Unfortunately, for methodological, ethical, and economic reasons, the neuroendocrine tests are rarely performed in battery (ie, several tests for each patient) and this limits their application from a pathophysiological and therapeutic viewpoint. For instance, in depression, the absence of chronobiological dysfunction of the IKK inhibitor thyroid axis (ie, normal ΔΔTSH) is significantly associated with decreased serotonergic function, and vice versa.39 Therefore, the response to ΔΔTSH test may be of great value since a normal ΔΔTSH test could orientate the clinician

towards antidepressants that increase “serotonergic” transmission; while a blunted ΔΔTSH test, which is often associated with a blunted clonidine Inhibitors,research,lifescience,medical test,97 could orientate the clinician toward antidepressants that increase “noradrenergic” transmission. The relationship between neuroendocrine test results and clinical outcome has mostly been described in retrospective study protocols. On the basis of our observations, and those Inhibitors,research,lifescience,medical of others, one may propose the following strategies, which could be the theme of prospective clinical trials of antidepressants (strategies marked with an asterisk have not yet been evaluated in depressed patients): SSRI appear to be perfectly suitable for the first-line treatment for Inhibitors,research,lifescience,medical depression, especially when there is no evidence for chronobiological

dysfunction of the thyroid axis (normal ΔTSH). “Noradrenergic” antidepressants appear to be suitable when the GH response to clonidine is blunted and/or when there is evidence for chronobiological dysfunction of the thyroid axis (blunted ΔTSH). “Dopaminergic” antidepressants appear to be suitable in case of normal TRH-PRL Inhibitors,research,lifescience,medical response associated with blunted TRH-TSH response Inhibitors,research,lifescience,medical (performed

at 11 pm) and/or in case of blunted PRL response to apomorphine test (which is often observed in bipolar depression).* In case of a positive DST, frequently associated with severe depression, antidepressant treatment alone will probably not suffice and therefore calls for a different approach (ie, adjunction of “antiglucocorticoids” to antidepressants, or antipsychotics, since in some melancholic/psychotic depressed patients DST is associated with blunted ACTH/cortisol response Electron transport chain to apomorphine, reflecting a possible presynaptic DA hypersecretion at the hypothalamic level). In case of nonresponse or partial response In patients with pretreatment 11 pm blunted TRH-TSH response, one may propose adjunctive thyroid hormone therapy.* In this Indication, T3 seems to be more efficacious than T4.98 Since TSH blunting could be secondary to hyper-secretion of endogenous TRH, It may be that treatment with exogenous thyroid hormone Increases the negative feedback and, In this way, tends to correct the hypersecretion of endogenous TRH.