits of soluble guanylate cyclase. Importantly, the loss of caveolin-1 is associated with reciprocal activation of signal transducer and activator of transcription (STAT) 3 to PY-STAT3, known to be preferentially activated by downstream effectors of proinflammatory cytokine IL-6/gp130 signaling pathway. In addition, the expression of Bcl-xL is increased simultaneously with the activation of PY-STAT3. PY-STAT3 plays a critical role in cell growth, inhibition of apoptosis, survival, and in immune function and inflammation. Persistent phosphorylation of STAT3 has been reported in a number of primary tumors, and activation of STAT3 signaling confers resistance to apoptosis.Some of the downstream effectors of PY-STAT3 are survivin and Bcl-xL (antiapoptotic factors), and cyclin D1 (cell-cycle regulator). All these factors have been shown to be upregulated in PH. Importantly, activation of PY-STAT3 has been observed in endothelial cells obtained from patients with idiopathic PAH. RhoA/Rho kinase activation is well established in PH, and interestingly, Rho GTPases is required for STAT3 activation, and Rho GTPases-mediated cell proliferation and migration occur via STAT3. Caveolin-1 functions as a suppressor of cytokine signaling (SOCS) 3 and inhibits PY-STAT3 activation. Therefore, it is not surprising that the rescue of endothelial caveolin-1 not only inhibits STAT3 activation but also restores the endothelial cell membrane integrity and attenuates MCT-induced PH and vascular remodeling. These results underscore the importance of endothelial cell membrane integrity and the expression of endothelial caveolin-1 in maintaining vascular health.
Studies with caveolin-2 KO mice have shown pulmonary defects such as alveolar wall thickening and increased cell proliferation similar to what has been reported in caveolin-1 KO mice. Unlike caveolin-1 KO, caveolin-2 KO has no effect on vascular reactivity, nor does it participate in the formation of caveolae. Interestingly, in the MCT and myocardial infarction models of PH, in addition to loss of caveolin-1, caveolin-2 loss occurs, and the rescue of caveolin-1 attenuates PH and also restores caveolin-2 expression. Since caveolin-2 requires caveolin-1 for its transport to the membrane surface, caveolin-2 loss may accompany the caveolin-1 loss in these models of PH. It is likely that caveolin-2 participates with caveolin-1 in pulmonary vascular health and disease. It is not clear what independent role caveolin-2 might have in the pathogenesis of PH. Further studies are warranted to examine the specific role of caveolin-2 in PH.
Perturbation of Endothelial Cell Membrane and Dysfunction of Caveolin-1-
PH is an important cause of heart failure and increased mortality in patients suffering from chronic lung diseases associated with alveolar hypoxia. Hypoxia induces pulmonary vasoconstriction and vascular remodeling leading to PH. In hypoxia-induced PH, similar to the MCT model, low bioavailability of NO, low basal and agonist-induced cGMP levels, and impaired endothelium-dependent NO-mediated relaxation responses in pulmonary arteries have been reported. Interestingly, BH4 or L-arginine administration does not improve eNOS dysfunction. However, unlike the MCT model, in hypoxia-induced PH, there is no reduction in caveolin-1 expression. Murata et al. have further shown that in pulmonary arteries from rats with hypoxia-induced PH, eNOS forms a tight complex with caveolin-1 and becomes dissociated from HSP90 and calmodulin, resulting in eNOS dysfunction. In addition, the long-term effect of prenatal hypoxia results in impaired endothelium-dependent and NO-mediated relaxation responses coupled with increased caveolin-1 and eNOS association. Interestingly, hypoxia-induced PH and pulmonary endothelial cells exposed to hypoxia exhibit hyperactivation of PY-STAT3. Hypoxia-inducible factor (HIF) 1α is thought to play a significant role in hypoxia-induced hyperplasia of SMC. STAT3 plays a significant role in stabilizing HIF1α, and its interaction with HIF1α mediates transcriptional activation of vascular endothelial growth factor (VEGF) promoter. Targeting STAT3 blocks HIF1α and VEGF, thus modulating proliferation and angiogenesis. These results strongly suggest that PY-STAT3 may be an important regulator of VSMC proliferation in PH irrespective of the underlying etiology.
Since caveolin-1 has been shown to inhibit PY-STAT3 activation, the activation of PY-STAT3 in hypoxia-induced PH despite the unaltered expression of caveolin-1 protein strongly suggests that caveolin-1 is dysfunctional and has lost its inhibitory function. Furthermore, within 24 hr exposure to hypoxia, bovine pulmonary artery endothelial cells reveal caveolin-1 and eNOS complex formation accompanied by PY-STAT3 activation. These results indicate that the tight complex formation of caveolin-1 and eNOS in hypoxia-induced PH renders both eNOS and caveolin-1 dysfunctional. In this context, it is worth noting that statins protect eNOS function in hypoxia-induced PH. The major effect of statins is reported to be the uncoupling of eNOS/caveolin-1 complex, thus freeing eNOS for activation. This effect on eNOS is not accompanied with lowering of cholesterol. It is likely that the statins disrupt the tight cavolin-1/eNOS coupling resulting from hypoxia- induced perturbation of endothelial cell membrane, thus restoring antiproliferative properties of caveolin-1 and NO production by eNOS. Unlike the MCT model, hypoxia does not appear to cause physical disruption of EC membrane but causes perturbation of the endothelial cell membrane and leading to “mislocalization” of caveolin-1 and eNOS.

