Brain, Behavior, and Immunity 109 (2023) 51–62

Contents lists available at ScienceDirect

Brain Behavior and Immunity

journal homepage: www.elsevier.com/locate/ybrbi

Hyper-inflammation of astrocytes in patients of major depressive disorder:

Evidence from serum astrocyte-derived extracellular vesicles
Xin-hui Xie a, b, Wen-tao Lai a, Shu-xian Xu b, Marta Di Forti c, Jing-ya Zhang d, Mian-mian Chen b,
Li-hua Yao b, Peilin Wang a, Ke-ke Hao b, Han Rong a, e, *
a
Department of Psychiatry, Shenzhen Kangning Hospital, and Shenzhen Mental Health Center, Shenzhen, Guangdong, China
b
Department of Psychiatry, Renmin Hospital of Wuhan University, Wuhan, China
c
Department of Social Genetics and Developmental Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King’s College London, London, United Kingdom
d
Department of Clinical Psychology, Second People’s Hospital of Huizhou, Huizhou, Guangdong, China
e
Affiliated Shenzhen Clinical College of Psychiatry, Jining Medical University, Jining, Shandong, China

A R T I C L E I N F O A B S T R A C T

Keywords: Astrocyte-derived extracellular vesicles (ADEs) allow the in vivo probing of the inflammatory status of astrocytes
Major depressive disorder practical. Serum sample and ADEs were used to test the inflammatory hypothesis in 70 patients with major
Astrocyte depressive disorder (MDD) and 70 matched healthy controls (HCs). In serum, tumor necrosis factor α (TNF-α)
Extracellular vesicle
and interleukin (IL)-17A were significantly increased, where as IL-12p70 was significantly reduced in the MDD
Astrocyte-derived extracellular vesicles
Inflammation
patients compared with HCs. In ADEs, all inflammatory markers (Interferon-γ, IL-12p70, IL-1β, IL-2, IL-4, IL-6,
Central nervous system TNF-α, and IL-17A) except IL-10 were significantly increased in the MDD patients, the Hedge’s g values of
elevated inflammatory markers varied from 0.48 to 1.07. However, there were no differences of all inflammatory
markers whether in serum or ADEs between MDD-drug free and medicated subgroups. The association of in­
flammatory biomarkers between ADEs and serum did not reach statistically significance after multi-comparison
correction neither in the HCs nor MDD patients. The spearman coefficients between inflammatory factors and
clinical characteristics in the MDD patients, such as onset age, disease course, current episode duration, and
severity of depression, were nonsignificant after multi-comparison correction. In the receiver operating char­
acteristic curves analysis, the corrected partial area under the curve (pAUC) of each inflammatory markers in
ADEs ranged from 0.522 to 0.696, and the combination of these inflammatory factors achieved a high pAUC
(>0.9). Our findings support the inflammatory glial hypothesis of depression, and suggests that in human ADEs
could be a useful tool to probe the in vivo astrocyte status.

1. Introduction inflammatory factors were found in depressed patients compared with

Major depressive disorder (MDD) which carrying a high prevalence,
a high recurrence rate, and also a suicidal tendency (Belmaker and
Agam, 2008) is among the leading causes of burden and disability
worldwide (Collins et al., 2011). Multiple factors are believed to play
important roles in the pathologies of MDD, and the new major candi­
dates are the inflammation hypothesis (Najjar et al., 2013; Troubat et al.,
2021; Woelfer et al., 2019) in which the inflamed glia, as well as
microglia and astrocyte played a critical role (Leng et al., 2018).
Inflammation has been linked to depression for a long time. Multiple
peripheral cytokine concentrations are connected to brain function,
wellbeing and cognition (Bollen et al., 2017). Elevated peripheral
healthy controls (HCs) (Kohler et al., 2017; Liu et al., 2012; Osimo et al.,
2020), while these factors had a significant association with the subse­
quent development of depressive symptoms (Valkanova et al., 2013) and
the poor outcome of first-line antidepressant treatments (Arteaga-Hen­
riquez et al., 2019). Likewise, depression was highly prevalent in the
individuals with inflammatory disorders, such as rheumatoid arthritis
(Matcham et al., 2013), inflammatory bowel disease (Barberio et al.,
2021), and systemic lupus erythematosus (Moustafa et al., 2020). Lon­
gitudinal cohorts also revealed that the higher levels of serum inter­
leukin 6 (IL-6) and C-reactive protein (CRP) in childhood are associated
with an increased risk of developing depression in young adulthood
(Khandaker et al., 2014). The prior presence of inflammation implies its

* Corresponding author at: Department of Psychiatry, Shenzhen Kangning Hospital, and Shenzhen Mental Health Center, Shenzhen, Guangdong, China.
E-mail address: ronghansz@126.com (H. Rong).

