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3 authors, including:
Cristian Bonvicini
Catia Scassellati
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Introduction
The aetiology and pathogenesis of attention-deficit/hyperactivity disorder (ADHD) is not yet fully understood [1, 2].
ADHD is also a highly heritable disease, with estimated
heritability rates of up to 80 % [3]. A recent review on genetics
of ADHD summarized that all variants associated with the
pathology explain only a small fraction of heritability: phenotype complexity and variants of small effect contribute to the
missing heritability issue [4]. To gain more insight into the
mechanisms leading from a genetic/biological basis of the
disease to the full clinical phenotype, endophenotypes are a
promising strategy [5].
The DSM and ICD diagnoses of ADHD are based on a
consensus about clusters of clinical symptoms. However, this
diagnostic procedure has been criticized for not allowing
sufficiently reliable and valid diagnoses [6]. NIMH recently
has approved the Research Domain Criteria (RDoC) project
where a set of assumptions permit to found a new classification system, by integrating genetics, imaging and cognitive
information [6]. The RDoC approach suggests that a biomarker
approach to diagnosis may be a more valid way to classify
complex mental disorders such as ADHD. Biomarkers offer the
opportunity to standardize and improve diagnostic assessment
while providing insights into etiological mechanisms.
S. V. Faraone
Department of Psychiatry, SUNY Upstate Medical University,
Syracuse, NY, USA
What is a Biomarker?
S. V. Faraone
Department of Neuroscience and Physiology, SUNY Upstate
Medical University, Syracuse, NY, USA
C. Bonvicini : C. Scassellati (*)
Genetic Unit - IRCCS Centro S. Giovanni di Dio Fatebenefratelli,
Via Pilastroni 4, 25123 Brescia, Italy
e-mail: cscassellati@fatebenefratelli.it
The United States food and drug administration (FDA) defines a biomarker as an objective measure of normal processes, pathological processes or pharmacological response [7].
For psychiatry, biomarkers could be used to screen for, diagnoses, or predict the development of, not only psychiatric
disorders but also of personality or behavioral traits and
497, Page 2 of 20
Genomics
Dopaminergic system
Systems
Dopamine D2 receptor
(DRD2)
Encodes a transmembrane
transport protein mediating
the active reuptake of DA
from the synapse and serves
as a critical regulator of
dopaminergic
neurotransmission in the
brain.
1) dopaminergic neurotransmission
is controlled by the DAT1;
2) it is the main target for MPH;
Gene function/rationale
Dopamine D4 receptor
(DRD4)
Dopamine transporter
(DAT1, SLC6A3)
Potential biomarker
Exon, rs6350
Location, polymorphism,
risk allele, functionality
Meta-analysis (OR, 2,
p value)
[34]
GWAS/
CNVs
studies
-Association haplotype
rs403636 (G)/rs463379 (C)/
rs393795 (C)/rs37020 (G)
and spatial working memory
[28].
-Association with alerting and
executive control
performance [29].
-Response inhibition:
association 10R allele and
poorer response inhibition
on the Opposite Word Task;
-Association 10R and spatial
attentional bias [reviews 21,
22].
Neuropsychological
endophenotypes
Table 1 Data from genomic and metabolomic studies classified according to neurophysiological/neuropsychological, neuroimaging, pharmacogenomic, biochemical and gene expression findings
Metabolomics
Genomics
Metabolomics
Noradrenergic system
Systems
Table 1 (continued)
Normetanephrine (NM)
3-methoxy-4hydroxyphenyl glycol
(MHPG)
Norepinephrine (NE)
Dopamine (DA)
Phenylethylamine (PEA)
Dopamine D5 receptor
(DRD5)
Potential biomarker
It is released by noradrenergic
neurons located in the
specific central nervous
system apart from
dopaminergic neurons.
Main metabolite of NE.
Main metabolite of NE.
A DA receptor agonist,
synthesized by the
decarboxylation of
phenylalanine
In ADHD the turnover is
reduced with excessive reuptake and intra-synaptic
monoamine concentrations
are decreased.
Main DA metabolite.
Codes for a protein responsible
for the reuptake of NE from
the synaptic cleft back into
the presynaptic neuron.