Dual Role of Caveolin-1-
Loss of caveolin-1 has been shown to induce oncogenic transformation, and the cells become resistant to apoptosis. Furthermore, the introduction of caveolin-1 scaffolding domain inhibits cancer progression. Many oncogenes transcriptionally downregulate caveolin-1 expression. However, caveolin-1 regulation impacts both negatively and positively on several aspects of tumor progression. Caveolin-1 acts as a tumor suppressor in the early stages of cancer, but in late stages it promotes metastasis, multidrug resistance, and portends poor prognosis. Caveolin-1 function is thought to be interdependent on tumor stage and the expression of molecular effectors that may have an impact on its role during tumor progression. Similarly in PH, the switch from an antiproliferative to proproliferative function may depend on alteration in caveolin-1 conformation, localization, cell context, and the stage of the disease.
Caveolae and caveolin-1 play an important role in pulmonary vascular system. Depending on the type of endothelial injury, the end result is either the loss of caveolin-1 secondary to endothelial cell membrane disruption or in endothelial caveolin-1 dysfunction. A classic example of the latter case is hypoxia-induced PH in which a tight complex formation of caveolin-1/eNOS resulting in dysfunction of both molecules is an important feature. Both these alterations, however, do lead to pulmonary vascular remodeling and PH. Disruption of endothelial cell membrane integrity as in the former case is often progressive leading to extensive EC damage and/or loss with subsequent enhanced expression of caveolin-1 in SMC, which participates in further proliferation, cell migration, and neointima formation. These alterations in caveolin-1 may determine reversibility versus irreversibility of the disease process. Thus, depending on the underlying pathology, cellular involvement, and the stage of the disease, modulation of caveolin-1 function may be considered a therapeutic target in PH.
Increased Smooth Muscle Cell Expression Of Caveolin-1 And Caveolae Contribute To The Pathophysiology Of Idiopathic Pulmonary Arterial Hypertension:-
Recent efforts to understand the pathogenesis and to develop treatments for IPAH have emphasized increased proliferation of PASMC leading to vascular wall hypertrophy and increased vascular tone as possible therapeutic targets. This “hyperproliferative” state has been linked to increased [Ca2+] levels in PASMC , but little is known regarding the precise molecular and cellular determinants. The data shown here involving assessment of mRNA, protein, ultrastructure, function, and molecular manipulation are all consistent with the idea that increased [Ca2+] in PASMC from IPAH patients is linked to overexpression of Cav-1 and caveolae. We found overexpression of Cav-1 in tissue sections and in PASMC cultured from patients with IPAH. In addition, two different interventions (MβCD and lovastatin) that deplete cholesterol and perturb the structure of caveolae decreased CCE and proliferation of IPAH-PASMC. We observed similar effects in IPAH-PASMC treated with siRNA directed against Cav-1. By contrast, overexpression of Cav-1 in normal PASMC increased formation of caveolae (to levels comparable to those found in IPAH) and recapitulated the enhanced CCE observed in IPAH-PASMC. Taken together, these multiple complementary pieces of evidence strongly implicate the expression of Cav-1 and caveolae in the regulation of [Ca2+] in IPAH-PASMC. The results suggest that statins (or perhaps other cholesterol-lowering agents) or therapies that reduce Cav-1 expression in PASMC may have therapeutic benefit for IPAH. However, such caveolae-targeted therapeutics must take into account the possibility of effects on other cell types; further data are needed to develop such a therapeutic approach.
Certain neoplasms [i.e., prostate cancer, bladder cancer, adenocarcinomas, esophageal squamous cell carcinomas, and both benign and malignant smooth muscle tumors] have elevated Cav-1 expression. Timme et al. have shown an interplay between Cav-1 and c-Myc-induced apoptosis: the Cav-1 gene can be down-regulated by c-myc, and maintaining high levels of Cav-1 suppresses c-myc-induced apoptosis. Cav-1 has also been shown to maintain active Akt in prostate cancer cells by inhibiting protein phosphatase activity, an additional mechanism that may contribute to cellular resistance to apoptosis. Such findings imply that, in IPAH, Cav-1 overexpression may be antiapoptotic and/or block proapoptotic pathways. Mutations in Cav-3 have been linked to a pathological process (i.e., muscular dystrophy). The current results indicate that another caveolin, Cav-1, contributes to pathology and may serve as both a marker and therapeutic target in IPAH.
Cav-1-deficient mice, which lack Cav-1 and -2 expression and caveolae formation, develop pulmonary hypertension, right ventricular hypertrophy, as well as structural remodeling, vasculopathies, and hyperproliferation in the lung. Recent data suggest that administration to rats of a cell-permeable Cav-1 peptide prevents monocrotaline-induced pulmonary hypertension. Such findings contrast with our findings in human IPAH, implying that the latter disease is not easily approximated in animal models. It is likely that the Cav-1-knockout mice develop pulmonary hypertension secondary to other pathologies. Expression of Cav-1 and Cav-2 is decreased in the lungs of rats with SPH, including monocrotaline- and myocardial infarction-induced pulmonary hypertension. Such data contrast with our results shown here for IPAH-PASMC, further demonstrating the difficulty of modeling the human disorder in studies with experimental animals. Limited data for patients with IPAH have utilized whole lung tissue and shown a reduction in caveolin mRNA and protein. When we analyzed tissue from whole lung, we, too, found a decrease in Cav-1 expression; however, assessment of specific cell types revealed a dramatic elevation of Cav-1 expression in vascular smooth muscle of IPAH patients with decreased expression in endothelial cells, the latter of which are likely the predominant contributors to analyses of caveolin expression in whole lung preparations. Our other data show that increased caveolin expression contributes to the altered smooth muscle cell function in patients with IPAH. One must therefore be cautious in extrapolating animal datato a complex human disease such as IPAH, which may show cell-specific changes such as those we observe in the expression of caveolins.