https://doi.org/10.1016/j.bbi.2022.12.014
Received 6 September 2022; Received in revised form 3 December 2022; Accepted 16 December 2022
Available online 29 December 2022
0889-1591/© 2022 Elsevier Inc. All rights reserved.
X.-h. Xie et al.
probability of biological cause of depression. However, inflammatory
markers were considered to be the sensitive rather than specific in­
dicators of various somatic illnesses, unhealthy status such as obesity
(Milaneschi et al., 2019) and of exposure to stressful life events (Her­
berth et al., 2008), and could result in a significant heterogeneity in
related studies. To eliminate potential biases and test the inflammatory
hypothesis, Cassano et al. (2017) rigorously recruited MDD patients
without significant medical comorbidity, and finally found no signifi­
cant alternations of 22 plasma cytokines in MDD patients compared with
well-matched HCs. On the opposite, some studies and meta-analyses
have provided evidence to the contrary, showing that patients with
depression had higher levels of inflammatory markers than controls
after accounting for various confounders (Lindqvist et al., 2017; Osimo
et al., 2020). Pitharouli et al. further showed an association between
peripheral inflammation and depression after adjusting for confounders
in a very large sample (Pitharouli et al., 2021). Nevertheless, depression
is a brain disease, and the relationship of inflammation between the
central nervous system (CNS) and the periphery is currently under
debate. The results of some studies support the existence of a significant
relationship between the CNS and the periphery (Felger et al., 2020;
Lindqvist et al., 2013; Miller et al., 2017), while others suggested that
the peripheral inflammatory status may not accurately represent the
inflammatory status in the CNS (Enache et al., 2019; Hannestad et al.,
2013; Holmes et al., 2018; Lindqvist et al., 2009; Richards et al., 2018;
Sasayama et al., 2013). The many studies that directly focused on
measuring CNS inflammation markers in depressed patients, still found
heterogeneous results. A comprehensive meta-analysis (Enache et al.,
2019) summarized relevant markers of central inflammation in MDD
patients and suggested a significant higher pro-inflammatory levels of
IL-6, IL-8, IL-1β, and tumor necrosis factor α (TNF-α) in cerebrospinal
fluid (CSF), and reduction of astrocytes that may result from the CNS
inflammation. These findings suggest that we should concentrate on the
glia most closely associated with neuroinflammation, namely microglia
and astrocytes, the latter of which is the target of this study.
Astrocytes are considered important glial cells implicated in the
pathology of MDD (Peng et al., 2015; Rajkowska and Stockmeier, 2013).
Impaired astrocytes were found in several post-mortem studies on sub­
jects with depression (Cotter et al., 2002; Medina et al., 2016; Nagy
et al., 2015; Ongur et al., 1998; Rajkowska et al., 1999). As the second
abundant glial cells, astrocytes not only maintain the synaptic function,
nerve fiber integrity, neurogenesis, neurotrophic and energy meta­
bolism (Khakh and Deneen, 2019), but also play a vital role in CNS
inflammation regulation (Linnerbauer et al., 2020). Astrocytes produce
both pro- and anti-inflammatory cytokines as well as other chemokines
to influence the CNS inflammatory status (Dong and Benveniste, 2001;
Falsig et al., 2006). Inflamed astrocytes could lead to depression-like
behaviors in rodent models (Leng et al., 2018), and a postmortem
investigation (Torres-Platas et al., 2011) found that, compared with
sudden-death controls, astrocytes in anterior cingulate cortex had
significantly larger cell bodies, longer and ramified processes in
depressed suicides, these results may reflect a state of chronic inflam­
mation in limbic region and support the neuroinflammatory hypothesis
of depression.
Despite emerging evidence support the hypothesis of inflammatory
astrocytes in depression, little is known about the in vivo astrocytes
status in individuals suffering from MDD, because probing the astrocytes
status in CNS on human individuals in vivo is challenging due to the
limitations of methodology. Fortunately, the development of technology
in the field of the CNS-derived extracellular vesicles (EVs) extraction
have recently made it possible to measure the in vivo status of the CNS
without performing a brain biopsy (Goetzl et al., 2021; Shi et al., 2019).
Same as other EVs, CNS-derived EVs, which were secreted by almost all
types of cells and contained the surface biomarkers of their source cells,
including neurons, oligodendrocytes, microglia and astrocytes, could
help to identify their parent cells (Mustapic et al., 2017). EVs showed
close relationship of protein (Casella et al., 2020; Delgado-Peraza et al.,
52
Brain Behavior and Immunity 109 (2023) 51–62
2021) and lipid composition (Losito et al., 2013; Vidal et al., 1989) with
their source cells. Most importantly, EVs could cross the blood–brain
barrier (BBB) from both directions (Saint-Pol et al., 2020; Terstappen
et al., 2021), and further, CNS-derived EVs could be detected and
collected in the peripheral blood and reveal the status of their source
cells without brain biopsy or lumbar puncture (Mustapic et al., 2017; Shi
et al., 2019). For some target molecules, the correlation coefficients
between the concentration level in the CNS-derived EV and CSF excee­
ded 0.9 (Jia et al., 2019). Specifically, for astrocyte-derived EVs (ADEs),
Delgado-Peraza et al. (2021) found that ADEs C1q had strong correla­
tions with C1q in the cortex brain homogenate and the correlation co­
efficient reached higher than 0.85, this suggested that ADEs could be
used as a “liquid biopsy” for CNS. Therefore, to contribute to clarify the
dual role of astrocytes in the pathology of depression (Wang et al., 2017)
and CNS inflammatory process (Linnerbauer et al., 2020), we use ADEs
as the “window of brain” to test the in vivo inflammatory status of as­
trocytes in CNS.
In the present study, the primary aim was to investigate if in patients
with MDD compared with HCs, there are alterations of inflammatory
biomarkers in ADEs and serum. Secondly, we aimed to carry out
exploratory analyses to investigate: 1) whether there are differences in
these inflammatory biomarkers between the drug-free (MDD-DF) and
medicated (MDD-M) subgroup of MDD patients; 2) the relations of these
inflammatory biomarkers between ADEs and serum; 3) the relations
between these inflammatory biomarkers and clinical features and finally
to 4) the potential of inflammatory markers in ADEs as a biomarker for
MDD.
2. Material and methods
This observational study was conducted at the Shenzhen Kangning
Hospital (Mental Health Center of Shenzhen, Shenzhen, Guangdong, PR
China) from June 2018 to July 2019 in accordance with the Declaration
of Helsinki (revised edition, 2008). This study was approved by the
Institutional Review Board of Shenzhen Kangning Hospital. Written
informed consents were obtained from all participants or their legal
guardians. The present report followed the STROBE statement (von Elm
et al., 2007).
2.1. Sample size calculation
A most widely measured peripheral inflammatory marker—IL-6 was
chosen as the reference for our sample size calculation according to the
lack of studies on inflammatory markers in ADEs in MDD patients. In the
recent meta-analyses, effect size of IL-6 between MDD and control group
were 0.62 (Cakici et al., 2020) and 0.76 (Goldsmith et al., 2016).
Therefore, effect size of 0.65 with a power (1-β) of 0.95, α of 0.05 (two
sided) were set and then 126 (63 per group) subjects were needed in our
study. Taking the other unexpected factors into account, the final sample
size was set at 140 (70 per group). Sample size calculation was per­
formed by using G*Power software (Faul et al., 2009) (ver. 3.1.9.7).
2.2. Participants
Inclusion criteria for the MDD group were: 1) aged between 18 and
60 years; 2) meeting ICD-10(Organization, 1992) criteria for the diag­
nosis of MDD using the Mini International Neuropsychiatric Interview
(Sheehan et al., 1998); 3) Hamilton Depression Rating Scale (HAMD-17)
(Hamilton, 1960) > 17; 4) ability to provide informed consent. Using
several mode of online and offline advertising HCs were recruited to
match for sex- and age the MDD group. HCs were required to be in good
physical health, and with no history of personal, or first-degree family,
psychiatric disorder.
Considering the inflammatory markers are sensitive to several so­
matic conditions which also may have interaction with depression sta­
tus, a rigorous exclusion criteria for both groups included: 1) with
X.-h. Xie et al.
current or chronic inflammatory disorders; 2) antibiotic use within the
prior one month; 3) history of neurological disorders such as epilepsy,
multiple sclerosis, stroke, and neurodegenerative diseases; 4) history of
metabolic syndromes, such as obesity (BMI > 30), diabetes, hyperlip­
idemia; 5) cancer; 6) cardiovascular illness; 7) presence of severe stress
events, such as severe injuries or surgeries within the prior one month;
8) current pregnancy; 9) other unstable, serious comorbidities; 10)
psychoactive substance abuse in the last year.
2.3. Collection of serum and ADEs
Two milliliters peripheral fasting blood samples were collected after
a 12-h fast from each subject between 06:00–09:00 in the morning and
stored in a serum separator tube and was centrifuged at 3000×g for 10
min to obtain the serum. The serum samples were divided into 500 μl per
tube and stored at − 80 ℃. On the test day, all samples were tested
simultaneously. For each participant, a tube of 500 μl of serum was
thawed, of which 250 μl of serum was used to test for peripheral
inflammation markers. The remaining 250 μl of serum was used to
extract ADEs. ADEs were separated according to a two-step widely
tested and well certified protocol (Chen et al., 2019; Fiandaca et al.,
2015; Goetzl et al., 2016; Goetzl et al., 2018; Goetzl et al., 2020; Jia
et al., 2019; Mustapic et al., 2017; Winston et al., 2019a; Winston et al.,
2019b). In brief, 250 ul of serum was gently mixed with 250 ul calciu­
mand magnesium-free Dulbecco’s phosphate-buffered saline (DPBS,
Thermo Fisher Scientific, Catalog number: 14190136) with protease and
phosphatase inhibitor cocktails (Roche Life Science, Catalog number:
4,693116001 and 4906837001) at 4 ℃, and followed the centrifugation
at 3000×g for 30 min to remove possible cells or cell debris. After that,
the supernatants were mixed with 126 ul of ExoQuick exosome pre­
cipitation solution (EXOQ; System Biosciences, CA, Catalog number:
EXOQ20A) and incubated at 4 ◦ C for 60 min. After centrifugation at
1500×g for 30 min, the pellets (total EVs) were then resuspended in 350
ul of DPBS and placed in a rotating mixer for 2 h at 4 ◦ C. Each sample
was incubated for 1 h at room temperature with 1.5 μg of mouse anti-
human glutamine aspartate transporter (ACSA-1) biotinylated anti­
body (Miltenyi Biotec, Auburn, CA, Catalog number: 130-118-984) after
being combined with 50 ul 3 % bovine serum albumin (Sangon Biotech
(Shanghai) Co., ltd., Catalog number: A600332). After that, 10 μl of
streptavidinagarose resin (Thermo Fisher Scientific, Catalog number:
53117) and 40 μl of 3 % bovine serum albumin was added and then
incubated for 30 min at room temperature with continuous mixing,
followed by centrifugation at 800×g for 10 min at 4 ℃ and removal the
supernatant. Each sample was then resuspended using 100 μl cold 0.05
M glycine-HCl (pH = 3.0) and was centrifugated at 4000×g for 10 min.
The supernatant was recovered and then mixed with 25 ul DPBS con­
taining 3 % bovine serum albumin, and adjust the pH to 7.0 by adding
10 ul 1 M Tris-HCl (pH = 8.0). The samples were then incubated at 37 ℃
for 10 min and then the ADEs were isolated for further confirmation and
protein measurements.
2.4. Confirmation of ADE
An ADE sample of MDD-M patient was used for the ADE confirma­
tion, and the supernatants of total exosomes and ADE were used as the
negative controls. The ADE were confirmed by three different well-
established methods, namely, the transmission election microscopy,
nanoparticle tracking analysis, and western blotting.
2.4.1. Transmission electron microscopy
Transmission electron microscopy scanning was performed to
observe the shape of ADEs. In brief, after immunoprecipitation, 10 ul
ADE sample was added dropwise to 200-mesh grids and incubated at
room temperature for 5 min, then were negatively stained with uranium
dioxide acetate solution for 1 min, and the remaining liquid was
removed by filter paper. A FEI Tecnai G2 Spirit transmission electron
53
Brain Behavior and Immunity 109 (2023) 51–62
microscope (FEI Company, Hillsboro, USA) was used for imaging.
2.4.2. Nanoparticle tracking analysis
The diameter (nm) and concentration (particles/ml) of ADEs was
determined using the Nanosight NS500 system (Malvern Panalytical,
Malvern, UK) with a G532 nm laser module and NTA 3.4.003 nano­
particle tracking software (Malvern Instruments, Malvern, UK).
2.4.3. Western blotting
Western blot was performed to detect three exosomal marker (cluster
of differentiation (CD) 63, CD81 and tumor susceptibility (TSG) 101),
and astrocyte marker glial fibrillary acidic protein (GFAP) using corre­
sponding anti-human antibodies according to the manufacturer’s in­
structions (CD63, Abcam, Cambridge, UK, Catalog number: ab134045;
CD81, Abcam, Catalog number: ab109201; TSG101, Abcam, Catalog
number: ab125011; GFAP, Abcam, Catalog number: ab68428).
2.5. Protein measurements
For protein measurements, 365 ul of mammalian protein extraction
reagent (M-PER, Thermo Fisher Scientific, Catalog number: 78503) was
added to an ADE sample. The levels of interferon-γ (IFN-γ), IL-12p70, IL-
1β, IL-2, IL-4, IL-6, TNF-α, IL-10, and IL-17A in both serum and ADE
were measured with the High Sensitivity 9-Plex Human ProcartaPlex™
Panel (Thermo Fisher Scientific, Catalog number: EPXS090-12199-901).
The levels of CD81 protein in ADEs were measured with the enzyme-
linked immunosorbent assay (ELISA, American Research Products Inc.,
Catalog number: CSB-EL004960HU). The amount of CD81 protein
concentrations in ADEs were used to normalize the EV content as
following, the mean value of CD81 levels in each group was set to 1.00,
and the relative values for each sample were used to normalize their
recovery (Fiandaca et al., 2015; Goetzl et al., 2016; Goetzl et al., 2018;
Goetzl et al., 2020; Jia et al., 2019; Winston et al., 2019a). All samples
were tested in duplicate at the same time.
2.6. Statistical analyses
Descriptive analyses for categorical data, such as sex, were analyzed
using the Fisher exact test. Numerical data were first tested for equal
variance and normality (Shapiro-Wilk test). Welch’s two-sample t-tests
were used for normally distributed data, and Mann-Whitney U tests were
used for non-normality numerical data. To test for differences of in­
flammatory markers between two groups, general linear models (GLM)
were used. Inflammatory markers were set as dependent variables and
the group was set as the independent variable; sex, age, and BMI were
added as covariates. The model-fitted estimated marginal means
(EMMs) and their associated 95 % CI were used to represent the dif­
ferences between two groups. For multiple comparisons correction, after
considering the advantages and disadvantages of different methods
(Perneger, 1998), the false discovery rate (FDR) correction (Benjamini
and Yekutieli method) (Benjamini and Yekutieli, 2001) was conducted
to accommodate false positive results. Considering that inflammation
markers in peripheral and CNS may affect each other, sensitivity anal­
ysis was conducted as follow: when comparing the group differences of
inflammatory markers in ADEs, the values of the same inflammatory
marker in serum was added as a covariate, and vice versa. Hedges’ g was
also used to present the original effect size between two groups. In the
exploratory analyses, similar methods were used, namely, GLMs were
used to test the differences of inflammatory markers between two sub­
groups, the MDD-DF and MDD-M subgroups; spearman coefficients were
used for correlation analyses of the inflammatory markers’ concentra­
tion levels between the serum and the ADEs, and clinical features.
Receiver operating characteristic curves (ROCs) and corrected partial
area under the curve (pAUC) were used to further explore the potential
of inflammatory markers in ADEs as biomarkers of MDD; and FDR
correction was also conducted to control false positive results. A two-
X.-h. Xie et al. Brain Behavior and Immunity 109 (2023) 51–62