Expressed in the frontal lobes.
Gene function/rationale
Intron, rs3785155
5 Flank, rs28386840
(A-3081T), T allele,
reduced levels of NET
within the brain.
Intron, rs998424, Intron,
rs3785157
Exon 9, rs5569, A
5Flank, Dinucleotide
repeat, 136 bp
5Flank, Dinucleotide
repeat, 148 bp
Location, polymorphism,
risk allele, functionality
Meta-analysis (OR, 2,
p value)
[34]
GWAS/
CNVs
studies
Neuropsychological
endophenotypes
497, Page 4 of 20
Curr Psychiatry Rep (2014) 16:497
Genomics/
metabolomics
Metabolomics
Genomics
Metabolism enzymes
Adrenergic system
Systems
Table 1 (continued)
Dopamine Beta
Hydroxylase (DBH)
Monoamine oxidase A
(MAOA)
Metanephrine (M)
Catechol-Omethyltransferase
(COMT)
Epinephrine (EPI)
Intron, rs12843268, A,
It is associated to impulsive,
aggressive behavior.
MAOA knockout mouse
showed increased levels of
aggressive behavior and
monoaminergic
neurotransmitter levels.
Exon, rs1137070, T
Intron, rs3027400, T,
Location, polymorphism,
risk allele, functionality
Encodes alpha-2A-adrenergic
receptors regulating
neurotransmitter release from
sympathetic nerves and from
adrenergic neurons.
Influences executive functions
in the prefrontal cortex.
Neuroimaging and animal
studies support alteration in
EPI in ADHD.
Main metabolite of EPI.
Enzyme catalyzing the
inactivation of DA within the
PFC. Expressed in frontal
lobe regions of brain.
It regulates synaptic DA levels.
Neuropeptide Y (NPY)
Alpha-2A-adrenergic
receptor (ADRA2A)
Gene function/rationale
Potential biomarker
Meta-analysis (OR, 2,
p value)
[44]
GWAS/
CNVs
studies
-Association of rs12843268
and symptoms and reward
deficiency or insufficient
response inhibition [56].
Neuropsychological
endophenotypes
Dopamine transporter
(DAT1, SLC6A3)
Potential biomarker
Metabolomics
Neurophysiological
endophenotypes
-Association 10R with
smaller caudate volumes
particularly in the left
than right hemisphere
[14].
Pharmacogenetics/drugs effect
Neuropsychological
endophenotypes
[34]
GWAS/
CNVs
studies
Gene expression
3-UTR, rs1051312, T
Biochemical/proteomics
endophenotypes
Meta-analysis (OR, 2,
p value)
3-UTR, rs3746544,
unknown
Location, polymorphism,
risk allele, functionality
Encodes a neurotrophin
promoting neurogenesis,
development, functional
maintenance, and plasticity
of neurons.
Expressed in pons,
hippocampus, frontal cortex,
colliculi, and olfactory tract.
Encodes a protein involved in
axonal growth, synaptic
plasticity, docking, and fusion
of synaptic vesicles in
presynaptic neurons.
Expressed in hippocampus.
Coenzyme of tyrosine
hydroxylase and MAO. Iron
deficiency is associated with
ADHD symptoms.
Cofactor for metabolism
relevant to neurotransmitters,
and it affects DA metabolism.
Zinc deficiency is associated
with behavior problems in
ADHD.
Gene function/rationale
Oxidative stress
Zinc (Zn)
Synaptosomal-associated
protein 25 (SNAP-25)
Genomics
Environmental risk
factors
Brain-Derived
Neurotrophic Factor
(BDNF)
Potential biomarker
Genomics/
metabolomics
CNS development
pathways
Systems
Table 1 (continued)
497, Page 6 of 20
Curr Psychiatry Rep (2014) 16:497
Dopamine D4 receptor
(DRD4)
Potential biomarker
Table 1 (continued)
Neurophysiological
endophenotypes
-Association 7R with a
delay in cerebral cortical
maturation [32, 33].