In the current study we show that increased caveolar formation increases CCE and [Ca2+]. [Ca2+] is tightly regulated: a rise in [Ca2+] is a trigger for vasoconstriction, and a stimulant of cell proliferation. [Ca2+] also regulates numerous enzymes. Depletion of Ca2+ from the SR leads to the opening of plasma membrane TRPC channels, thereby increasing Ca2+ influx (CCE), to refill the SR stores and allowing for sustained increase in cytoplasmic [Ca2+]. PASMC isolated from IPAH patients have higher [Ca2+] levels than do normal cells, likely attributable to up-regulation of TRPC that comprise the SOC. Increased expression of Cav-1 and caveolae in IPAH may contribute to this increased [Ca2+]viaup-regulation of TRPC expression and localization in caveolae. Disruption of caveolae via MβCD and lovastatin, as used in our study, may displace components of the Ca2+ signaling machinery from close association with SR whose proximity is necessary for activation of SOC in a local microenvironment. Since Cav-1 also localizes with BMPR2 and nitric oxide synthase, such interactions may also influence IPAH. The current findings provide complementary evidence from upward and downward manipulation of expression of Cav-1 to establish a molecular proof-of-principle for the role of enhanced Cav-1 expression and caveolae formation in altered Ca2+ handling and cellular responses in IPAH.
The therapeutic role of statins in PAH has been assessed in animals with hypoxia- and monocrotaline-induced pulmonary hypertension, but such studies do not reveal the cellular and molecular mechanisms for beneficial responses. Although statins have pleiotropic effects, the findings we obtained with PASMC imply that statins may act via cholesterol depletion and resultant decreased expression of caveolae; this mechanism will require further studies in animals that are administered such drugs. Our data showing that statins modulate CCE in IPAH-PASMC in parallel with altered membrane morphology and disruption of caveolae suggest that statins modify IPAH-PASMC physiology toward a nonproliferative phenotype linked to a decrease in [Ca2+].
Our results should be interpreted with certain limitations. Although the current data emphasize the increase in expression of Cav-1 in IPAH-PASMC, other data (not shown) indicate that expression of Cav-2 mRNA and protein are increased in IPAH-PASMC and that siRNA for Cav-1 also results in a down-regulation of Cav-2. The latter finding is consistent with reports in the literature indicating that Cav-1 is the dominant caveolin isoform that regulates cell physiology and that expression and localization of Cav-2 depend on the expression and localization of Cav-1. Such data suggest that Cav-1 is the more important isoform and are consistent with findings we obtained in siRNA and overexpression studies. In addition, we observed no expression of Cav-3 in either normal or IPAH-PASMC.
It is theoretically possible that the treatments administered to the IPAH patients we studied may have altered the expression of Cav-1 and caveolae; samples from untreated patients were not available to us. As noted above, it is possible that the beneficial effects we observed with statins are mediated independent of cholesterol reduction and, in turn, are independent of caveolae expression. Nevertheless, the current findings provide evidence for a previously unappreciated role of increased expression of Cav-1 and caveolae in the pathophysiology of IPAH and suggest that modifying their expression may have therapeutic benefit.
References:-
1.Cohen AW, Hnasko R, Schubert W, Lisanti MP. Role of caveolae and caveolins in health and disease. Physiol Rev. 2004; 84: 1341–1379.
2.Li XA, Everson WV, Smart EJ. Caveolae, lipid rafts, and vascular disease. Trends Cardiovasc Med. 2005; 15: 92–96.
3.Fleming I, Busse R. Signal transduction of eNOS activation. Cardiovasc Res. 1999; 43: 532–541.
4.Bucci M, Gratton JP, Rudic RD, Acevedo L, Roviezzo F, Cirino G, Sessa WC. In vivo delivery of the caveolin-1 scaffolding domain inhibits nitric oxide synthesis and reduces inflammation. Nat Med. 2000; 6: 1362–1367.
5.Peterson TE, d'Uscio LV, Cao S, Wang X-L, Katusic ZS. Guanosine triphosphate cyclohydrolase I expression and enzymatic activity are present in caveolae of endothelial cells. Hypertension. 2009; 53: 189–195.
6.Schmidt TS, Alp NJ. Mechanisms for the role of tetrahydrobiopterin in endothelial function and vascular disease. Clin Sci (Lond). 2007; 113: 47–63.
7.Du YH, Guan YY, Alp NJ, Channon KM, Chen AF. Endothelium-specific GTP cyclohydrolase I overexpression attenuates blood pressure progression in salt-sensitive low-renin hypertension. Circulation. 2008; 117: 1045–1054.
8.Lambert S, Vind-Kezunovic D, Karvinen S, Gniadecki R. Ligand-independent activation of the EGFR by lipid raft disruption. J Invest Dermatol. 2006; 126: 954–962.
9.Krajewska WM, Maslowska I. Caveolins: structure and function in signal transduction. Cell Mol Biol Lett. 2004; 9: 195–220.
10.Ratajczak P, Damy T, Heymes C, Oliviero P, Marotte F, Robidel E, Sercombe R, Boczkowski J, Rappaport L, Samuel JL. Caveolin-1 and -3 dissociations from caveolae to cytosol in the heart during aging and after myocardial infarction in rat. Cardiovasc Res. 2003; 57: 358–369.
11.T C Thompson, S A Tahir, L Li, M Watanabe, K Naruishi, G Yang, D Kadmon, C J Logothetis, P Troncoso,C Ren, A Goltsov, S ParkProstate Cancer Prostatic Dis. 2010;13(1):6-11.
12.M. Humbert, O. Sitbon, A. Chaouat et al., “Pulmonary arterial hypertension in France: results from a national registry,” American Journal of Respiratory and Critical Care Medicine, vol. 173, no. 9, pp. 1023–1030, 2006. View at Publisher • View at Google Scholar • View at PubMed • View at Scopus.
13.A. J. Peacock, N. F. Murphy, J. J. V. McMurrey, L. Caballero, and S. Stewart, “An epidemiological study of pulmonary arterial hypertension,” European Respiratory Journal, vol. 30, no. 1, pp. 104–109, 2007. View at Publisher • View at Google Scholar • View at PubMed • View at Scopus
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15.S. Rich, D. R. Dantzker, S. M. Ayres, et al., “Primary pulmonary hypertension. A national prospective study,” Annals of Internal Medicine, vol. 107, no. 2, pp. 216–223, 1987. View at Scopus