tailed p-values <0.05 was considered significant. All statistical analyses
were performed using R version 4.1.0 (R Project for Statistical
Computing) within RStudio version 1.4.1106 (RStudio).
3. Results
3.1. Participant characteristics
A total of 70 patients with MDD and 70 HCs were recruited. Table 1
reports the characteristics of the participants. As to be expected there
were no differences in sex and age between the two groups and the same
was for BMI. Similarly, there were no differences in sex ratio, age, BMI,
age of onset, total disease course, current episode duration, and HAMD-
17 score between the MDD-DF and the MDD-M subgroups (see sTable 1).
3.2. Confirmation of ADEs
ADEs were confirmed by transmission electron microscopy, nano­
particle tracking analysis and western blotting (Fig. 1). The transmission
electron microscopy image of an MDD-DF patient’s ADEs clearly shows
the exosomes-like shape. The results of nanoparticle tracking analysis
show the diameter distribution of the EVs, which also corroborate with
the prior knowledge of exosomes-like small EVs. Western blotting results
showed that three exosomes marker CD63, CD81, TSG101, and an
astrocyte marker GFAP was expressed in the ADE samples (The original
whole piece pictures of western blotting are shown in sFigure 1). Based
on these results, we confirmed that ADEs were successfully collected.
In ADEs, the distribution of CD81 was not norm. As shown in Fig. 1e,
the difference of CD81 was non-significant between the MDD (median
(inter quartile range (IQR)) = 1013 (1698) pg/ml serum) group and HC
(median (IQR) = 993 (675) pg/ml serum) group (Mann-Whitney U test,
W = 2108, p = 0.154). In subgroups, the difference of CD81 was non-
significant between the MDD-DF (median (IQR) = 1010 (1956) pg/ml
serum) subgroup and MDD-M (median (IQR) = 1016 (1684) pg/ml
serum) subgroup (Mann-Whitney U test, W = 540, p = 0.783,
sFigure 3a).
3.3. Main objective: Group differences of inflammatory markers in serum
and ADEs
significantly increased, where as IL-12p70 was significantly reduced in
the MDD group compared with HCs. The differences of other six in­
flammatory markers between MDD and HCs were non-significant,
detailed results are demonstrated in Table 2 and Fig. 2.
For inflammatory markers in ADEs, all inflammatory markers except
IL-10 were significantly increased in the MDD group compared with
HCs, the Hedge’s g value of these eight inflammatory markers varied
from 0.48 to 1.07, detailed results are demonstrated in Table 2 and
Fig. 3.
In the sensitivity analyses, the results were generally similar to the
main analysis, except that the IL-12p70 in ADEs became statistically
non-significant (PFDR = 0.073) after the IL-12p70 level in serum was
added as a covariate, and the IL-17A in serum became statistically non-
significant (PFDR = 1.000) after the IL-17A level in ADEs was added as a
covariate. Detailed results are demonstrated in sTable 2.
3.4. Exploratory objective 1: Subgroup differences
In total, the subgroup differences of all inflammatory markers
whether in serum or ADEs between MDD-DF and MDD-M subgroups
were non-significant (all PFDR values > 0.05). Detailed results are
demonstrated in sTable 3.
3.5. Exploratory objective 2: Relations of inflammatory biomarkers
between ADEs and serum
No spearman coefficients of inflammatory biomarkers between ADEs
and serum of neither in HCs nor MDD group reached statistically sig­
nificance after the FDR correction (all PFDR values > 0.05). Detailed
results are demonstrated in sTable 4.
3.6. Exploratory objective 3: Relations between inflammatory biomarkers
and clinical features.
In analyses exploring the correlation between inflammatory factors
and clinical characteristics, such as onset age, disease course, current
episode duration, and HAMD-17 score, no correlation coefficients
remained significant after FDR correction, although some original P
values <0.05. Detailed results are demonstrated in sTable 5.

For inflammatory markers in serum, TNF-α and IL-17A were 3.7. Exploratory objective 4: Potentiality of inflammatory markers in
ADEs as biomarkers for MDD.
Table 1
Descriptive data of included participants.
The corrected pAUCs of each inflammatory markers ranged from
0.522 to 0.696, while IL-6 being the most differentiated (pAUC = 0.696,
Parameters MDD HC pa
95 % CI = (0.605, 0.792)), further, the combination of these inflam­
Subject, n 70 70 – matory factors had a very high discriminatory effect on MDD group and
Sex, Female/Male 42/28 42/28 1.000 HCs (pAUC = 0.919, 95 % CI = (0.860, 0.974)). Detailed results are
Age, years, median (IQR) 41.0 (18.5) 37.0 (15.8) 0.398
BMI, kg/m2, median (IQR) 21.6 (3.65) 22.2 (3.63) 0.079
demonstrated in Fig. 4 and sTable 6.
Clinical characteristics
Medication, yes/no 45/25 NA – 3.8. Data availability statement
SSRIsb, yes/no 28/17 NA –
SNRIsb, yes/no 19/26 NA –
The data that support the findings of this study are available from the
Other antidepressantsb, yes/no 7/38 NA –
Mood stabilizerb, yes/no 2/43 NA – corresponding author, upon reasonable request.
Atypical antipsychoticsb, yes/no 10/35 NA –
Equivalent fluoxetine doseb, mg, mean (SD) 33.2 (16.6) NA – 4. Discussion
Age of onset, years, mean (SD) 32.5 (12.4) NA –
Total disease course, years, mean (SD) 6.7 (7.8) NA –
Current episode duration, months, mean (SD) 2.4 (2.3) NA –
This is the first study to show significantly higher inflammatory
HAMD-17, mean (SD) 25.7 (5.5) NA – markers in ADEs in MDD patients compared with HCs. Our results
support the neuroinflammatory hypothesis of depression via a unique
Note: a: For categorical data, Fisher exact test was used, for numerical data; the
and direct perspective. Further, the inflammatory markers in ADEs
distribution of age and BMI are not normal, therefore, the Mann-Whitney U tests
were used. b: Only medicated patients were calculated (n = 45).
demonstrated to be potential new biological markers of MDD.
Abbreviations: MDD = major depressive disorder; HC = health control; SD =
standard deviation; BMI = body mass index; IQR = inter quartile range; SSRI = 4.1. Inflammatory status in serum
selective serotonin reuptake inhibitor; SNRI = serotonin and norepinephrine
reuptake inhibitor; HAMD-17 = Hamilton’s Depression Scale (17-item version). We found only two significant higher levels of serum pro-

54
X.-h. Xie et al. Brain Behavior and Immunity 109 (2023) 51–62

Fig. 1. Confirmation of astrocyte-derived extracellular vesicles (ADEs). a) The results of nanoparticle tracking analysis show the diameter distribution of the EVs,
which also corroborate with the prior knowledge of exosomes-like small EVs (diameter: 118.4 ± 45.5 nm, Concentration: 2.01 ± 0.12 109 particles/ml); b–c) The
transmission electron microscopy image of ADEs isolated from a drug-free patient with major depressive disorder (MDD) patient, the images clearly shows the
exosomes-like shape (red arrows); d) Western blotting results of ADE sample: three exosomes marker cluster of differentiation (CD) 63, CD81, tumor susceptibility
(TSG) 101, and an astrocyte marker glial fibrillary acidic protein (GFAP) was identified; e) Boxplot of CD81 between the MDD (median (inter quartile range (IQR)) =
1013 (1698) pg/ml serum) group and HC (median (IQR) = 993 (675) pg/ml serum) group (Mann-Whitney U test, p = 0.154). (For interpretation of the references to
colour in this figure legend, the reader is referred to the web version of this article.)