-Association 7R with
thinner prefrontal and
parietal cortex;
-Haplotype studies:
a) Association 10/6 and
dopaminergic rewardprocessing circuitry [26];
-Haplotype studies:
-Neuroimaging/
Biochemical/proteomics
endophenotypes
Gene expression
Pharmacogenetics/drugs effect
Biochemical/proteomics
endophenotypes
Alpha-2A-adrenergic
receptor (ADRA2A)
Neuropeptide Y (NPY)
-Increased plasma
concentrations in ADHD
[39].
Normetanephrine (NM)
3-methoxy-4hydroxyphenyl glycol
(MHPG)
Norepinephrine (NE)
Norepinephrine
transporter protein 1
NET (SLC6A2)
Dopamine (DA)
Neurophysiological
endophenotypes
Phenylethylamine (PEA)
Dopamine D5 receptor
(DRD5)
Dopamine D2 receptor
(DRD2)
Potential biomarker
Table 1 (continued)
Gene expression
Pharmacogenetics/drugs effect
497, Page 8 of 20
Curr Psychiatry Rep (2014) 16:497
Synaptosomal-associated
protein 25 (SNAP-25)
Brain-Derived
Neurotrophic Factor
(BDNF)
Biochemical/proteomics
endophenotypes
Dopamine Beta
Hydroxylase (DBH)
-Association with
antisocial and
aggressive
behaviors of
ADHD [50, 51].
Neurophysiological
endophenotypes
Monoamine oxidase A
(MAOA)
Catechol-Omethyltransferase
(COMT)
Metanephrine (M)
Epinephrine (EPI)
Potential biomarker
Table 1 (continued)
Gene expression
Pharmacogenetics/drugs effect
Gene expression
Biochemical/proteomics
endophenotypes
Variations in brain function
(functional MRI finding)
Variations in brain anatomy
(structural MRI finding)
Oxidative stress
Zinc (Zn)
Neurophysiological
endophenotypes
Potential biomarker
Table 1 (continued)
Note: ADHD: Attention-deficit/hyperactivity disorder; OR: Odd Ratio; 2 : chi-square; VNTR: Variable number tandem repeat; UTR: Untranslated region; MPH: methylphenidate; DA: Dopamine;
WGAS: Genome Wide Association study; CNVs: Copy number variations; MRI: Magnetic resonance imaging; TMT: Trail making test; RTV: Reaction time variability; CPT: Continuous performance test;
SART: Sustained attention to response test; TOL: Tower of London test; WISC-III: Wechsler intelligence scale for children-III; SOPT: Self ordered pointing Test; FDI: Freedom from distractibility index;
IQ: Intelligence quotient; AMP: Amphetamine; MFFT: Matching familiar figures test
Pharmacogenetics/drugs effect
497, Page 10 of 20
[102]
[10]
[10]
[63]
Review Neuropsychological
endophenotypes
-Prognostic
measure [62];
-potential
biomarker [63].
Note: ADHD: Attention-deficit/hyperactivity disorder; MRI: Magnetic resonance imaging; SMA: Supplementary motor area
Prefrontal cortex
Anterior cingulated
Meta-analysis
Rationale
Potential biomarker
Table 2 Data extracted from endophenotypes studies to define a potential signature set of biomarkers useful for ADHD diagnosis
497, Page 12 of 20
in noradrenergic and dopaminergic reuptake [80]. A frequently studied SNP (rs5569 or G1287A) located in exon 9 was not
significant in a meta-analysis of candidate gene studies [13],
but a nominal association was observed in a genome-wide
association study [34]. No association was found between this
variant and CPT performance [21]. A recent review on pharmacogenetics concluded that NET1 influence on response to
MPH is small [17], although a recent genome-wide association study found two SNPs in SLC6A2 gene associated with
MPH response [81]. In a study rs3785143 was associated with
atomoxetine response [47].
Moreover children with the G/G genotype at G1287A showed
a greater decrease in mean omission error scores after MPH
administration compared to A allele carriers. Another polymorphism A-3081T at 5flank, demonstrated to be functional, was
associated with T allele with greater decrease in mean commission errors scores, meaning improved impulsive behavior [40,
41]. Other variants such as rs998424 and rs3785157 were linked
to high performance on the similarities subtest of the WISCIII,
but not with the cerebral volume or thickness of the cortex [42].
Another SNP rs3785155 was associated to RTV [43].