Tuesday 18 June 2013

CANCER PATIENTS UNDERGOING CHEMOTHERAPY TO DEVELOP DEPRESSION

ABSTRACT:
The aim of the study was to determine the developed depression during chemotherapy. Depression is a common symptom in cancer patients, which is difficult to be detected and consequently to be treated. It deteriorates over the the course of cancer treatment, persists long after the end of therapy and influences negatively the quality of life. Early diagnosis of depression consists a matter of great importance for a medical treatment. Patients with depressive symptoms scored significantly higher in behavioral disengagement and self-blame as their coping strategies compared to those who were not depressed. The final rationale for this study was to produce research which could be used to educate oncology nurses to create an awareness of psychological side effects in chemotherapy patients.


INTRODUCTION:
Depression as a disease should be clearly differentiated from depressive symptoms or depressive moods, which are an integral part of human emotions. There are qualitative as well as quantitative differences between a state of unhappiness in reaction to the adverse events in the world outside, and depression as a disease state. It is essential for doctors, the general public and health planners to understand that depression as a disease, unlike depressive moods, is neither a normal variation of mood nor an appropriate reaction to severe stress. Also, depression does not constitute a failure of "will power" or "weak character" in a person.There are some people who periodically or chronically remain in a depressed state in spite of their having all social privileges and material comforts, severely compromising all their functions, culminating in about 15% of cases in suicide.
Major depression is a common psychiatric disorder among cancer patients and is associated with psychosocial impairment and decreased quality of life. Although some research has explored psychological interventions with cancer patients, outcome studies investigating the benefits of behavior therapy among cancer patients with well diagnosed depression are nonexistent.Depressed cancer patients also experience a more rapid progression of cancer symptoms, increased mortality, more metastasis and pain, and increased medical utilization. Thus, the need to explore effective psychosocial and pharmacological interventions for depressed cancer patients has been highlighted as a pressing need.[1]. Major depression may represent a spectrum of disorders, varying in severity from mild and self-limited conditions to extraordinarily severe, psychotic, incapacitating, and deadly diseases. Physiological and pharmacological modifications of these brain regions may have important behavioral consequences and useful clinical effects regardless of the underlying cause of any mental disorder. Clinical depression must be distinguished from normal grief, sadness, disappointment, and the dysphoria or demoralization often associated with medical illness.[2].In the last 50 years, rapid strides have been made in the treatment of depression. Newer drugs have been discovered with better efficacy, less side-effects and better tolerance, and are being used for short-term and long-term treatment. Besides drugs, non- pharmacological therapies like psychotherapy and cognitive therapy have been found beneficial. In the modern day and age, there is absolutely no reason why people anywhere in the world should continue to suffer from depression.When the negative reactions to life`s situations become repetitively intense and frequent we develop symptoms of depression. Life throws up innumerable   situations, which we greet with both negative and positive emotionssuch as excitement, frustration, fear, happiness, anger, sadness, Depressionis prevalent among all age groups, in almost all walks of life. In the last 50 years, rapid strides have been made in the treatment of depression. Newer drugs have been discovered with better efficacy, less side-effects and better tolerance, and are being used for short-term and long-term treatment. Besides drugs, non-pharmacological therapies like psychotherapy and cognitive therapy have been found beneficial. In the modern day and age, there is absolutely no reason why people anywhere in the world should continue to suffer from depression.