Table 2
Comparisons of EMMs of inflammatory markers in serum and ADEs based on general linear model.
HC MDD Difference P PFDR Hedge’s g (95 % CI)
EMM (95 % CI) EMM (95 % CI) MDD - HC (95 % CI)

In Serum
IFN-γ 1.36 (1.21, 1.52) 1.53 (1.38, 1.69) 0.17 (− 0.04, 0.39) 0.118 0.601 0.30 (− 0.03, 0.64)
IL-12p70 0.65 (0.60, 0.71) 0.49 (0.44, 0.54) − 0.16 (− 0.23, − 0.09) <0.001 <0.001 − 0.73 (− 1.09, − 0.40)
IL-1β 0.12 (0.09, 0.14) 0.15 (0.12, 0.18) 0.03 (− 0.01, 0.07) 0.118 0.601 0.34 (0.01, 0.68)
IL-2 1.46 (1.08, 1.84) 1.72 (1.35, 2.09) 0.26 (− 0.27, 0.79) 0.333 1.000 0.14 (− 0.19, 0.48)
IL-4 1.55 (1.25, 1.86) 1.69 (1.39, 1.99) 0.14 (− 0.29, 0.57) 0.512 1.000 0.13 (− 0.21, 0.46)
IL-6 1.35 (0.99, 1.70) 1.13 (0.78, 1.48) − 0.22 (− 0.72, 0.28) 0.389 1.000 − 0.22 (− 0.56, 0.11)
TNF-α 0.84 (0.54, 1.13) 1.47 (1.18, 1.76) 0.63 (0.22, 1.05) 0.003 0.038 0.52 (0.18, 0.86)
IL-10 0.21 (0.18, 0.25) 0.24 (0.20, 0.27) 0.03 (− 0.02, 0.07) 0.268 1.000 0.16 (− 0.17, 0.50)
IL-17A 0.06 (0.02, 0.11) 0.15 (0.11, 0.19) 0.08 (0.02, 0.14) 0.005 0.045 0.45 (0.12, 0.80)
In ADEs
IFN-γ 9.17 (7.31, 11.0) 16.73 (14.90,18.60) 7.56 (4.95, 10.17) <0.001 <0.001 0.99 (0.65, 1.36)
IL-12p70 5.14 (4.17, 6.11) 7.14 (6.18, 8.10) 2.00 (0.63, 3.36) 0.004 0.001 0.48 (0.14, 0.82)
IL-1β 3.73 (2.88, 4.59) 7.16 (6.32, 8.00) 3.42 (2.23, 4.62) <0.001 <0.001 0.93 (0.60, 1.30)
IL-2 20.7 (15.1, 26.4) 44.8 (39.2, 50.4) 24.10 (16.12, 32.08) <0.001 <0.001 0.99 (0.65, 1.36)
IL-4 14.3 (11.3, 17.2) 22.6 (19.7, 25.5) 8.36 (4.18, 12.53) <0.001 <0.001 0.70 (0.36, 1.05)
IL-6 13.2 (10.1, 16.4) 27.5 (24.4, 30.6) 14.29 (9.89, 18.69) <0.001 <0.001 1.07 (0.73, 1.44)
TNF-α 15.70 (12.40, 19.10) 26.90 (23.60, 30.20) 11.19 (6.46, 15.92) <0.001 <0.001 0.77 (0.44, 1.13)
IL-10 1.11 (0.81, 1.40) 1.57 (1.29, 1.86) 0.47 (0.06, 0.88) 0.026 0.073 0.37 (0.04, 0.71)
IL-17A 0.89 (0.58, 1.21) 1.81 (1.50, 2.13) 0.92 (0.48, 1.37) <0.001 <0.001 0.63 (0.30, 0.98)

Note: Age, sex, and BMI are added as covariates, and the concentrations of inflammatory markers were normalized to CD81 concentration level.
Abbreviations: MDD = major depressive disorder; HC = health control; ES = effect size; EMM = estimated marginal mean; CI = confidence interval; ADEs = astrocyte-
derived extracellular vesicles; IFN = interferon; IL = interleukin; TNF = tumour necrosis factor; BMI = body mass index; FDR = false discovery rate.

55
X.-h. Xie et al. Brain Behavior and Immunity 109 (2023) 51–62

Fig. 2. Boxplots of inflammatory markers in serum between major depressive disorder (MDD) and healthy control (HC) group. Note: *Pfalse discovery rate (FDR) < 0.05;
**PFDR < 0.01; ***PFDR < 0.001.

56
X.-h. Xie et al. Brain Behavior and Immunity 109 (2023) 51–62

Fig. 3. Boxplots of inflammatory markers in astrocyte-derived extracellular vesicles (ADEs) between major depressive disorder (MDD) and healthy control (HC)
group. Note: *Pfalse discovery rate (FDR) < 0.05; **PFDR < 0.01; ***PFDR < 0.001.

57
X.-h. Xie et al. Brain Behavior and Immunity 109 (2023) 51–62

Fig. 4. Receiver operating characteristic curves (ROCs) of inflammatory markers in astrocyte-derived extracellular vesicles (ADEs). The corrected partial area under
the curves (pAUCs) of each inflammatory marker ranged from 0.522 to 0.696 (interferon (IFN)-γ: 0.624; interleukin (IL)-12p70: 0.558; IL-1β: 0.607; IL-2: 0.642; IL-4:
0.603; IL-6: 0.696; tumor necrosis factor (TNF)-α: 0.593; IL-10: 0.548; IL-17A: 0.522; Combination of above inflammatory markers: 0.919.).

inflammatory cytokines (TNF-α and IL-17A) in MDD group, and inter­
estingly, one serum pro-inflammatory cytokine higher in HC group. No
other significant alternations of cytokines were found between MDD and
HC groups. Significant heterogeneity of inflammatory markers in pe­
riphery is a lasting issue in MDD studies. Confounding by somatic co­
morbidity is one potential reason. The prevalence of depression in
medically ill patients is significantly higher than in the general popu­
lation (Cassano and Fava, 2002), especially in patients with
inflammation-related diseases (Barberio et al., 2021; Matcham et al.,
2013; Moustafa et al., 2020), and with some unhealthy lifestyles (Chang
et al., 2019; Kohno et al., 2019; Milaneschi et al., 2019). As a result,
some associations between elevated peripheral inflammatory markers
and depression in prior studies that did not rigorously control for these
potential confounders may have been coincidental (Cassano et al.,
2017), or, these elevated peripheral inflammatory markers and
depressive symptoms could be a common result of some pathology
source of depression. To control these confounding factors, Cassano
et al. rigorously recruited a group of depressed patients with no sub­
stantial medical comorbidities, obesity and problem substance use, as
well as a group of one-by-one matched HCs, and observed no significant
differences in 22 cytokine levels between MDD patients and HCs (Cas­
sano et al., 2017). Their findings suggested that some shared con­
founding factors associated with both depression and inflammatory
markers may have influenced the findings in the inflammatory studies in
MDD patients. Likewise, to reduce the confounding factors as much as
possible, we applied the similar rigorous criteria for somatic illnesses
that may increase inflammation levels in our study, it might explain why
our proinflammatory markers in serum were not widely raised in the
MDD group. Unexpectedly, the higher serum level of IL-12p70 was
found in the HC group, not the MDD group. This is consistent with
Cassano et al.(2017), who reported an approximately 3-fold higher level
of IL-12p70 in HC group compared to MDD group, but did not reach a
statistically significant level may due to the low detectable rate. Un­
fortunately, due to the lack of relevant research on IL-12 in MDD
patients, we cannot yet make any trustworthy conclusions based on the
sparse and inconsistent clinical data. We hope to see more pertinent
studies in the future.
However, it should be noted that, the rigorous exclusion of somatic
co-morbidities may excluded a subtype of depression, in which somatic
co-morbidities may be a causal factor of inflammation or a key mediator
of depression. A more ideal approach would be to perform a subgroup
analysis of MDD individuals who do not have somatic co-morbidities in a
much larger MDD sample, but this would result in a markedly larger
sample size. We expect that the findings of this investigation will provide
a priori data for the next study with larger sample size. Hitherto, absence
or inconsistent peripheral inflammatory status do not falsify the in­
flammatory hypothesis of MDD which is partly due to the poor corre­
lation of inflammatory markers between peripheral serum and the CNS
in participants with depression(Enache et al., 2019).
4.2. Neuro-inflammation, astrocytes, and depression
Astrocyte is a protagonist in neuro-inflammation. About 20–40 %
glial cells in CNS are astrocytes (Herculano-Houzel, 2014; Rowitch and
Kriegstein, 2010). Cytokines are not only produced in the periphery by
immune cells, but recent research has shown that glia, such as astro­
cytes, can also produce cytokines within the CNS (Rothhammer and
Quintana, 2015). In the inflammatory status, the total number of as­
trocytes increases, and they differentiate into the reactive type (Ben
Haim et al., 2015; Goetzl and Miller, 2017; Liddelow and Barres, 2017).
These reactive astrocytes lose their neuronal trophic potential and in­
crease the expression of proinflammatory pathways(Ceyzeriat et al.,
2016; Liddelow and Barres, 2017; Sofroniew, 2014; Zamanian et al.,
2012), and produce IL-6, TNF, IL-1β, IFN-γ, and other pro-inflammatory
cytokines(Ben Haim et al., 2015; John et al., 2003; Krumbholz et al.,
2005; Lau and Yu, 2001; Rothhammer and Quintana, 2015; Van
Wagoner et al., 1999). In fact, for IL-6, astrocytes are the major gener­
ator in CNS inflammation status (Gruol and Nelson, 1997), the elevated