Metabolomics
Norepinephrine (NE)
Concerning NE levels, a meta-analysis [39] indicated higher
urinary levels in ADHD compared with controls, and a normalization of NE concentrations has been observed after
treatment with polyphenol complex and with fenfluramine
and AMP [39].
3-Methoxy-4-Hydroxyphenylglycol (MHPG)
MHPG is the main metabolite of NE. Its urinary levels
were lower in ADHD patients and stimulant trials
showed that decreases in ADHD symptoms with treatment were associated with greater reductions in urinary
MHPG excretion [39].
Catechol-O-Methyltransferase (COMT)
COMT is an enzyme responsible for the degradation of DA
and NE. It is highly expressed in frontal lobe where it regulates synaptic DA levels [84]. Studies examining the association between COMT and ADHD have largely focused on a
functional SNP in exon 4 that creates an amino acid substitution (valine/methionine). This variant affects COMT enzyme
activity, such that homozygotes for the valine allele shows 34
times greater activity than homozygotes for the methionine
497, Page 14 of 20
Metabolomics
Iron
It is a coenzyme of tyrosine hydroxylase and MAO, which are
critical in the synthesis and degradation, respectively. Ferritin
is a major intracellular iron storage protein and serum ferritin
levels are an indication of iron stores in the body and brain.
Children with iron deficiency exhibited ADHD symptoms,
such as inattention, hyperactivity, and/or impulsivity [review
90]. A meta-analysis indicated that serum ferritin levels were
lower for ADHD patients compared with controls, although
the finding was lost after Bonferroni correction [39].
Zinc
Zinc is another essential cofactor for neurotransmitter metabolism which affects DA metabolism. Zinc deficiency is
associated with behavior problems in children with ADHD
[review 90]. Although a systematic review of randomized
controlled clinical trials demonstrated that using zinc, either
alone or in combination with stimulants, did not improve
ADHD symptoms [93], a meta-analysis reported reduced
serum/plasma/urine levels in ADHD [39].
Oxidative Stress
The normal oxidation-reduction reactions that create energy in the
cell create toxic oxidants or reactive oxygen species. These byproducts of normal oxidation-reduction reactions are highly unstable. Antioxidants counteract the effects of oxidants. When
antioxidants are not sufficient, oxidative stress occurs and damages cellular proteins, lipids, carbohydrates, and nucleic acids.
Brain tissue is especially susceptible to oxidative stress. Indirect
evidence for oxidative stress in ADHD comes from studies showing some treatment efficacy for anti-oxidant compounds such as
omega-3 fatty acids, pycnogenol and N-acetylcysteine [9497].
A meta-analysis of oxidative stress in ADHD suggested
that patients with ADHD have normal levels of anti-oxidant
production but that their response to oxidative stress is insufficient, leading to oxidative damage [61].
497, Page 16 of 20
Conclusion
The study of psychiatric biomarkers is very complex because
of the heterogeneous nature of psychiatric disorders which are
often referred to as syndromes with several subtypes, not
uniform problems. Therefore, a single biomarker is very unlikely to provide enough information to identify cellular and
metabolic pathways involved in a particular individual.
Identification of a signature set of biomarkers for disorder
subtypes each based on their underlying biological pathways
will be the most effective for diagnosis and treatment
selection.
Starting from the literature, we have built an hypothetical
pyramid representing a putative set of biomarkers where at the
top there are potentially useful biomarkers for ADHD and at
the bottom those that are probably not useful (Fig. 1).
Following Pies et al.s [12] example, a potential geneticbiomarker could be represented by the variants in DAT1 and
DRD4 genes as the best candidates as biomarkers for ADHD.
Indeed the 10R allele at the 3UTR of SLC6A3, is associated
with specific neuropsychological tasks [21, 22], generates
more activation in specific brain areas [33], and is associated
to MPH response [16, 17]. Similarly the 7R allele at exon 3
of DRD4 is involved in specific neuropsychological tasks [21,
22], brain structure [32, 33], MPH response [16, 17], and
expression levels of DRD4 [31].
References
Papers of particular interest, published recently, have been
highlighted as:
Of importance
Of major importance
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497, Page 18 of 20
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