When the negative reactions to life`s situations become repetitively intense and frequent we develop symptoms of depression. Life throws up innumerable   situations, which we greet with both negative and positive emotionssuch as excitement, frustration, fear, happiness, anger, sadness, Depressionis prevalent among all age groups, in almost all walks of life.
We all go through ups and downs in our mood. Sadness is a normal reaction to life’s struggles, setbacks, and disappointments. Many people use the word “depression” to explain these kinds of feelings, but depression is much more than just sadness. Some people describe depression as “living in a black hole” or having a feeling of impending doom. However, some depressed people don't feel sad at all—instead, they feel lifeless, empty, and apathetic. Rates of depression in women are twice as high as they are in men.[3]
What is depression
Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities. At its worst, depression can lead to suicide, a tragic fatality associated with the loss of about 850 000 lives every year.
 A depressive disorder is a syndrome (group of symptoms) that reflects a sad and/or irritable mood exceeding normal sadness or grief. More specifically, the sadness of depression is characterized by a greater intensity and duration and by more severe symptoms and functional disabilities than is normal.  .Depression is a prolonged and persistent state of sadness –
  • Pathological/morbid condition.
  • Depression is a significant public health problem because of its high prevalence, the suffering,    and sometimes death, that it causes.
  • Depression leads to considerable dysfunction in all areas of life in an affected person.
  • Depression is seen in many medical disorders, and persons with depression are more prone  to develop secondary medical disorders.
  • Suicide is a major risk during the course of depression.
Despite effective treatment being available, a large number of  depressed patients receive no treatment.   
Facts about Depression:
a. Depression is common, affecting about 121 million people worldwide.
b. Depression is among the leading causes of disability worldwide.
c. Depression can be reliably diagnosed and treated in primary care.
d. Fewer than 25 % of those affected have access to effective treatments.
Depression can be reliably diagnosed in primary care. Antidepressant medications and brief, structured forms of psychotherapy are effective for 60-80 % of those affected and can be delivered in primary care. However, fewer than 25 % of those affected (in some countries fewer than 10 %) receive such treatments. Barriers to effective care include the lack of resources, lack of trained providers, and the social stigma associated with mental disorders including depression.[4]
Primary care based quality improvement programs for depression have been shown to improve the
  • quality of care,
  • satisfaction with care
  • health outcomes,
  • functioning,
  • economic productivity,
  • household wealth at a reasonable cost
Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration. These problems can become chronic or recurrent, substantially impairing an individual’s ability to cope with daily life. At its most severe, depression can lead to suicide. Most cases of depression can be treated with medication or psychotherapy
Types of Depression:[5]
There are several forms of depressive disorders. The most common and major depressive disorder are following.
Atypical Depression:Atypical depression is a type of depression that overwhelms an individual almost to the point of emotional paralysis. The name atypical depression comes from the fact that many of its symptoms are opposite to those of some severe depressions. For example people with atypical depression tend to overeat and oversleep. In contrast, people with depression can't eat or sleep. People with atypical depression are externally validated. They feel good when people give them positive compliments and they feel bad when someone criticizes them. Their moods change and shift as quickly as the wind depending if they are isolated and lonely or with a group of friends enjoying a night out on the town.
Bipolar Depression:This depression is a mood disorder with manic episodes. Bipolar disorder normally begins in adolescence or early adulthood and continues throughout life. Consequently, those who have it may suffer needlessly for years without treatment. This illness can be effectively treated and must be as it is very serious. Without treatment, marital breakups, job loss, alcohol and drug abuse, and suicide may result from the chronic, episodic mood swings. This is a serious judgment problem. As the manic episode progresses, concentration becomes difficult, thinking becomes more grandiose, and problems develop. Many individuals with bipolar disorder abuse drugs or alcohol during manic episodes, and some of these develop secondary substance abuse problems. 
Cyclothymic Disorder:Cyclothymic disorder is when a person has mild and alternating mood swings of elation and depression occurring over a long time period. Because the mood swings are mild, and the elation is often enjoyable, frequently people with cyclothymic disorder do not seek medical help. The periods of elation and depression can last for lengthy periods, such as a few months. Often, a person with cyclothymic disorder has a relative with bipolar disorder, or they may develop bipolar disorder themselves.
Dysthymia Depression:The Greek word dysthymia means "bad state of mind" or "ill humor." As one of the two chief forms of clinical depression, it usually has fewer or less serious symptoms than major depression but lasts longer. Dysthymia refers to a prevalent form of sub threshold depressive pathology with gloominess, anhedonia, low drive and energy, low self-esteem and pessimistic outlook. Although co-morbidity with panic, social phobic and alcohol use disorders has been described, the most significant association is with major depressive episodes. Dysthymia and major depression naturally have many symptoms in common, including depressed mood, disturbed sleep, low energy, and poor concentration. Like major depression, it is more common in women than in men, but it tends to arise earlier in life.
Major Depression:Major depression is a serious medical illness. Unlike normal emotional experiences of sadness, loss, or passing mood states, major depression is persistent and can significantly interfere with an individual's thoughts, behavior, mood, activity, and physical health. Approximately twice as many women as men suffer from major depression. This is partially because of hormonal changes throughout a woman's life: During menstruation, pregnancy, miscarriage and menopause.. Major depression, also known as clinical depression or unipolar depression, is only one type of depressive disorder.
Postpartum Depression:A rare form of depression occurring in women within approximately one week to six months after giving birth to a child. After pregnancy, hormonal changes in a woman's body may trigger symptoms of depression. Tiredness, problems sleeping, stronger emotional reactions, and changes in body weight may occur during pregnancy and after pregnancy. But these symptoms may also be signs of depression. Researchers think the fast change in hormone levels may lead to depression, just as smaller changes in hormones can affect a woman's moods before she gets her menstrual period.