58
X.-h. Xie et al.
IL-6 and other pro-inflammatory cytokines such as TNF-α, IL-1β, IL-17A
may further promote IL-6 production in astrocytes (Ma et al., 2010; Van
Wagoner et al., 1999). As a result, these widely elevated levels of in­
flammatory molecules in their producer—astrocytes could be detected
in ADEs.
Furthermore, the inflammation hypothesis (Beurel et al., 2020;
Miller and Raison, 2016) suggests that the inflammatory cytokine may
passage through leaky regions in the BBB, such as the circumventricular
organs, and the binding of cytokines to saturable transport molecules on
the BBB, then drive inflammation in the brain leading to depression.
Hence, measuring the same inflammatory markers in periphery and CNS
simultaneously may provide a more integrated picture. Because of the
various measurement techniques used and the absence of unstandard­
ized effect sizes, it is difficult to compare the results of different studies
directly. Therefore, we compared the differences of the same cytokines
in periphery and CNS in the same participants, using the same kits from
the same batch at the same time, and to get a comparable result, we use
Hedges’ g as the effect size index. In this study, Hedges’ g values in ADEs
are more consistent and relatively larger, on the contrary, the g values in
serum are smaller and more heterogeneous. Furthermore, no significant
correlations of cytokines between serum and ADEs were found. This
suggests that inflammatory differences are more significant in ADEs.
Additionally, it appears that CNS inflammation is a process independent
from peripheral inflammation. It also should be noted that a main
function of EVs is intercellular communication (Kalluri and LeBleu,
2020; Meldolesi, 2018), and inflammatory factors are cargos in these
vesicles; therefore, when we detect the cargos, namely these cytokines,
EVs may play a role of enrichment amplification of these cargos. On one
hand, this possible amplification effect may result in an overestimation
of the concentration of inflammatory markers in CNS, and subsequently
lead to an overestimation of the between-group effect size. On the other
hand, if this assumption is correct, we may be able to employ ADEs as a
natural bio-amplifier to detect changes in inflammation in CNS, which
warrants additional exploration. Whatever the case, this work offers a
fresh perspective on the inflammation in the CNS, and raises new
questions about the importance of measuring inflammation directly in
the CNS in vivo.
The inflammatory markers in ADEs also demonstrated their potential
as biomarkers for MDD. For single cytokine, the pAUC is approximate
0.6, but the combination of these cytokines can achieve a powerful
distinguishing capability for MDD patients from HCs. We speculated that
the combination of these pro- and anti-inflammatory markers may better
depict a more comprehensive picture of the inflammatory status in CNS
and therefore enhanced the distinguishing ability.
Another intriguing finding was that while we found significant in­
creases in a variety of pro-inflammatory factors in ADEs in the MDD
group, an essential anti-inflammatory cytokine, IL-10, whose levels were
found to be non-significantly different between MDD and HC groups
neither in serum nor in ADEs. Clinical studies on peripheral IL-10 are
highly heterogeneous (Hiles et al., 2012), a recent meta-analysis(Kohler
et al., 2017) demonstrated no significant alternation of peripheral IL-10
in antidepressant-free participants with MDD, but significantly elevated
in medicated patients. In CNS, IL-10 could reduce the expression of pro-
inflammatory cytokine and chemokine in astrocytes (Kenison et al.,
2020; Mayo et al., 2016; Zhang et al., 2020). Production of IL-10 after
different types of CNS injuries has been demonstrated to have protective
anti-inflammatory functions (Arimoto et al., 2007; Park et al., 2007; Xin
et al., 2011), and in addition, IL-10 administration could also rescue
depression-like behavior (Mesquita et al., 2008; Zhang et al., 2020) and
associated learning and memory deficits in depression animal model
(Worthen et al., 2020). In line to this study, widespread increased pro-
inflammatory cytokines but no elevation of anti-inflammatory IL-10 in
ADEs provided another postulate for the inflammation hypothesis of
depression. The insufficient responsive anti-inflammatory cytokines
production in CNS might provide a concise interpretation of the highly
heterogeneous low-grade inflammatory status in depression population
59
Brain Behavior and Immunity 109 (2023) 51–62
among the various studies. Of course, this requires further replication.
4.3. Inconsistent inflammatory status in serum and ADEs
Our study failed to find significant relations of cytokines between
ADEs and serum. Further, in the sensitive analysis, when analysis the
cytokines in ADEs, we add the concentration of the same cytokine in
serum as the control variable, and vice versa, the results remained.
Although, the immune dysregulation is present in both periphery-CNS
and CNS-peripheral directions (Miller et al., 2017), the issue of the
correlation between the specific inflammatory markers in CNS and pe­
riphery is debatable. Among the most commonly tested inflammatory
markers, the relationships for each inflammatory markers are various. In
clinical studies, CRP was found has the strongest significant correlation
between periphery and CSF (Felger et al., 2020; Lindqvist et al., 2013),
whereas the periphery-CNS correlations of IL-1β (Felger et al., 2020;
Lindqvist et al., 2009), IL-6 (Felger et al., 2020; Sasayama et al., 2013),
IL-8 (Lindqvist et al., 2009), and TNF-α (Felger et al., 2020; Lindqvist
et al., 2013; Lindqvist et al., 2009) were found nonsignificant, similar to
our results (sTable 4). For IL-1 receptor antagonist (IL-1ra) (r = 0.298)
and IL-6 soluble receptor (IL-6sr) (r = 0.418), moderate peripheral-CNS
correlations were found in 73 unmedicated adult outpatients with MDD
(Felger et al., 2020). For some inflammatory chemokines, several small
sample studies found significant correlations between periphery and
CSF (Hestad et al., 2016; Levine et al., 1999). This lack of association is
also shown in preclinical studies including both peripheral and central
inflammatory status (Bay-Richter et al., 2011; McColl et al., 2016; Qin
et al., 2007; Thomson et al., 2014). In brief, due to the heterogeneity of
inflammatory markers and the methodological restriction, immune-to-
brain communication’s processes have yet to be fully explored. Thus,
considering the higher effect sizes of cytokines in ADEs and the non-
significant periphery–central coefficients, our findings suggest a possi­
bility that, these cytokines may originate from the CNS, where glia as
astrocytes are known as the major cytokines producer (Gruol and
Nelson, 1997; John et al., 2003; Krumbholz et al., 2005; Lau and Yu,
2001; Lindqvist et al., 2009; Rothhammer and Quintana, 2015; Van
Wagoner et al., 1999). Fortunately, ADEs demonstrated their potential
as the in vivo “liquid biopsy” for CNS (Delgado-Peraza et al., 2021), and
allow us to test related hypotheses in the future.
4.4. Limitations
Our study has several limitations. First, the amount of ADEs is rela­
tively small and insufficient for some high-throughput omics tests, such
as proteomics, transcriptomics, lipidomics, and makes it difficult to gain
a comprehensive understanding of ADEs. Second, we chose a highly
sensitive multi-factor assay kit for nine cytokines because the small
amounts of ADEs and low-grade levels of peripheral/central inflamma­
tory markers, but the limited number of cytokines targeted of kits limits
our ability to explore cytokines extensively. The findings of this study,
however, suggest that future studies should broaden the scope of testing
in order to gain an integrity picture of important inflammation markers.
Third, we did not isolate neuron-derived EVs and microglia-derived EVs
due to serum sample volume and funding constraints, so there is no way
to estimate the cross-talk among the three major cells in brain, we will
continue to investigate the interactions in the next study. Forth, neu­
roimaging studies have revealed cytokine-induced alterations in
regional brain activity which involved regulating motivation and motor
activity as well as arousal, anxiety and alarm. However, we are currently
unable to precisely localize the source brain regions for these ADEs due
to the methodology restriction. We will develop new protocols,
combining neuroimaging methods and EVs, and anticipate it providing
some coupled position information. Fifth, in the exploratory analysis, no
significant correlations between ADEs and clinical characteristics were
observed, limiting our ability to draw further inferences between the
biological process and clinical features. We plan to enhance the
X.-h. Xie et al.
collection of clinical characteristics for more detailed exploration in the
next studies.
5. Conclusions
Our findings on the overall evidence of nine cytokines both in serum
and ADEs support the inflammatory glia hypothesis of depression, and
suggests that ADEs could be a useful tool to test the in vivo astrocyte
status in human participants and their role in Depression. Most impor­
tantly, our study suggests that in vivo CNS probing via brain-derived EVs
on human participants is feasible and attractive for evaluating existing
hypotheses or developing new ones.
CRediT authorship contribution statement
Xin-hui Xie: Conceptualization, Methodology, Formal analysis,
Writing – original draft. Wen-tao Lai: Investigation, Data curation,
Writing – review & editing. Shu-xian Xu: Data curation, Writing – re­
view & editing. Marta Di Forti: Writing – review & editing. Jing-ya
Zhang: Formal analysis, Writing – review & editing. Mian-mian Chen:
Formal analysis, Visualization. Li-hua Yao: Writing – review & editing.
Peilin Wang: Writing – review & editing. Ke-ke Hao: Writing – review
& editing. Han Rong: Project administration, Supervision, Funding
acquisition.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Data availability
Data will be made available on request.
Acknowledgements
This work was supported by the Sanming Project of Medicine in
Shenzhen (Grant Number: SZSM201812052), Natural Science Founda­
tion of Guangdong Province (Grant Number: 2020A1515011290), Sci­
ence and Technology Program of Shenzhen (Grant Numbers:
JCYJ20190809155403596), and Chinese National Natural Science
Foundation (Grant Number: 81201047). This work has not received
funding/assistance from any commercial organizations.
Role of the funding sources
The funding sources had no roles in the design of this study and will
not have any roles during the execution, analyses, interpretation of the
data, or decision to submit results.
References
Arimoto, T., Choi, D.Y., Lu, X., Liu, M., Nguyen, X.V., Zheng, N., Stewart, C.A., Kim, H.C.,
Bing, G., 2007. Interleukin-10 protects against inflammation-mediated degeneration
of dopaminergic neurons in substantia nigra. Neurobiol. Aging 28, 894–906.
Arteaga-Henriquez, G., Simon, M.S., Burger, B., Weidinger, E., Wijkhuijs, A., Arolt, V.,
Birkenhager, T.K., Musil, R., Muller, N., Drexhage, H.A., 2019. Low-grade
inflammation as a predictor of antidepressant and anti-inflammatory therapy
response in MDD patients: a systematic review of the literature in combination with
an analysis of experimental data collected in the EU-MOODINFLAME Consortium.
Front. Psych. 10, 458.
Barberio, B., Zamani, M., Black, C.J., Savarino, E.V., Ford, A.C., 2021. Prevalence of
symptoms of anxiety and depression in patients with inflammatory bowel disease: a
systematic review and meta-analysis. Lancet Gastroenterol. Hepatol. 6, 359–370.
Bay-Richter, C., Janelidze, S., Hallberg, L., Brundin, L., 2011. Changes in behaviour and
cytokine expression upon a peripheral immune challenge. Behav. Brain Res. 222,
193–199.
Belmaker, R.H., Agam, G., 2008. Major depressive disorder. N. Engl. J. Med. 358, 55–68.
60
Brain Behavior and Immunity 109 (2023) 51–62
Ben Haim, L., Carrillo-de Sauvage, M.A., Ceyzeriat, K., Escartin, C., 2015. Elusive roles
for reactive astrocytes in neurodegenerative diseases. Front. Cell. Neurosci. 9, 278.
Benjamini, Y., Yekutieli, D., 2001. The control of the false discovery rate in multiple
testing under dependency. Ann. Stat. 1165–1188.
Beurel, E., Toups, M., Nemeroff, C.B., 2020. The bidirectional relationship of depression
and inflammation: double trouble. Neuron 107, 234–256.
Bollen, J., Trick, L., Llewellyn, D., Dickens, C., 2017. The effects of acute inflammation
on cognitive functioning and emotional processing in humans: A systematic review
of experimental studies. J. Psychosom. Res. 94, 47–55.
Cakici, N., Sutterland, A.L., Penninx, B., Dalm, V.A., de Haan, L., van Beveren, N.J.M.,
2020. Altered peripheral blood compounds in drug-naive first-episode patients with
either schizophrenia or major depressive disorder: a meta-analysis. Brain Behav.
Immun. 88, 547–558.
Casella, G., Rasouli, J., Boehm, A., Zhang, W., Xiao, D., Ishikawa, L.L.W., Thome, R., Li,
X., Hwang, D., Porazzi, P., Molugu, S., Tang, H.Y., Zhang, G.X., Ciric, B., Rostami, A.,
2020. Oligodendrocyte-derived extracellular vesicles as antigen-specific therapy for
autoimmune neuroinflammation in mice. Sci. Transl. Med., 12.
Cassano, P., Fava, M., 2002. Depression and public health: an overview. J. Psychosom.
Res. 53, 849–857.
Cassano, P., Bui, E., Rogers, A.H., Walton, Z.E., Ross, R., Zeng, M., Nadal-Vicens, M.,
Mischoulon, D., Baker, A.W., Keshaviah, A., Worthington, J., Hoge, E.A., Alpert, J.,
Fava, M., Wong, K.K., Simon, N.M., 2017. Inflammatory cytokines in major
depressive disorder: A case-control study. Aust. N. Z. J. Psychiatry 51, 23–31.
Ceyzeriat, K., Abjean, L., Carrillo-de Sauvage, M.A., Ben Haim, L., Escartin, C., 2016. The
complex STATes of astrocyte reactivity: How are they controlled by the JAK-STAT3
pathway? Neuroscience 330, 205–218.
Chang, H.B., Munroe, S., Gray, K., Porta, G., Douaihy, A., Marsland, A., Brent, D.,
Melhem, N.M., 2019. The role of substance use, smoking, and inflammation in risk
for suicidal behavior. J. Affect. Disord. 243, 33–41.
Chen, Y., Xia, K., Chen, L., Fan, D., 2019. Increased interleukin-6 levels in the astrocyte-
derived exosomes of sporadic amyotrophic lateral sclerosis patients. Front. Neurosci.
13, 574.
Collins, P.Y., Patel, V., Joestl, S.S., March, D., Insel, T.R., Daar, A.S., Scientific
Advisory, B., the Executive Committee of the Grand Challenges on Global Mental, H.,
Anderson, W., Dhansay, M.A., Phillips, A., Shurin, S., Walport, M., Ewart, W.,
Savill, S.J., Bordin, I.A., Costello, E.J., Durkin, M., Fairburn, C., Glass, R.I., Hall, W.,
Huang, Y., Hyman, S.E., Jamison, K., Kaaya, S., Kapur, S., Kleinman, A.,
Ogunniyi, A., Otero-Ojeda, A., Poo, M.M., Ravindranath, V., Sahakian, B.J.,
Saxena, S., Singer, P.A., Stein, D.J., 2011. Grand challenges in global mental health.
Nature 475, 27–30.
Cotter, D., Mackay, D., Chana, G., Beasley, C., Landau, S., Everall, I.P., 2002. Reduced
neuronal size and glial cell density in area 9 of the dorsolateral prefrontal cortex in
subjects with major depressive disorder. Cereb. Cortex 12, 386–394.
Delgado-Peraza, F., Nogueras-Ortiz, C.J., Volpert, O., Liu, D., Goetzl, E.J., Mattson, M.P.,
Greig, N.H., Eitan, E., Kapogiannis, D., 2021. Neuronal and astrocytic extracellular
vesicle biomarkers in blood reflect brain pathology in mouse models of Alzheimer’s
disease. Cells 10.
Dong, Y., Benveniste, E.N., 2001. Immune function of astrocytes. Glia 36, 180–190.
Enache, D., Pariante, C.M., Mondelli, V., 2019. Markers of central inflammation in major
depressive disorder: A systematic review and meta-analysis of studies examining
cerebrospinal fluid, positron emission tomography and post-mortem brain tissue.
Brain Behav. Immun. 81, 24–40.
Falsig, J., Porzgen, P., Lund, S., Schrattenholz, A., Leist, M., 2006. The inflammatory
transcriptome of reactive murine astrocytes and implications for their innate
immune function. J. Neurochem. 96, 893–907.
Faul, F., Erdfelder, E., Buchner, A., Lang, A.G., 2009. Statistical power analyses using
G*Power 3.1: tests for correlation and regression analyses. Behav. Res. Methods 41,
1149–1160.
Felger, J.C., Haroon, E., Patel, T.A., Goldsmith, D.R., Wommack, E.C., Woolwine, B.J.,
Le, N.A., Feinberg, R., Tansey, M.G., Miller, A.H., 2020. What does plasma CRP tell
us about peripheral and central inflammation in depression? Mol. Psychiatry 25,
1301–1311.
Fiandaca, M.S., Kapogiannis, D., Mapstone, M., Boxer, A., Eitan, E., Schwartz, J.B.,
Abner, E.L., Petersen, R.C., Federoff, H.J., Miller, B.L., Goetzl, E.J., 2015.
Identification of preclinical Alzheimer’s disease by a profile of pathogenic proteins in
neurally derived blood exosomes: A case-control study. Alzheimers Dement. 11
(600–607), e601.
Goetzl, E.J., Miller, B.L., 2017. Multicellular hypothesis for the pathogenesis of
Alzheimer’s disease. FASEB J. 31, 1792–1795.
Goetzl, E.J., Mustapic, M., Kapogiannis, D., Eitan, E., Lobach, I.V., Goetzl, L., Schwartz, J.
B., Miller, B.L., 2016. Cargo proteins of plasma astrocyte-derived exosomes in
Alzheimer’s disease. FASEB J. 30, 3853–3859.
Goetzl, E.J., Schwartz, J.B., Abner, E.L., Jicha, G.A., Kapogiannis, D., 2018. High