Premenstrual Dysphoric Disorder:This is an uncommon type of depression affecting a small percentage of menstruating women. It refers to the variation of physical and mood symptoms that appear during the last one or two weeks of the menstrual cycle and disappear by the end of a full flow of menses. It is a cyclical condition in which women may feel depressed and irritable for one or two weeks before their menstrual period each month. If you have unpleasant, disturbing emotional and physical symptoms before your monthly menstrual periods and these symptoms disrupt your life and interfere with your usual activities and your relationships with others and the symptoms go away when your flow begins or shortly thereafter, only to return before your next period then this condition is known as Premenstrual Dysphoric Disorder.
Psychotic Depression:This is a more serious form of depression which is frequently seen by psychiatrists though it is rather rare, compared to the wider context of general medical practice. Patients may develop beliefs about themselves and the world, which are false at times bizarrely and obviously so. Psychotic depression has a very low spontaneous remission rate. It responds only to physical treatments (such as antidepressant drugs). The defining features of psychotic depression are:
  • More severely depressed mood
  • More severe psychomotor disturbance than is the case with melancholic depression
  • Psychotic symptoms like either delusions or hallucinations and over-valued guilt ruminations.
Cause of Depression
There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.
Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior appear to function abnormally. In addition, important neurotransmitters—chemicals that brain cells use to communicate—appear to be out of balance. But these images do not reveal whythe depression has occurred.
Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well.Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.[6]
In addition, trauma, loss of a lived one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.
Some types of depression run in families, indicating that a biological vulnerability to depression can be inherited. This seems to be the case, especially with bipolar disorder. Families in which members of each generation develop bipolar disorder have been studied. The investigators found that those with the illness have a somewhat different genetic makeup than those who do not become ill. However, the reverse is not true. That is, not everybody with the genetic makeup that causes vulnerability to bipolar disorder will develop the illness. Apparently, additional factors, possibly a stressful environment, are involved in its onset and protective factors are involved in its prevention.Thus, a serious loss, chronic illness, difficult relationship, financial problem, or any unwelcome change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Stressors that contribute to the development of depression sometimes affect some groups more than others. For example, minority groups who more often feel impacted by discrimination and are disproportionately represented. Socioeconomically disadvantaged groups have higher rates of depression compared to their advantaged counterparts. Immigrants to the United States may be more vulnerable to developing depression, particularly when isolated by language.[7]
The Signs of Depression
Depression is a loss of an important life goal without anyone to blame. Such a loss affects our behavior, our moods or subjective feelings, our skills, our attitudes or motivations, and our physical functioning and health. Several writers Beck,
Behavioral excesses--complaints about money, job, housing, noise, poor memory, confusion, loneliness, lack of care and love... acting out (adolescents), running away from home, rebellious, aggressive... obsessed with guilt and concern about doing wrong, about being irresponsible, about the welfare of others, and about "I can't make up my mind anymore"... crying... suicidal threats or attempts.
Behavioral deficits--socially withdrawn, doesn't talk, indecisive, can't work regularly, difficulty communicating, slower speech and gait... loss of appetite, weight change, stays in bed... less sexual activity, poor personal grooming, and doing less for fun.
Emotional reactions--feels sad, feels empty or lacks feelings of all kinds, tired ("everything is an effort")... nervous or restless, angry and grouchy (adolescents), irritable, overreacts to criticism... bored, apathetic, "nothing is enjoyable," feel socially abandoned and/or has less interest in relationships, sex, food, drink, music, current events, etc.
Attitudes and motivation--low self-concept, lack of self confidence and motivation,   pessimistic or hopeless, feels helpless or like a failure, expects the worst... self-critical, guilt, self-blaming, "People would hate me if they knew me"... suicidal thoughts, "I wish I had never been born."
Physical symptoms --difficulty sleeping or sleeping excessively, awaking early... hyperactivity or sluggishness, diurnal moods (worse in the morning)... low sex drive, loss of appetite, weight loss or gain, indigestion, constipation, headaches, dizziness, pain, and other somatic problems or complaints.[6]
Classification, mode of action, adverse reaction[6]
S.no
Class
Drug
MOA
AdR



1
Reversible inhibitors of MAO-A
Moclobemide
Clorgyline
Selective MAO-A inhibitor
Insomnia        liver damage
2
A



B


TricyclicAntidepresson
NA+5HT reuptake inhibitors


Predominatly NA reuptake inhibitors.