complement levels in astrocyte-derived exosomes of Alzheimer disease. Ann. Neurol.
83, 544–552.
Goetzl, E.J., Yaffe, K., Peltz, C.B., Ledreux, A., Gorgens, K., Davidson, B., Granholm, A.C.,
Mustapic, M., Kapogiannis, D., Tweedie, D., Greig, N.H., 2020. Traumatic brain
injury increases plasma astrocyte-derived exosome levels of neurotoxic complement
proteins. FASEB J. 34, 3359–3366.
Goetzl, E.J., Wolkowitz, O.M., Srihari, V.H., Reus, V.I., Goetzl, L., Kapogiannis, D.,
Heninger, G.R., Mellon, S.H., 2021. Abnormal levels of mitochondrial proteins in
plasma neuronal extracellular vesicles in major depressive disorder. Mol. Psychiatry
26, 7355–7362.
Goldsmith, D.R., Rapaport, M.H., Miller, B.J., 2016. A meta-analysis of blood cytokine
network alterations in psychiatric patients: comparisons between schizophrenia,
bipolar disorder and depression. Mol. Psychiatry 21, 1696–1709.
X.-h. Xie et al.
Gruol, D.L., Nelson, T.E., 1997. Physiological and pathological roles of interleukin-6 in
the central nervous system. Mol. Neurobiol. 15, 307–339.
Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23,
56–62.
Hannestad, J., DellaGioia, N., Gallezot, J.D., Lim, K., Nabulsi, N., Esterlis, I., Pittman, B.,
Lee, J.Y., O’Connor, K.C., Pelletier, D., Carson, R.E., 2013. The neuroinflammation
marker translocator protein is not elevated in individuals with mild-to-moderate
depression: a [(1)(1)C]PBR28 PET study. Brain Behav. Immun. 33, 131–138.
Herberth, G., Weber, A., Roder, S., Elvers, H.D., Kramer, U., Schins, R.P., Diez, U.,
Borte, M., Heinrich, J., Schafer, T., Herbarth, O., Lehmann, I., Group, L.I.s., 2008.
Relation between stressful life events, neuropeptides and cytokines: results from the
LISA birth cohort study. Pediatr. Allergy Immunol. 19, 722–729.
Herculano-Houzel, S., 2014. The glia/neuron ratio: how it varies uniformly across brain
structures and species and what that means for brain physiology and evolution. Glia
62, 1377–1391.
Hestad, K.A., Engedal, K., Whist, J.E., Aukrust, P., Farup, P.G., Mollnes, T.E., Ueland, T.,
2016. Patients with depression display cytokine levels in serum and cerebrospinal
fluid similar to patients with diffuse neurological symptoms without a defined
diagnosis. Neuropsychiatr. Dis. Treat. 12, 817–822.
Hiles, S.A., Baker, A.L., de Malmanche, T., Attia, J., 2012. A meta-analysis of differences
in IL-6 and IL-10 between people with and without depression: exploring the causes
of heterogeneity. Brain Behav. Immun. 26, 1180–1188.
Holmes, S.E., Hinz, R., Conen, S., Gregory, C.J., Matthews, J.C., Anton-Rodriguez, J.M.,
Gerhard, A., Talbot, P.S., 2018. Elevated translocator protein in anterior cingulate in
major depression and a role for inflammation in suicidal thinking: a positron
emission tomography study. Biol. Psychiatry 83, 61–69.
Jia, L., Qiu, Q., Zhang, H., Chu, L., Du, Y., Zhang, J., Zhou, C., Liang, F., Shi, S., Wang, S.,
Qin, W., Wang, Q., Li, F., Wang, Q., Li, Y., Shen, L., Wei, Y., Jia, J., 2019.
Concordance between the assessment of Abeta42, T-tau, and P-T181-tau in
peripheral blood neuronal-derived exosomes and cerebrospinal fluid. Alzheimers
Dement. 15, 1071–1080.
John, G.R., Lee, S.C., Brosnan, C.F., 2003. Cytokines: powerful regulators of glial cell
activation. Neuroscientist 9, 10–22.
Kalluri, R., LeBleu, V.S., 2020. The biology, function, and biomedical applications of
exosomes. Science (New York N.Y.) 367.
Kenison, J.E., Jhaveri, A., Li, Z., Khadse, N., Tjon, E., Tezza, S., Nowakowska, D.,
Plasencia, A., Stanton Jr., V.P., Sherr, D.H., Quintana, F.J., 2020. Tolerogenic
nanoparticles suppress central nervous system inflammation. PNAS 117,
32017–32028.
Khakh, B.S., Deneen, B., 2019. The emerging nature of astrocyte diversity. Annu. Rev.
Neurosci. 42, 187–207.
Khandaker, G.M., Pearson, R.M., Zammit, S., Lewis, G., Jones, P.B., 2014. Association of
serum interleukin 6 and C-reactive protein in childhood with depression and
psychosis in young adult life: a population-based longitudinal study. JAMA Psychiat.
71, 1121–1128.
Kohler, C.A., Freitas, T.H., Maes, M., de Andrade, N.Q., Liu, C.S., Fernandes, B.S.,
Stubbs, B., Solmi, M., Veronese, N., Herrmann, N., Raison, C.L., Miller, B.J.,
Lanctot, K.L., Carvalho, A.F., 2017. Peripheral cytokine and chemokine alterations in
depression: a meta-analysis of 82 studies. Acta Psychiatr. Scand. 135, 373–387.
Kohno, M., Link, J., Dennis, L.E., McCready, H., Huckans, M., Hoffman, W.F., Loftis, J.M.,
2019. Neuroinflammation in addiction: A review of neuroimaging studies and
potential immunotherapies. Pharmacol. Biochem. Behav 179, 34–42.
Krumbholz, M., Theil, D., Derfuss, T., Rosenwald, A., Schrader, F., Monoranu, C.M.,
Kalled, S.L., Hess, D.M., Serafini, B., Aloisi, F., Wekerle, H., Hohlfeld, R., Meinl, E.,
2005. BAFF is produced by astrocytes and up-regulated in multiple sclerosis lesions
and primary central nervous system lymphoma. J. Exp. Med. 201, 195–200.
Lau, L.T., Yu, A.C., 2001. Astrocytes produce and release interleukin-1, interleukin-6,
tumor necrosis factor alpha and interferon-gamma following traumatic and
metabolic injury. J. Neurotrauma 18, 351–359.
Leng, L., Zhuang, K., Liu, Z., Huang, C., Gao, Y., Chen, G., Lin, H., Hu, Y., Wu, D., Shi, M.,
Xie, W., Sun, H., Shao, Z., Li, H., Zhang, K., Mo, W., Huang, T.Y., Xue, M., Yuan, Z.,
Zhang, X., Bu, G., Xu, H., Xu, Q., Zhang, J., 2018. Menin deficiency leads to
depressive-like behaviors in mice by modulating astrocyte-mediated
neuroinflammation. Neuron 100 (551–563), e557.
Levine, J., Barak, Y., Chengappa, K.N., Rapoport, A., Rebey, M., Barak, V., 1999.
Cerebrospinal cytokine levels in patients with acute depression. Neuropsychobiology
40, 171–176.
Liddelow, S.A., Barres, B.A., 2017. Reactive astrocytes: production, function, and
therapeutic potential. Immunity 46, 957–967.
Lindqvist, D., Janelidze, S., Hagell, P., Erhardt, S., Samuelsson, M., Minthon, L.,
Hansson, O., Bjorkqvist, M., Traskman-Bendz, L., Brundin, L., 2009. Interleukin-6 is
elevated in the cerebrospinal fluid of suicide attempters and related to symptom
severity. Biol. Psychiatry 66, 287–292.
Lindqvist, D., Hall, S., Surova, Y., Nielsen, H.M., Janelidze, S., Brundin, L., Hansson, O.,
2013. Cerebrospinal fluid inflammatory markers in Parkinson’s disease–associations
with depression, fatigue, and cognitive impairment. Brain Behav. Immun. 33,
183–189.
Lindqvist, D., Dhabhar, F.S., James, S.J., Hough, C.M., Jain, F.A., Bersani, F.S., Reus, V.I.,
Verhoeven, J.E., Epel, E.S., Mahan, L., Rosser, R., Wolkowitz, O.M., Mellon, S.H.,
2017. Oxidative stress, inflammation and treatment response in major depression.
Psychoneuroendocrinology 76, 197–205.
Linnerbauer, M., Wheeler, M.A., Quintana, F.J., 2020. Astrocyte Crosstalk in CNS
Inflammation. Neuron 108, 608–622.
Liu, Y., Ho, R.C., Mak, A., 2012. Interleukin (IL)-6, tumour necrosis factor alpha (TNF-
alpha) and soluble interleukin-2 receptors (sIL-2R) are elevated in patients with
61
Brain Behavior and Immunity 109 (2023) 51–62
major depressive disorder: a meta-analysis and meta-regression. J. Affect. Disord.
139, 230–239.
Losito, I., Patruno, R., Conte, E., Cataldi, T.R., Megli, F.M., Palmisano, F., 2013.
Phospholipidomics of human blood microparticles. Anal. Chem. 85, 6405–6413.
Ma, X., Reynolds, S.L., Baker, B.J., Li, X., Benveniste, E.N., Qin, H., 2010. IL-17
enhancement of the IL-6 signaling cascade in astrocytes. J. Immunol. 184,
4898–4906.
Matcham, F., Rayner, L., Steer, S., Hotopf, M., 2013. The prevalence of depression in
rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology (Oxford)
52, 2136–2148.
Mayo, L., Cunha, A.P., Madi, A., Beynon, V., Yang, Z., Alvarez, J.I., Prat, A., Sobel, R.A.,
Kobzik, L., Lassmann, H., Quintana, F.J., Weiner, H.L., 2016. IL-10-dependent Tr1
cells attenuate astrocyte activation and ameliorate chronic central nervous system
inflammation. Brain 139, 1939–1957.
McColl, A., Thomson, C.A., Nerurkar, L., Graham, G.J., Cavanagh, J., 2016. TLR7-
mediated skin inflammation remotely triggers chemokine expression and leukocyte
accumulation in the brain. J. Neuroinflammation 13, 102.
Medina, A., Watson, S.J., Bunney Jr., W., Myers, R.M., Schatzberg, A., Barchas, J.,
Akil, H., Thompson, R.C., 2016. Evidence for alterations of the glial syncytial
function in major depressive disorder. J. Psychiatr. Res. 72, 15–21.
Meldolesi, J., 2018. Exosomes and ectosomes in intercellular communication. Curr. Biol.
28, R435–R444.
Mesquita, A.R., Correia-Neves, M., Roque, S., Castro, A.G., Vieira, P., Pedrosa, J.,
Palha, J.A., Sousa, N., 2008. IL-10 modulates depressive-like behavior. J. Psychiatr.
Res. 43, 89–97.
Milaneschi, Y., Simmons, W.K., van Rossum, E.F.C., Penninx, B.W., 2019. Depression and
obesity: evidence of shared biological mechanisms. Mol. Psychiatry 24, 18–33.
Miller, A.H., Raison, C.L., 2016. The role of inflammation in depression: from
evolutionary imperative to modern treatment target. Nat. Rev. Immunol. 16, 22–34.
Miller, A.H., Haroon, E., Felger, J.C., 2017. Therapeutic implications of brain-immune
interactions: treatment in translation. Neuropsychopharmacology 42, 334–359.
Moustafa, A.T., Moazzami, M., Engel, L., Bangert, E., Hassanein, M., Marzouk, S.,
Kravtsenyuk, M., Fung, W., Eder, L., Su, J., Wither, J.E., Touma, Z., 2020. Prevalence
and metric of depression and anxiety in systemic lupus erythematosus: A systematic
review and meta-analysis. Semin. Arthritis Rheum. 50, 84–94.
Mustapic, M., Eitan, E., Werner Jr., J.K., Berkowitz, S.T., Lazaropoulos, M.P., Tran, J.,
Goetzl, E.J., Kapogiannis, D., 2017. Plasma extracellular vesicles enriched for
neuronal origin: a potential window into brain pathologic processes. Front. Neurosci.
11, 278.
Nagy, C., Suderman, M., Yang, J., Szyf, M., Mechawar, N., Ernst, C., Turecki, G., 2015.
Astrocytic abnormalities and global DNA methylation patterns in depression and
suicide. Mol. Psychiatry 20, 320–328.
Najjar, S., Pearlman, D.M., Alper, K., Najjar, A., Devinsky, O., 2013. Neuroinflammation
and psychiatric illness. J. Neuroinflammation 10, 43.
Ongur, D., Drevets, W.C., Price, J.L., 1998. Glial reduction in the subgenual prefrontal
cortex in mood disorders. PNAS 95, 13290–13295.
Organization, W.H., 1992. The ICD-10 Classification of Mental and Behavioural
Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health
Organization.
Osimo, E.F., Pillinger, T., Rodriguez, I.M., Khandaker, G.M., Pariante, C.M., Howes, O.D.,
2020. Inflammatory markers in depression: A meta-analysis of mean differences and
variability in 5,166 patients and 5,083 controls. Brain Behav. Immun. 87, 901–909.
Park, K.W., Lee, H.G., Jin, B.K., Lee, Y.B., 2007. Interleukin-10 endogenously expressed
in microglia prevents lipopolysaccharide-induced neurodegeneration in the rat
cerebral cortex in vivo. Exp. Mol. Med. 39, 812–819.
Peng, L., Verkhratsky, A., Gu, L., Li, B., 2015. Targeting astrocytes in major depression.
Expert Rev. Neurother. 15, 1299–1306.
Perneger, T.V., 1998. What’s wrong with Bonferroni adjustments. BMJ 316, 1236–1238.
Pitharouli, M.C., Hagenaars, S.P., Glanville, K.P., Coleman, J.R.I., Hotopf, M., Lewis, C.
M., Pariante, C.M., 2021. Elevated C-reactive protein in patients with depression,
independent of genetic, health, and psychosocial factors: results from the UK
biobank. Am. J. Psychiatry 178, 522–529.
Qin, L., Wu, X., Block, M.L., Liu, Y., Breese, G.R., Hong, J.S., Knapp, D.J., Crews, F.T.,
2007. Systemic LPS causes chronic neuroinflammation and progressive
neurodegeneration. Glia 55, 453–462.
Rajkowska, G., Stockmeier, C.A., 2013. Astrocyte pathology in major depressive
disorder: insights from human postmortem brain tissue. Curr. Drug Targets 14,
1225–1236.
Rajkowska, G., Miguel-Hidalgo, J.J., Wei, J., Dilley, G., Pittman, S.D., Meltzer, H.Y.,
Overholser, J.C., Roth, B.L., Stockmeier, C.A., 1999. Morphometric evidence for
neuronal and glial prefrontal cell pathology in major depression. Biol. Psychiatry 45,
1085–1098.
Richards, E.M., Zanotti-Fregonara, P., Fujita, M., Newman, L., Farmer, C., Ballard, E.D.,
Machado-Vieira, R., Yuan, P., Niciu, M.J., Lyoo, C.H., Henter, I.D., Salvadore, G.,
Drevets, W.C., Kolb, H., Innis, R.B., Zarate Jr., C.A., 2018. PET radioligand binding
to translocator protein (TSPO) is increased in unmedicated depressed subjects.
EJNMMI Res. 8, 57.
Rothhammer, V., Quintana, F.J., 2015. Control of autoimmune CNS inflammation by
astrocytes. Semin. Immunopathol. 37, 625–638.
Rowitch, D.H., Kriegstein, A.R., 2010. Developmental genetics of vertebrate glial-cell
specification. Nature 468, 214–222.
Saint-Pol, J., Gosselet, F., Duban-Deweer, S., Pottiez, G., Karamanos, Y., 2020. Targeting
and crossing the blood-brain barrier with extracellular vesicles. Cells 9.
Sasayama, D., Hattori, K., Wakabayashi, C., Teraishi, T., Hori, H., Ota, M., Yoshida, S.,
Arima, K., Higuchi, T., Amano, N., Kunugi, H., 2013. Increased cerebrospinal fluid
X.-h. Xie et al.
interleukin-6 levels in patients with schizophrenia and those with major depressive
disorder. J. Psychiatr. Res. 47, 401–406.
Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E.,
Hergueta, T., Baker, R., Dunbar, G.C., 1998. The Mini-International
Neuropsychiatric Interview (M.I.N.I.): the development and validation of a
structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin.
Psychiatry 59 Suppl 20, 22-33;quiz 34-57.
Shi, M., Sheng, L., Stewart, T., Zabetian, C.P., Zhang, J., 2019. New windows into the
brain: central nervous system-derived extracellular vesicles in blood. Prog.
Neurobiol. 175, 96–106.
Sofroniew, M.V., 2014. Multiple roles for astrocytes as effectors of cytokines and
inflammatory mediators. Neuroscientist 20, 160–172.
Terstappen, G.C., Meyer, A.H., Bell, R.D., Zhang, W., 2021. Strategies for delivering
therapeutics across the blood-brain barrier. Nat. Rev. Drug Discov. 20, 362–383.
Thomson, C.A., McColl, A., Cavanagh, J., Graham, G.J., 2014. Peripheral inflammation is
associated with remote global gene expression changes in the brain.
J. Neuroinflammation 11, 73.
Torres-Platas, S.G., Hercher, C., Davoli, M.A., Maussion, G., Labonte, B., Turecki, G.,
Mechawar, N., 2011. Astrocytic hypertrophy in anterior cingulate white matter of
depressed suicides. Neuropsychopharmacology 36, 2650–2658.
Troubat, R., Barone, P., Leman, S., Desmidt, T., Cressant, A., Atanasova, B., Brizard, B., El
Hage, W., Surget, A., Belzung, C., Camus, V., 2021. Neuroinflammation and
depression: A review. Eur. J. Neurosci. 53, 151–171.
Valkanova, V., Ebmeier, K.P., Allan, C.L., 2013. CRP, IL-6 and depression: a systematic
review and meta-analysis of longitudinal studies. J. Affect. Disord. 150, 736–744.
Van Wagoner, N.J., Oh, J.W., Repovic, P., Benveniste, E.N., 1999. Interleukin-6 (IL-6)
production by astrocytes: autocrine regulation by IL-6 and the soluble IL-6 receptor.
J. Neurosci. 19, 5236–5244.
Vidal, M., Sainte-Marie, J., Philippot, J.R., Bienvenue, A., 1989. Asymmetric distribution
of phospholipids in the membrane of vesicles released during in vitro maturation of
guinea pig reticulocytes: evidence precluding a role for “aminophospholipid
translocase”. J. Cell. Physiol. 140, 455–462.
62
Brain Behavior and Immunity 109 (2023) 51–62
von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gotzsche, P.C., Vandenbroucke, J.P.,
Initiative, S., 2007. The Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) statement: guidelines for reporting observational studies.
PLoS Med. 4, e296.
Wang, Q., Jie, W., Liu, J.H., Yang, J.M., Gao, T.M., 2017. An astroglial basis of major
depressive disorder? An overview. Glia 65, 1227–1250.
Winston, C.N., Goetzl, E.J., Schwartz, J.B., Elahi, F.M., Rissman, R.A., 2019a.
Complement protein levels in plasma astrocyte-derived exosomes are abnormal in
conversion from mild cognitive impairment to Alzheimer’s disease dementia.
Alzheimers Dement. (Amst) 11, 61–66.
Winston, C.N., Romero, H.K., Ellisman, M., Nauss, S., Julovich, D.A., Conger, T., Hall, J.
R., Campana, W., O’Bryant, S.E., Nievergelt, C.M., Baker, D.G., Risbrough, V.B.,
Rissman, R.A., 2019b. Assessing neuronal and astrocyte derived exosomes from
individuals with mild traumatic brain injury for markers of neurodegeneration and
cytotoxic activity. Front. Neurosci. 13, 1005.
Woelfer, M., Kasties, V., Kahlfuss, S., Walter, M., 2019. The role of depressive subtypes
within the neuroinflammation hypothesis of major depressive disorder.
Neuroscience 403, 93–110.
Worthen, R.J., Garzon Zighelboim, S.S., Torres Jaramillo, C.S., Beurel, E., 2020. Anti-
inflammatory IL-10 administration rescues depression-associated learning and
memory deficits in mice. J. Neuroinflammation 17, 246.
Xin, J., Wainwright, D.A., Mesnard, N.A., Serpe, C.J., Sanders, V.M., Jones, K.J., 2011.
IL-10 within the CNS is necessary for CD4+ T cells to mediate neuroprotection. Brain
Behav. Immun. 25, 820–829.
Zamanian, J.L., Xu, L., Foo, L.C., Nouri, N., Zhou, L., Giffard, R.G., Barres, B.A., 2012.
Genomic analysis of reactive astrogliosis. J. Neurosci. 32, 6391–6410.
Zhang, H.Y., Wang, Y., He, Y., Wang, T., Huang, X.H., Zhao, C.M., Zhang, L., Li, S.W.,
Wang, C., Qu, Y.N., Jiang, X.X., 2020. A1 astrocytes contribute to murine depression-
like behavior and cognitive dysfunction, which can be alleviated by IL-10 or
fluorocitrate treatment. J. Neuroinflamm. 17, 200.