Imipramine
Amitriptyline Trimimpramine
Doxepin,
Dothiepin
Clomipramine

Desipramine
Nortriptyline
Amoxapine
Reboxetine

It inhibited NA and 5-HT reuptake into neurons.


It inhibited NA  reuptake into neurons.

Anticolinergic Sedation       Sweating         Cardiac arrhythmias Jaundice
3
Selective serotonin reuptake inhibitor

Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Citalopram
Escitalopram
It inhibits the neuronal uptake of 5-HT.
Drowsiness  Insomnia     Diarrhoea    Epigastric distress.
4
Atypical antidepresson
Trazodone
Mianserin
Mirtazapine
Venlafaxine
Duloxetine
Tineptines
Amineptine
Bupropion
It inhibits the neuronal uptake of 5-HT in CNS.
Headache        Nausea          Dizziness   Drowsiness

Depression in children :
It was earlier believed that children and young adolescents are incapable of experiencing depressive symptoms and hence cannot suffer from depression. It is possible that many cases of childhood depression were being treated as school phobia or behavioural or temperamental aberrations.The risk of occurrence of major depression is between 15 and 20% among children and adolescents, which is almost similar to that of adult populations. Complicating the picture, however, is the fact that a large number of children and adolescents suffering from depression have other associated psychiatric illnesses such as anxiety, disruptive behaviour and drug abuse. The symptoms of depression among this group remain largely the same as in an adult group; however, most of the manifestations due to the illness pertain to adjustment with peers and friends, problems in school, and indifferent or deteriorating scholastic performance. Children also appear sad, cry easily, manifest loss of interest and withdrawal, complain of bodily symptoms, and express pessimistic ideas. However, suicide among children has remained infrequent, yet a disturbing rising trend has been observed in the last one decade, and suicide is reported to be the third leading cause of death among adolescents in the western world.
Depression in the elderly :
Depression in the older age group is significant for a variety of reasons. Approximately 20% of elderly people above the age of 60 have some depressive symptoms, but an identifiable diagnosis of depression is made only in 5% of the elderly population. However, depression occurs frequently among the medically ill elderly population where nearly 30% have associated depression. Depression is very common among residents of old age homes also. In spite of its common occurrence, depression among the elderly frequently remains undetected. Very often, depression is attributed to the ageing process and no intervention is sought or provided.
Elderly people have a much higher risk of suicide than the general population. Data from Member Countries of SEAR indicate that suicide rates among the elderly may be lower than in western countries, perhaps because of the protective role of the joint family system. Elderly people in traditional societies do not suffer from isolation and deprivation. However, with social values changing rapidly in the developing countries, elderly people are likely to face increasing stress and strain. With the rapidly increasing elderly population in the countries of this Region, it is imperative that adequate provisions be made for the care of psychiatrically and medically ill elderly people.
Management of depression  in cancer  patient :
Cancer is the uncontrolled growth of abnormal cells anywhere in a body. The abnormal cells are termed cancer cells, malignant cells, or tumor cells. Many cancers and the abnormal cells that compose the cancer tissue are further identified by the name of the tissue that the abnormal cells originated from. (for example, breast cancer, lung cancer, colon cancer).[7]
Cancer is a class of diseases characterized by out-of-control cell growth. Cancer harms the body when damaged cells divide uncontrollably to form lumps or masses of tissue called tumors (except in the case of leukemia where cancer prohibits normal blood function by abnormal cell division in the blood stream). Tumors can grow and interfere with the digestive, nervous, and circulatory systems, and they can release hormones that alter body function. Tumors that stay in one spot and demonstrate limited growth are generally considered to be benign.[8]
Causes of cancer:
Cancer is ultimately the result of cells that uncontrollably grow and do not die. Normal cells in the body follow an orderly path of growth, division, and death. Programmed cell death is called apoptosis, and when this process breaks down, cancer begins to form. Unlike regular cells, cancer cells do not experience programmatic death and instead continue to grow and divide. This leads to a mass of abnormal cells that grows out of control.
Cancers are primarily an environmental disease with 90-95% of cases attributed to environmental factors and 5-10% due to genetics.[1]Environmental, as used by cancer researchers, means any cause that is not genetic. Common environmental factors that contribute to cancer death include: tobacco(25-30%), diet and obesity(30-35%), infections(15-20%), radiation(both ionizing and non ionizing, up to 10%), stress, lack of physical activity, and environmental pollutants.[9]
Classification, mode of action, adverse reaction[6] :
A.
Drugs acting directly on cells ( Cytotoxic drugs ) :
S. No
Class
Drug
MOA
Adr



1.
Alkylating agents
Mechlorethamine Cyclophosphaminde Chlorambucil         Thio-tepa         
Abnormal base pairing / Cross linking
Haemodynamic changes,Bone marrow depression
2.



Antimetabolites
Purine
Pyrimidine
5-Fluorouracil
Methotrexate6-Mercaptopurine  6-Thioganine
Inhibit the Conversion of DHFA to THFA
Bone marrow depression
3.
Vinca Alkaloids
Vincristine(Oncovin),
Vinblastin
Mitotic inhibitors 
Bone marrow depression, Neurotoxicity
4.
Taxanes
Pacitaxel, Docetaxel
It enhance polymerization of tubulin
Neutropenia 
5.
Epipodophyllotoxin
Etopside
Arrest cells in the G2  phase
g.i.t disturbances
6.
Camptothecin analogues
Topotecan, Irinotecan
Arrest cells in the G2  phase
Neutropenia 
7.
Antibiotics
Actinomycin D, Doxorubicin, Bleomycin,   Mitomycin C
Anti tumour
Bone marrow depression
8.
Miscellaneous
Hydroxyurea, Procarbazine, Cisplantin,   Carboplatin
Interferes with DNA synthesis
Neutropenia
B
Drugs altering hormonal milieu :
1.
Glucocorticoids
Prednisolone
GnRH inhibt
Hyperglycaemia,Peptic ulceration,Glaucoma
2.
Estrogens
Fosfestrol ,Ethinylestradiol
Inhibt ER dimerization
Suppresion of  libido,
Gynaecomastia
3.
Selective estrogen receptor modulator
Tamoxifen,
Toremifene
GnRH inhibt
 Decrease libido,vaginal bleeding,dermatitis
4.
Selective estrogen receptor downregulator
Fulvestrant
Inhibt ER dimerization
Decrease libido,vaginal bleeding,dermatitis
5.
Aromatase inhibitor
Letrozole,
Anastrozole
Inhibit  aromatization
Diarrhoea,dyspepsia, joint pain
6.
Antiandrogen
Flutamide, Bicalutamide
Inhibit androgen
Liver damage,gynaecomastia
7.
5-α reductase inhibitor
Finasteride,   Dutasteride
Inhibit conversion of testosterone into dihydrotestosterone
Impotency,decrease libido
8.
GnRH analogues
Nafarelin,       Triptorelin
Inhibit androgen and endrogen secretion
Decrease libido,osteoporosis
9.
Progestins
Hydroxyprogesterone acetate
Inhibt ER dimerization
Esophageal reflux,amenorrhoea







Fig 2 : Mechanisam of action for anticancer drugs :

Role of pharmacist :
There is scant knowledge of the involvement of developing country pharmacists in mental healthcare. The World Health Organization (WHO) estimates that 25% of any population will suffer from neuro-psychiatric conditions during their lifetime [10]
Health professionals have identified people with mental illness as among their most challenging patients to manage [11]
Consequently, the primary goal of the pharmacist in mental health provision should be the safety and wellbeing of the patient, ensuring that patients who need medicines receive them and adhere to treatment [12].
Indeed, WHO has acknowledged pharmacists as dynamic members of the mental healthcare team who should assist in improving psychotropic medication use [13].
In developed countries, pharmacists are involved in both in-patient and out-patient psychiatric settings. Pharmacists routinely participate as pharmacotherapy experts and consultants, manage individual patient drug regimens, obtain drug histories, lead patient education discussion groups, and coordinate the use of drug assistance programs. A retrospective chart review has indicated that duties performed by pharmacists in psychiatric settings can improve physician prescribing practices and enhance treatment outcomes [14].
Pharmacists in the United Kingdom play a role at every stage of the patient's recovery, whether patients are being cared for in an acute setting or in the community.
CONCLUSION :
Now a days, cancer is considered to be a chronic disease, causes emotional problems to the patient, induces important changes to the functional capability, the body image and the social or familial role.
Health professionals should be aware of the consequences of depression in all dimensions of patients’ lives who undergo chemotherapy.
Early diagnosis of depression and the cognition of its impact, consist a matter of great importance for the evaluation, the medical treatment and the planning of personal care.
The survey demonstrated that local pharmacists in community practice  play any significant role in the management of mental illness, were restricted by several barriers in involving themselves in the management of mental illness and would welcome regular workshops on mental health
REFERENCE:
1. en.wikipedia.org/wiki/depresson
2. Goodman & Gilman’s. (2008)  “ Manual  of  Pharmacology  and Therapeutics” McGraw-Hill Companies, United States of America.,pp 289.
3. helpguide.org/mental/depression_signs_types_diagnosis_treatment.htm
4. ncbi.nlm.nih.gov/pubmed/979301
5. Brown E, Harris T. Social Origins of Depression. London: Tavistok; 1978.
6. Tripathi KD (2008) ‘Essentials of Medical Pharmacology’Jaypee Brothers  Medical Publishers, New Delhi,6th edition.,pp New Delhi page no.439-452,820-834.
7. medicinenet.com/cancer/page2.htm.
8. medicalnewstoday.com/info/cancer-oncology/
9. en.wikipedia.org/wiki/Cancer
10. Sirey JA, Bruce ML, Alexopoulos GS: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services 2001, 52:1615-1620.
11. WHO: The world health report 2001 - Mental Health: New Understanding, New Hope. 2001 [who.int/whr/2001/ chapter1/en/index.html].
12. Bryant SG, Guernsey BG, Pearce EL: Pharmacists' perceptions of mental health care, psychiatrists, and mentally ill patients. American Journal of Hospital Pharmacy 1985, 42:1366-1369.
13. WHO: Improving access and use of psychotropic medicines. [bipolarworld.net/pdf/ Improving_Access_Use_Psychotropic_Medicine.pdf].
14. Finley PR, Crismon ML, Rush JA: Evaluating the Impact of Pharmacists in Mental Health: A Systematic Review. Pharmacotherapy 2003, 23:1634-1644.